PQRI: Plant the Seeds of Participation Now

By Julie Orton Van, CPC, CPC-E/M, CPC-P-GENSG, OBGYN

You are either participating in the Physician Quality Reporting Initiative (PQRI) or are thinking about it. If you are among the latter, information may help with your decision. If you are already participating, I’ll clarify some confusing aspects of the initiative.

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Last December, President Bush signed the Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007, which authorized the continuation of PQRI for 2008.

The 2008 PQRI reporting period is Jan. 1 to Dec. 31, 2008. Eligible professionals who want to participate during the 2008 PQRI reporting period and who are not already reporting quality-data codes should begin reporting as soon as possible—the sooner you begin reporting, the easier it is to meet the 80 percent reporting criteria. Financial incentive for eligible professionals who successfully report the designated set of quality measures during 2008 is 1.5 percent of total allowed Medicare charges for covered services payable under the physician fee schedule (MPFS).

Identify Your Quality Measures

PQRI consists of 119 quality measures. These measures address various aspects of care such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For information regarding the 2008 PQRI measures and detailed specifications, go to the CMS website.

The Centers for Medicare and Medicaid Services (CMS) is posting a letter to Medicare beneficiaries with important information about the PQRI program and its implications. Because beneficiaries receive information referencing the quality reporting data on their explanation of benefits, provider offices may wish to provide a copy of the letter to patients. You can obtain a copy of the letter in PDF format.

All reporting for the PQRI program is claims-based. Current Procedural Terminology (CPT®) Category II codes or Healthcare Common Procedure Coding System (HCPCS) Level II temporary G-codes are for reporting quality measure data. Quality-data codes, which supply the measure numerator, must be reported on the same claim as the diagnosis or procedure code(s), which supply the measure denominator.

Special Category II CPT® modifiers, called exclusion modifiers, further specify the data. The modifiers consist of a number followed by the letter P (1P, 2P, 3P, and 8P). CPT® Category I modifiers should not be applied to CPT® Category II codes. Append only the appropriate exclusion modifier(s) to the numerator if any other modifier (CPT® Category I or HCPCS Level II modifier) is placed on the PQRI code line item, the claim may be returned or denied for an invalid procedure/modifier combination.

Meet the 80 Percent Minimum

Each of one to three measures must be reported for at least 80 percent of reportable cases to be eligible. Participants having only one or two applicable quality measures are still eligible for the bonus if they report on those measures at least 80 percent of the time. Validation is required to determine if additional measures should have been reported.

If four or more measures apply, a minimum of three must be reported for at least 80 percent of the cases. A practice may elect to report only one or two measures, which raises the risk of not meeting the 80 percent threshold. The more measures for which a practice reports and meets the threshold, the greater the bonus payment. The reporting threshold of 80 percent applies to each quality measure. If it is determined that reporting occurred less than 80 percent of the time for any one of the selected measures, the participant is ineligible for the bonus.

Capped at 1.5 Percent

A cap on the 1.5 percent bonus may apply when a participant reports relatively few instances of quality measures. The cap is to encourage more instances of measure reporting, and it promotes equity between those who report few instances and those who report many instances. Consider the cap when choosing measures to report, as more instances of reporting make it less applicable. The potential 1.5 percent incentive payment will be paid in mid-2009 as a lump-sum bonus payment to the practice at the taxpayer identification number (TIN) level.

CMS will provide confidential feedback reports to participants in mid-2009 with no feedback during 2008 and the quality data reported not reported publicly.

Guidelines for Claims Submission

Submitting codes for the PQRI is the same as for other services provided to a Medicare beneficiary. For electronic or paper claim submissions, complete all necessary data elements (or fields) on the billing line item. Necessary data elements include but are not necessarily limited to the following:

  • Date of service
  • Place of service
  • PQRI quality-data code, along with appropriate modifier
  • Diagnosis pointer
  • Submitted charge ($0.00 should be entered for PQRI codes)
  • Rendering provider’s National Provider Identifier (NPI)

Know the Correct Way to Submit Charges

Never leave the submitted charge field blank. The amount of $0.00 should be entered on the claim as the charge. If the physician’s billing software does not accept a $0.00 charge, a nominal amount can be substituted. (Note: the CMS claims processing systems cannot accept an entire claim with the total charge of $0.00.) Submit the PQRI quality-data codes on the claim where the patient diagnosis and service or procedure of the applicable quality-data code is billed. Claims submitted with only PQRI quality-data codes will not count in the analysis of reporting or performance rates. CMS does not allow retroactive submission of quality-data.

Whether the correct, $0.00 charge or a nominal amount is submitted to the carrier or Part A/Part B Medicare administrative contractor (A/B MAC), the PQRI code line is denied and tracked. The remittance advice associated with the claim containing the PQRI quality code line item includes a standard Remark Code (N365) and a message. Providers are not allowed to collect money from beneficiaries for charges submitted for PQRI codes. More information can be found online.

Claims where Medicare is the primary or secondary payer are included submission of non-zero charge values for PQRI quality-data line items may impact secondary payers’ ability to promptly process the claims for supplemental payment.

Include Provider’s NPI For Services

Be sure to include each performing provider’s NPI for the quality-data codes and all covered MPFS reported services. Use of the individual NPI to identify all covered services furnished is necessary to ensure the incentive amount calculation captures all allowable charges to the amount of any PQRI incentive earned.

For claims submitted via the ASC X12N 837 professional health care claim transaction, place the group practice NPI in the provider billing segment, loop 2010AA, and place the performing professional’s NPI in loop 2420A. For claims submitted via the CMS 1500 form, place the performing professionals’ NPI on the individual line item. Placing the performing eligible professionals’ NPI on the individual line item allows successful reporting analysis and incentive payment calculation at the individual level.

Several of the PQRI measures are applicable to care provided in hospitals, ambulatory surgery centers (ASCs), long-term care facilities, home visits or domiciliary care, and are reported as indicated in the PQRI quality measure specifications. Detailed specifications for each 2008 PQRI quality measure are available on the PQRI section of the CMS site.

Participation Considerations

If a professional satisfactorily submits quality-data codes for only one or two of the PQRI measures during the reporting period and does not submit quality-data codes for any other PQRI measure, that professional is subject to the measure-applicability validation process. Sampling methodology can be used to select professionals for validation, or CMS may determine all professionals who meet the validation criteria go through the validation process. Those who fail the validation process are not eligible to receive a bonus payment for the PQRI reporting period. PQRI-participating professionals who report quality-data codes for three or more PQRI measures during the reporting period are not subject to measure-applicability validation, although other Medicare program integrity statutes and regulations may apply.

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