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Q: Are modifiers (1P or 8P) used with the 3250F PQRI code?

A: No. For PQRI measure #99, 3250F acts as a denominator exclusion code and therefore does not allow a modifier to be appended to it.  Page 212 of the 2009 PQRI Measure Specifications Manual contains the following instruction, " If patient is not eligible for this measure because the specimen is not primary breast tissue (eg, liver, lung) report CPT II 3250F: Specimen site other than anatomic location of primary tumor

Q: Can individual measures be billed @ 6 months and how are payments calculated?

A: No, there is no reporting option for reporting individual PQRI measures VIA CLAIMS for a half-yr reporting period.  The only options available this late in the year are: 1) report a measures group via claims using 80% sample method for a 1% incentive,  or use the  30 consecutive patient sample method for a 2% incentive; 2) report one or more measures groups via registry; or 3) report at least 3 individual measures via registry for 12 mos reporting period for 2% incentive; or 4) report at least 3 measures via registry for a 6 mo reporting period for 1% incentive.  Calculation of incentive is based on Total Allowed Part B Medicare FFS charges not just the charges for the services billed for PQRI.  See http://www.cms.hhs.gov/PQRI/33_2007_PQRI_Program.asp#TopOfPage in the Downloads Section you will find "A Guide to Understanding Incentive Payment Calculation"  this document will be updated and posted for the 2008 PQRI Program

Q: Can you explain further the 30 consecutive PT measures group sample?

A:  Please refer to the 5/20/09 PQRI National Provider Call slides (#18 ) it describes how the sample works:  30 Part B FFS Medicare patients seen on consecutive dates of service.  Also, search FAQs using keyword "consecutive" (note that some FAQs will pertain to 2008 PQRI only)

Q: Could a Place of Service 22 participate in PQRI?

A: POS "22" denotes outpatient clinic.  If you are billing for a physician on a CMS 1500 or 837-P claim for Part B Medicare FFS (not Part A Medicare) and you are submitting that individual physician's NPI on the claim, the answer is Yes.    If you are submitting an institutional claim, the answer is No.

Q: Does the confidential feedback report give you a report of your PQRI reporting status, if you are successfully reporting as of now, or do you have to wait until the reporting is over to find out if your are successfully reporting the measures you have selected?

A: The feedback reports are only available at the conclusion of the program.  The ongoing feedback is by checking your remittance advice notice from the carrier/MAC to ensure you receive a denial code N365 which tells you the quality-data code(s) submitted were transferred to the NCH for analysis.  Also we recommend that you keep track of the claims you have submitted and that you ensure your workflow identifies all denominator-eligible claims for the measures you are reporting.  

Q: Weve received a N386 remark on a few of our medicare eob's which have the same verbage as the N365 remark...  what does it mean when the N386 remark is received?

A: The N365 denial code was answered during the call and is described on the slides.

Q: Does the incentive for e-prescribing apply to physician groups in outpatient service?

A: Both PQRI and eRx incentive programs are individual physician reporting programs.  If you are billing claims to a carrier/MAC on a CMS 1500 or 837-P for Medicare Part B physician fee schedule services using the physician's individual NPI, then you can include the quality-data codes (QDCs) on the claim.  The place of service such as outpatient does not matter. If you are billing institutional claims, then those claims will not count for either PQRI or eRx.

Q: Does the patient see the PQRI codes on their EOB?

A: Patients will see the the description of N365 on their eob. CMS has posted a letter to Medicare beneficiaries with important information about the PQRI. The letter is from Medicare to the patient explaining what the program is, and the implications for the patient. Physicians may choose to provide a copy to their patients in support of their PQRI participation. To obtain a copy of the letter, see the "Related Links Inside CMS" on the Overview section of the website.

Q: e-prescribing program only for Medicare patients or open to all insurance carriers?

A: Altough you can e-prescribe on any patient, the CMS eRx incentive program is only for reporting on Medicare Part B.  Please refer to the eRx website. 

Q: For the preventive measures, there are codes for problem E/M services, but none that would be billable outside of this range to qualify for a measure.  In ob/gyn practices, the preventive services are normally performed at a preventive visit, but the code G0101 is not listed as a service that counts.  For instance, measure 113 for colorectal screening.  Since the preventive medicine codes are not covered by Medicare, why isn’t G0101 on the list of applicable services to count toward such screening?

A:  The preventive care services measures apply broadly to a number of E/M services.  The only 2009 PQRI measures associated with HCPCS code G0101 – Cervical or vaginal cancer screening; pelvic and clinical breast examination are #124, 128, and 130.  You need to ask the quality area of your specialty society this question as the measures are developed by the AMA Physician Consortium for Performance Improvement in collaboration with the specialty societies.  You can also contact the measure developer, AMA PCPI - contact information is posted on the 2009 PQRI Measures List. I will also refer this question internally as we consider measures for future program years.

Q: How do you correct quality data codes?

A: You cannot submit a claim merely to add or correct a QDC.  You need to contact the carrier/MAC and follow their instructions.

Q: Can you please explain when you can use ONE G code instead of all measures IF the patient qualifies for all?

A:  You are referring to reporting of a measures group.  The composite G-code can only be used if all quality actions were performed. If a situation with a patient requires you to place an exclusion modifier (1P, 2P, 3P or 8P applies) on a CPT II code, you cannot report using the composie G-code, you need to submit the measures individually. Please refer to the Getting Started Guide for how to report a measures group - the URL is on the slides.

Q: If we have a claim that has more than 1 cpt code but the PQRI measure is only applicable to the E&M for example, do the PQRI codes need to be located directly beneath the E&M code or can they just be located anywhere on the claims?  the reason i'm asking is that i was at an AAOE seminar recently and we were told that the PQRI measure codes need to be directly beneath the applicable CPT code.

A: No, the PQRI quality-data codes (QDCs) do not need to be directly beneath the line item containing the CPT1 service code.  They just need to be listed on the claim, as all lineitems on the claim will be available for PQRI analysis when the claim is processed by the carrier/MAC.  You may need to check with your billing software/clearinghouse vendor b/c sometimes the software splits the claim after a certain number of lines.

Q: If we participate and submit successfully, how will the 2% be calculated?  Is that based on all patients seen in a year, 6 months or only the patients we reported on?

A: Depends on when (the reporting period) that chose to begin submitting QDCs - For full-year it is 2%, for half-year it is 1% of total allowed Medicare Part B charges based on the patients seen during that reporting period.

Q: We will begin reporting DM measures group on 7/1/09.  I would like to confirm that there is no registration required.

A: No registration is required to begin submitting.  You need to submit an intent G-code on the first patient that qualifies for the DM MG and then submit all the applicable QDC(s) on the claim for that first patient.  Please read the resources for MGs cited on the slides (URLS were provided).

Q: Could I get further clarification of "consecutive"?  Do we see 2 patients on day 1, 3 on day 2 and so forth until all 15 patients are seen?  Can there be days in between when a DM patient is not seen?

A: The 30-consecutive patient sample method for 2009 measures groups requires a miminum of 30 patients (not 15):  2 DM Medicare Part B (FFS) patients are seen on day 1, 3 DM pts on day 2 and so forth until all 30  patients are seen.  If on a day you only see Medicare Advantage DM patients, those patients are not part of your 30-consecutive sample.  We do not look at any Medicare Advantage claims when we extract claims from the NCH for PQRI analysis.You can start that sample AT ANY TIME OF THE YEAR to qualify for a full-year (2%) incentive.  Another alternative is to use the 80% sample method starting July 1 but this would be to qualify for  a half-yr (1% incentive).

Q: I'm confused about how the Registry is used.  Does the provider's office contract with a Registry?  Is there a fee from the Registries? Please explain the Registry process more completely.

A:  Instructions for reporting via a qualified registry is guided by the individual registry of interest.  All qualified registries are posted on the Reporting section of the CMS PQRI website.  We will update the list to include additional qualified registries at the end of July 2009.  Registries can either data mine your claims or request that you submit to them via a secure website.

Q: Is is okay if our provider started reporting on PQRI in June,under choosing 3 -4 claims based reporting options?  I heard you mention the 6 or 12 month option?  But starting in June does not qualify under either.

A:  The question is not clear - which reporting option was selected?  Did you start to report a 30-consecutive patient sample for a measures group in June? OR Did you begin to report individual measures via claims in June?  If the latter, you will not qualify for an incentive because you will not have met the 80% target reporting rate.

Q: Is it correct to submit PQRI to Medicare HMO's?

A: Why would you do this?  PQRI is a Part B (FFS) Medicare program not Part C Medicare Advantage (MA).  Many MA health plans are not equipped to handle PQRI QDCs on their claims systems and this will only slow your payment.  If after yhou bill a plan as a primary and then find that you need to bill Medicare as secondary payor, then you should submit the QDCs on that secondary claim to the carrier/MAC.

Q: Is it true that if you e-prescribe for incentive, you will not qualify for the emr incentive?

A: Where did you hear that?  eRx is its own incentive program separate from PQRI.  The ARRA incentive for a qualified EHR is also a separate program for which we are currently writing a proposed rule that will be published soon, so I cannot comment on that yet.
 

Q: When will 2009 PQRI Incentive Pmts be made?  Do you have an approximate time frame?

A:  Incentive payments are made as a lump-sum annually after the conclusion of the program.  2009 incentive will be paid in July 2010.  you can read about how incentives were calculated and paid on the Analysis/Payment section of the CMS PQRI website.

Q: MEASURE #185 - If you do not know the exact date of the last colonoscopy, do you not report the measure at all for that particular patient?

A: Medical record documentation should show the history of when the last colonoscopy was performed and findings- it does not necessarily have to be a specific date, but the record should document that the patient was asked and the year. Note that the patient population or this measure issurveillance colonoscopy  patients with a history of colonic polyps in a previous colonoscopy.

Q: Medicare is secondary insurance, submit PQRI?

A: YES!  Submit the QDCs on the claim that you send to the carrier/MAC.

Q: Our qualified e-prescribing system is not available until 7/1/09.  Will we be able to meet the 50% of applicable cases for the year?

A: Don't know - depends on how often your patients return for a visit.  Since it's so late, plan on submitting for 100% of the eligible claims durin the

Q: Are the Medicare Advantage Plans included in the e-prescibing submission or excluded like the PQRI measures?

A:  Altough you can transmit the eRx on Medicare Advantage (MA) patients to a pharmacy, you cannot place an eRx G-code on a MA claim -those claims are not considered for PQRI incentive analysis and  you will delay payment from the MA plan. This was answered during the webinar. Please refer to the slides.

Q: Right now PQRI  is voluntary.  Do you ever see a time when it will become mandatory?

A: When such a time starts, it will be announced in advance through rulemaking and national provider calls and on the website.

Q: So, we can submit 30 patients per doctor and be good with eRx?

A: NO - not for eRX!  For eRX, you need to meet the 50% reporting rate.  For PQRI, yes - you can submit 30-consecutively seen patients per NPI FOR A MEASURES GROUP - not for individual measures.

Q: If we want to report as a registry instead of per claim-how would you go about doing that?  Does the registry mean-you just report all at once for the year?

A: Yes, a registry allows you to report "all at once" - you need to decide which measures (must be at least 3 or more measures)  and then discuss with a qualified registry of interest.  There is a fee that registries charge.  Read about registries in the Reporting section of the website. The list of qualified registries and their contact numbers are posted there also.

Q: Sylvia mentioned you have to report at least 3 measures for claims based reporting.  What do you do if you only have 2 measures that apply to you?

A:  If only 2 are applicable and only 2 are reported (and no other measure is reported at all), the measure applicability validation process (MAV) applies.  Discussed with your colleague and an email was sent.  Please see MAV policy on the Analysis/Payment section of the CMS PQRI website.  We also have a number of FAQs posted about MAV.

Q: This is a stupid question, but is eRx a program we need to purchase ?

A: There are no stupid questions.  To participate in eRx you need to have purchased and implemented a qualified eRx system.

Q: If medicare is the secondary payer - do you list the PQRI QDC on the primary claim so it appears on the secondary claim that goes electronic?

A: No you cannot list QDCs on the primary claim, as many health plans do not recognize them and you will delay your payment.  AFTER the primary pays and you are going to bill Medicare as secondary for the balance, THEN you place those QDCs on the claim you submit to the carrier/MAC. If you meet with a circumstance when the primary paid the claim 100%, then that claim is not considered a Part B claim and you do not need to report QDCs.

Q: This presentation is only for outpatient physician  office and not for inpatient care.  Is this correct?

A: NO, not correct.  There are a number of measures that include physician services provided in the inpatient care area as well as the ED.  You need to study the measures carefully.

Q: under the Group - diabetes mellitus for Nephropathy screening there are 3 items under not performed - this also happens under Eye exam there are three  items under Not Performed - does it matter which one we mark not performed or do we always mark all three?

A: There is an "OR" statement after each item.  Therefore, you choose one of the three that applies and report that QDC.

Q: Can you explain when we can use the  code G8494?  (All quality actions for the spplicable measures in the diabetes Mellitus measures group have been performed)  Does this mean if the measure was not performed we can use the code?

A: You can only use the composite G-code when ALL clinical actions were performed.  If one or more were not performed and 1P, 2P, 3P or 8P applies, then you cannot report using G8494, you must report the measures individually on the claim

Q: If our eRX system does have a malfunction are you saying we can use any of the G codes?

A: NO.  If your eRx system malfunctions, you did  not eRX so you cannot report a G-code

Q: We are a FQHC but thought we would be eligible because we are paid under the PFS for all services other than office visits.

A: NO FQHCs are excluded - FQHCs are paid under a different methodology and the claims do not include the individual NPI.  See EP List posted on the PQRI and eRx websites.  Search FAQs using FQHC as a keyword.

Q: What is the incentive amount for the ERx

A: 2% of total allowed Medicare Part B PFS covered charges.  See CMS eRx website.

Q: We have a large practice with 9 offices.  Can only one provider participate, or does the entire group have to?

A: Depends on what they want to do it is voluntary by individual physician so one, two or all can participate - you must place the individual NPI in the Rendering Provider ID field on the claim for each physician.  As a larger group, you might consider reporting via registry.  See the Reporting section of the CMS PQRI website for a list of qualified registries.

Q: We just want to verify what you said about Medicare Advantage plans and PQRI. We can submit PQRI to MA but you will not receive incentive?

A: NO.  Do not submit PQRI (or eRx G-codes) on MA claims.  You will only succeed in delaying your payment.  PQRI and eRx are only for Part B claims that are submitted to the carrier/MAC.

Q: When will PQRI change to Paid for performance?

A: Not sure.  Not ready yet.  When it does it will be announced through rulemaking and through the website and listserv in advance.

Q: When will the 2008 PQRI results be available in IACS?

A: After the reports are posted and payment is distributed (Oct 2009).  We will announce availability through a National Provider Call and on the CMS PQRI website and listserv.