A Step-by-step Guide to Implementing PQRI

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The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system. The requirement called for an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries. CMS ultimately named this program the Physician Quality Reporting Initiative (PQRI). The program is now a centerpiece for organizations trying to improve clinical care and capture appropriate revenue.

Make PQRI work for your organization by following a checklist of six steps.

Step 1: Consider your reporting period. To get started, determine which reporting structure your organization will follow. There are two reporting periods available: a 12-month period that runs from January 1 through December 31 and a six-month period that runs from July 1 through December 31.

To qualify for the incentive, you must report the correct PQRI code on at least 80% of the claims eligible for each selected measure, and you must report on at least three measures. Eligible providers who meet the criteria for satisfactory submission of PQRI quality-measures data will qualify to earn a PQRI incentive payment equal to 2% of their total estimated Medicare Part B Physician Fee Schedule allowed charges for covered professional services furnished during the reporting period. Group practices also are eligible at the same rate.

Step 2: Check documentation and gather statistics. Each measure requires a specific ICD-9-CM diagnosis and CPT® procedure code match, as indicated within the measure. You then assign a PQRI code that represents the measure. All of the measures need specific provider documentation to apply the correct codes. Physicians are responsible for documenting appropriately; coding or billing staff may be responsible for entering and billing for PQRI.

A few tips can assist you with coding and documentation. Collection check sheets, measure descriptions, and coding specifications are available at the CMS PQRI website or the AMA website (AMA participation tools, by specialty): http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-im.... Consider adding PQRI data codes to your superbill with a description of what the codes represent, or add requirements for exams to your templates or macros.

Be on the lookout for the top four radiology measures applicable to diagnostic radiologists.

Measure 10: Stroke and stroke rehabilitation CT or MRI—percentage of final reports for CT or MRI studies of the brain for patients with diagnosis/symptoms of transient ischemic attack (TIA) or ischemic stroke that include documentation of the presence or absence of hemorrhage or mass lesion and acute infarction.

Measure 145: Exposure time reported for procedures using fluoroscopy—percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.

Measure 146: Inappropriate use of the probably benign assessment category in mammography screening—percentage of final reports for screening mammograms that are classified as category 3 (probably benign).

Measure 195: Stenosis measurement in carotid-imaging reports—percentage of final reports for carotid-imaging studies for patients with the diagnosis of ischemic stroke or TIA that include direct or indirect references to measurement of distal internal carotid diameter as the denominator for stenosis measurement.

For example, applying measure 145 (for exposure time reported for procedures using fluoroscopy) involves considering:

• whether the patient is a Medicare enrollee;

• whether you performed an exam that includes fluoroscopy, such as 74230 (swallowing function, with cineradiography/videoradiography); and

• whether you documented fluoroscopy/radiation time (if so, report PQRI code 6045F, and if not, report CPT PQRI code 6045F-8P).

Step 3: Assess your billing system or clearinghouse. Ensure that it can report measures on the claim to the carrier. You will need to work with your software or claims-processing service vendors to ensure that their systems are able to accept the codes. CMS will analyze claims data using all diagnoses from the base claim and service codes on the allowed/paid service line or the PQRI line item. The line item containing the PQRI code must point to the diagnosis relevant to the measure being reported.

Step 4: Set up the bill. The PQRI codes follow current rules for reporting