Wiki CMS PQRI Update


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Physician Quality Reporting Initiative (PQRI) Letter to Medicare

The Centers for Medicare & Medicaid Services has posted a letter to
Medicare beneficiaries with important information about the Physician
Quality Reporting Initiative (PQRI) at, on the CMS
website. 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

To access the letter, visit,
<> , on the CMS website. Once on the Overview page, scroll down to the "Downloads" section.

PQRI Questions of the Week

Q: If a Physician Quality Reporting Initiative (PQRI) quality-data code
is not listed on a line adjacent to the correct Current Procedural
Terminology (CPT) Category I code, will the quality-data code be

A: Yes, the PQRI analyses will match PQRI quality-data codes to the
Current Procedural Terminology (CPT) Category I codes that appear on any
non-denied service line on the claim, regardless of the order in which
the various line items appear.

Q: If I report a modifier to a Physician Quality Reporting Initiative
(PQRI) quality-data code on a claim, when use of that modifier is not
specifically allowed per the PQRI Measure Specifications document, will
I get credit for reporting?

A: No. In order to be considered an instance of appropriate quality
data submission, PQRI quality-data codes should be accurate and reflect
valid modifiers as in the measure specifications. Invalid codes will not
be included in reporting or performance rate calculations.

Q: I have questions about which PQRI measures are most applicable to my
specialty and practice, and how best to implement PQRI in my practice.
Where can I get more information and advice on these topics?

A: For specialty- or practice-specific questions, please contact your
professional organization or specialty association for guidance. In many
cases, these organizations have information and tools to enable
successful reporting of PQRI measures available on their websites.

Q: The 1.5% bonus is subject to a cap. How and when will CMS calculate
the cap for an individual eligible professional?

A: The bonus cap calculation is defined as follows: (the individual's
instances of reporting quality data) multiplied by (300%) multiplied by
(the national average per measure payment). The third factor, the
"national average per measure payment amount" can only be calculated
after the reporting period ends because it is equal to (the total amount
of allowed charges under the Physician Fee Schedule for all covered
professional services furnished during the reporting period on claims
for which quality measures were reported by all participants in the
program) divided by (the total number of instances where data were
reported by all participants in the program for all measures during the
reporting period.)

Because the "national average per measure payment amount" is not yet
available, the following is a hypothetical example:


Dr. Smith had $400,000 in allowed charges during the PQRI reporting

The 1.5% potential bonus is $6000.

Dr. Smith reported quality data codes in 500 instances.

The national average per measure payment amount for 2007 was calculated
in CY 2008 and turned out to be $100 ($100 M total national allowed
charges claims submitted from July through December, divided by, 1
million instances of PQRI quality data codes being reported in the same
time period).

The cap for Dr. Smith is $150,000 (500 x 3 x $100).

The bonus paid to Dr. Smith in early CY 2008 is $6,000.

For a complete listing of all questions and answers about the 2007 PQRI,
visit our website at,, and click on "All
PQRI FAQs" available on any page.
2008 Update?

Can anyone tell me where to go for info on 2008? I have the 2008 measures that were recently released, however I am looking for some more information ( like the payment timeframes for 2008). Has anyone seen it yet?