ED Coding and Reimbursement Alert

PQRI requires you to report quality measures, whether or not your doctor met them

EDs that want to be eligible for Medicare's 1.5 percent bonus should start reporting quality indicators immediately, or they can probably kiss the potential windfall goodbye.

How it works: You don't have to register for the Physician Quality Reporting Initiative (PQRI), experts say. Instead, you just have to start reporting special category II codes on your claims. The category II codes should be on the same claim as the visit to which they apply.

For example: Your practice sees a lot of patients with community-acquired bacterial pneumonia (CABP), and therefore decides to report on measures 56 through 59. 

Then, every time a patient comes in with CABP, you will examine the documentation to see whether your physician checked the patient's vital signs. If the physician did, you will add CPT code 2010F to the claim. If the physician didn't check the vital signs, you will still report 2010F, but you-ll also attach a modifier explaining why she did not perform the check.

For example, modifier 1P means the doctor didn't record the patient's vitals for medical reasons. (For more information on PQRI documentation, see -Physicians May Meet Quality Measures but Lack Proof- on page 72.)

Similarly, you will report 3028F, with or without a modifier, to note whether the doctor checked the patient's oxygen saturation results. And you-ll report 2014F for whether the doctor checked the patient's mental status, and 4045F for whether the doctor prescribed an -appropriate empiric antibiotic.-

Bonus: If your quality reporting meets standards, you get an extra 1.5 percent of all your Medicare billings from July 1 to Dec. 31. To receive the bonus, your doctor must report on up to three measures per claim.

Medicare PQRI Bonus Requirements

Also, Medicare will look at all the claims for patients with pneumonia and see whether your doctors reported on their chosen measures for them. -Where there are three or more measures identified for the specialty, the doctors have to report on at least three of them 80 percent of the time to be eligible for the bonus,- says Robert La Fleur, MD, FACEP, an emergency medicine physician and president of Medical Management Specialists in Grand Rapids, Mich.

-Many individual claims will likely only have one measure on them,- he says.

Cap: There's a cap that might reduce the amount of your bonus, if your doctor meets the 80 percent requirement but doesn't report measures very often.

For emergency medicine physicians, the measures that apply most are acetylsalicylic acid (ASA) for myocardial infarction, electrocardiogram (EKG) for chest pain, EKG for syncope, and the pneumonia measures, La Fleur says.

Important: Remember that it doesn't matter how many measures may apply to your patients, La Fleur says. You just have to report at least three measures at least 80 percent of the time to earn the bonus. And, for now at least, the PQRI has nothing to do with performance.

Remember, you get paid regardless of whether your doctor actually performed the PQRI measures you-re reporting on.