ED Coding and Reimbursement Alert

When physician doesn't meet measure, P modifier ensures compliance.

ED providers who want to recoup a bonus from Medicare can choose to participate in the Physician Quality Reporting Initiative (PQRI) again -- this time with a higher rate of return.

The basics: In 2008, the PQRI bonus was 1.5 percent for practices that met the measures. In 2009, PQRI pays a 2 percent bonus, relays Eli Berg, MD, FACEP, CEO of MRSI, an ED billing company in Woburn, Mass. Here's a primer on participating in this program.

The first step in PQRI participation is focusing your reporting on measures your ED will often meet. According to CMS, the 2009 PQRI includes 153 reporting measures; however, only a handful will be relevant to EDs. (For a list of ED-relevant measures, see "This List Guides You To ED-Relevant PQRI Measures" on page 21.)

The expanded list should not impede your PQRI coding, as you only need to report on three of the measures in at least 80 percent of cases to qualify; EDs that meet this threshold will get a 2 percent bonus on all total allowed charges for covered Medicare services.

You will, however, need to do a little extra coding for PQRI participation, relays Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "There are specific PQRI quality-data codes associated with each of the PQRI measures," she says. The PQRI quality-data codes are CPT Category II codes, located in the back of CPT 2009 and in Appendix H, where CPT lists the measures alphabetically by clinical condition or topic.

Follow these steps on each of your claims to increase PQRI reporting success:

- Review documentation to determine if treatment is consistent with the PQRI measure.

- Assign the CPT and ICD-9 codes as you would normally for the claim.

- Check to make sure your ICD-9 and CPT codes line up with the measure's requirements

- Assign the appropriate Category II code, and any modifiers that you might need.

Consider this example from Berg, which illustrates proper reporting on measure 28, "Aspirin at Arrival for Acute Myocardial Infarction" (AMI):

A 67-year-old male presents with an AMI. The physician performs a comprehensive history and comprehensive physical exam. After a 12-minute visit in the ED, the patient goes urgently to the catheter laboratory. The physician documents the patient receiving aspirin during the ED encounter.

Since the physician documented that the patient received aspirin, and had an AMI, this encounter counts toward your PQRI total. On the claim, you would report the following:

- 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the E/M

- 410.x (Acute myocardial infarction - ) appended to 99285 to represent the AMI

- 4084F (Aspirin received within 24 hours before emergency department arrival or during emergency department stay [EM]) for PQRI purposes.

If a patient's condition mirrors a PQRI measure, but the physician does not meet all the treatment requirements during the visit, you can still report the encounter to PQRI. Just remember to append a P modifier to the Category II code, reminds Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists in Grand Rapids, Mich.

These modifiers, which explain to Medicare why the physician did not meet the PQRI measure, are:

- 1P -- Measure not met for medical reasons

- 2P -- Patient declined treatment associated with measure

- 3P -- Measure not met for system reasons

- 8P -- Measure not met, reason not specified

Example: Let's say a 62-year-old patient presents to the ED with syncope. PQRI measure 55 calls for the physician to perform a 12-lead electrocardiogram (EKG or ECG) on all patients over 60 with syncope to qualify for PQRI reporting.

"If your physician did not perform an ECG at that visit, you could still report a PQRI code, but would also need a modifier to indicate the ECG was not performed," explains Pinckney.

So if notes indicate a level-three ED E/M service, and that the patient refused the ECG for financial reasons, you would report the following:

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

- 780.2 (Syncope and collapse) for the syncope

- 3120F (12-lead ECG performed [EM]) for the PQRI measure

- modifier 2P appended to 3120F to show why the EKG was not performed