PQRI: Earn While You Learn

Fledgling Physician Quality Reporting Initiative offers bonus payments to participants.

By Jacqueline Thelian, CPC
The Physician Quality Reporting Initiative (PQRI) is a voluntary quality-reporting program created in 2007 by the Centers for Medicare & Medicaid Services (CMS) which offers a financial incentive for eligible professionals who provide professional services that are reimbursed under the Medicare physician fee schedule.
The goal of PQRI is to determine best practices, define measures, support improvement and improve systems. PQRI focuses on the measurement of quality of care determined by evidence-based measures developed by professionals. The PQRI reporting is the first step toward pay for performance.
Participation in the PQRI program is voluntary and registration is not necessary. However, any eligible professional deciding to participate must have begun reporting the appropriate quality measure data on submitted claims to their Medicare Administrator Contractor on July 1, 2007 and must accurately and consistently use individual National Provider Identifiers (NPIs).
Participants will receive confidential feedback reports and may also earn a bonus incentive.
Those who successfully report a designated set of quality measures may earn a bonus payment of 1.5 percent of total allowed charges for covered Medicare fee schedule services between July 1 and Dec. 31, 2007, and not solely on the charges from claims that contained the quality codes. The bonus payment is subject to a cap.
The potential 1.5 percent bonus will be based upon the total allowed charges paid under the fee schedule. This includes patient portion, technical component, anesthesia services, drug administration and Railroad Retirement Board (RRB) charges. This excludes laboratory services, drugs, HPSA bonuses and denied line items.
Additionally, a nationally-applicable completion factor will be added to the charges for the services provided during the reporting period prior to calculating the bonus payment to account for the clean claims submitted by Feb. 29 2008, but not yet in the National Claims History (NCH) file.
The purpose of the cap is to encourage more instances of measure reporting. The cap also promotes a rough equity between those who have reported a few instances and those who have reported many instances. When selecting measures to report, keep the cap in mind. The more instances of reporting will make the cap less likely to apply.
The bonus payment will be made to the owner of the tax identification number on file. If a professional is reporting under more than one tax identification number, the bonus will be paid to each tax identification holder on record.
For 2007, PQRI reporting is based upon 74 unique measures. These measures are associated with clinical conditions that are routinely represented on Medicare claims via use of diagnosis codes. The specifications will describe different aspects of care. For example: prevention, management of chronic conditions, acute episodes of care and procedure-related care. Resource utilization and care coordination are also included in the specifications. Descriptions for each PQRI measure, along with instructions on how to code each measure’s numerator and denominator, are outlined in the specifications document which can be found on the CMS PQRI website.
Additionally, each measure will have a frequency requirement for each eligible patient seen during the reporting period, (e.g., report one-time only, once for each procedure performed, once for each acute episode of care, per eligible patient). Some measures include specific performance timeframes such as “within 12 months” or “most recent.”
PQRI codes are mostly CPT® Category II codes; however, temporary G codes (HCPCS) codes will be used where Category II codes have not yet been adopted.
Additionally, a PQRI measure may require modifiers. There are two kinds of CPT® II modifiers:

  1. Performance Measure Exclusion Modifiers – used to indicate that an action specified in the measure was not provided due to medical, patient or system reason(s) documented in the patient’s record.
  2. Performance Measure Reporting Modifier– facilitates reporting a case when the patient is eligible but an action described in a measure is not performed and the reason is not specified or documented.

Example: Measure #64, Asthma Assessment
Reporting Description: Percentage of patients aged 5 through 40 years with asthma and an applicable CPT® Category II code reported a minimum of once during the reporting period.
Performance Description: Percentage of patients aged 5 through 40 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms.
Sample Clinical Scenario: A 38-year-old patient with known asthma is seen by the clinician for follow-up care. The clinician documents in the medical record the numeric frequency of daytime and nocturnal asthma symptoms.

Eligible Professionals


Oral Surgeon


Physical Therapist
Occupational Therapist
Qualified Speech-Language pathologist


Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional

Implementation Guidelines

Review clinical data (within the last 12 months of this encounter) regarding the presence or absence of the most recent asthma assessment performed at an encounter occurring during the reporting period (between July 1 and Dec. 31, 2007). Select and submit the appropriate CPT® Category II code corresponding to the measure.
To be counted in calculations of this measure, symptom frequency must be numerically quantified. Measure may also be met by clinician documentation or patient completion of an asthma assessment tool/survey/questionnaire. Assessment tools may include the Quality Metric Asthma Control Test™, National Asthma Education & Prevention Program (NAEPP) Asthma Symptoms and Peak Flow Diary.
Each eligible patient seen during the reporting period will be counted once when calculating the eligible professional’s reporting rate for this measure. The measure may be reported again at a subsequent visit during the reporting period. If the measure is reported more than once for an eligible patient during the reporting period, the single instance of reporting most advantageous to performance will be used when calculating the eligible professional’s performance rate for this measure. Failure to report applicable CPT® Category II code(s) in an eligible case will result in both a reporting and performance failure. Medical record documentation is required for all clinical actions described in a measure.
For complete information on how to implement PQRI measures in your practice and to assure successful reporting, CMS has published a handbook with information to assist you with:

  • Identification of eligible cases based upon ICD-9-CM and CPT® Category I codes
  • Selecting the correct quality data codes to report
  • Knowing when to use exclusion modifiers
  • Knowing when to use a reporting modifier

Download the handbook and for a PQRI Tool Kit and Measure Finder Tool.
The CMS PQRI website also provides information on how to complete your claim form to submit the PQRI quality of data codes.

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