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Thread: CMS PQRI Update

  1. #1
    Join Date
    Apr 2007
    Gainesville (NCF) Florida

    Default CMS PQRI Update

    AAPC: Back to School
    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, www.cms.hhs.gov/PQRI 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, http://www.cms.hhs.gov/PQRI
    <http://www.cms.hhs.gov/PQRI> , 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, http://www.cms.hhs.gov/PQRI, and click on "All
    PQRI FAQs" available on any page.

  2. #2

    Wink 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?


  3. #3


    The CMS Web site has a section for the 2008 PQRI program - this is the place to go. In addition, you might want to check the Federal Register. I believe payments, for 2008 reporting, are to be made in mid 2009.

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