ED Coding and Reimbursement Alert

When physician doesn't meet measure, P modifier ensures compliance. ED providers who want to recoup a bonus from Medicare can choose to participate in the Physician Quality Reporting Initiative (PQRI) again -- this time with a higher rate of return. The basics: In 2008, the PQRI bonus was 1.5 percent for practices that met the measures. In 2009, PQRI pays a 2 percent bonus, relays Eli Berg, MD, FACEP, CEO of MRSI, an ED billing company in Woburn, Mass. Here's a primer on participating in this program. Choose Measures Your ED Sees Often The first step in PQRI participation is focusing your reporting on measures your ED will often meet. According to CMS, the 2009 PQRI includes 153 reporting measures; however, only a handful will be relevant to EDs. (For a list of ED-relevant measures, see "This List Guides You To ED-Relevant PQRI Measures" on page 21.) The expanded list should not impede your PQRI coding, as you only need to report on three of the measures in at least 80 percent of cases to qualify; EDs that meet this threshold will get a 2 percent bonus on all total allowed charges for covered Medicare services. You will, however, need to do a little extra coding for PQRI participation, relays Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "There are specific PQRI quality-data codes associated with each of the PQRI measures," she says. The PQRI quality-data codes are CPT Category II codes, located in the back of CPT 2009 and in Appendix H, where CPT lists the measures alphabetically by clinical condition or topic. Follow these steps on each of your claims to increase PQRI reporting success: - Review documentation to determine if treatment is consistent with the PQRI measure. - Assign the CPT and ICD-9 codes as you would normally for the claim. - Check to make sure your ICD-9 and CPT codes line up with the measure's requirements - Assign the appropriate Category II code, and any modifiers that you might need. Consider this example from Berg, which illustrates proper reporting on measure 28, "Aspirin at Arrival for Acute Myocardial Infarction" (AMI): A 67-year-old male presents with an AMI. The physician performs a comprehensive history and comprehensive physical exam. After a 12-minute visit in the ED, the patient goes urgently to the catheter laboratory. The physician documents the patient receiving aspirin during the ED encounter. Since the physician documented that the patient received aspirin, and had an AMI, this encounter counts toward your PQRI total. On the claim, you would report the following: - 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components [...]