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.
: 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.
: 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-improvement/clinical-quality/participation-tools-individual-2010.shtml. 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.
: 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.
: Exposure time reported for procedures using fluoroscopy—percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.
: 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).
: 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).
: 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.
: Set up the bill. The PQRI codes follow current rules for reporting other CPT codes. To set up the bill, enter PQRI codes on the CMS 1500 form in field 24D; enter the date and place of service; add PQRI codes, along with any modifiers, if appropriate, and the diagnosis pointer; and submit a charge of $0.00 for PQRI codes.
The submitted-charge field cannot be left blank. If the physician's billing software does not accept a $0.00 charge, a nominal amount can be substituted. PQRI codes must be on the same claim as the billing codes, for the same beneficiary, on the same day of service, and under the same national provider identifier (NPI) for the person who performed the service. All submitted diagnosis codes are included in the PQRI analysis. Do not resubmit claims only to add PQRI codes.
: Check your remittance. When you submit the $0.00 (or nominal) charge, the PQRI code line is denied and tracked. The remittance advice associated with the claim containing the PQRI line item will include a standard remark code (N365): “This procedure code is not payable. It is for reporting/information purposes only.” This remittance advice confirms that the PQRI code(s) passed into the National Claims History file for use in calculating incentive eligibility.
: Pay attention to details. Common reasons for PQRI claim ineligibility include missing diagnosis pointers, missing individual NPIs, incorrect CPT codes, incorrect diagnosis codes, both incorrect CPT and diagnosis codes, and all line items being PQRI (missing CPT codes). Be sure you don’t let these simple errors derail your claims.
Rules to Live By
In order to make PQRI work for your organization, remember these rules. Check eligibility, select the measures that seem appropriate for your practice, and assemble an implementation team to assist with the collection of data. Ensure that the practice’s billing software and clearinghouse can capture all the codes and associated modifiers. Read, and discuss with the staff, the reporting principles and specifications for each of the measures that you wish to report; use the AMA website for specifics.
Check your macros and templates, adding the required documentation fields. Assess your billing system and/or clearinghouse to ensure that it can handle quality-data PQRI codes and modifiers. Review the remittance-advice notices from CMS to ensure that you receive the N365 remark code for each PQRI code submitted.
These tips will help you capture the appropriate PQRI incentive payments. Enjoy your bonus.
Helpful Sites for PQRI
JoAnn Baker, CCS, CPC-H, CPC, CHCC, CAC, is a coding analyst for CodeRyte, Bethesda, Maryland.