ED Coding and Reimbursement Alert

Your ED performs a measure that might qualify for the physician quality reporting initiative (PQRI): however, the patient refuses the described PQRI treatment for religious reasons.

What to do: Report the measure as you would have otherwise, with a modifier 2P (Performance measure exclusion modifier due to patient reasons) appended to the E/M code.

Why? "Providers will receive credit for PQRI measures whether modified or not," says Sarah Todt, RN, CPC, CEDC, associate director for QA and compliance at MRSI Inc. in Woburn, Mass.

Any time your ED physician treats a patient with a PQRI ICD-9 code trigger, it will count toward your overall score. CMS has provided a mechanism to report PQRI codes, even if the described treatment isn't performed. You append a special modifier to the PQRI code to show that even though the measure wasn't fully performed, the group is committed to the reporting process.

Depending on the situation, you should list one of the following modifiers when a PQRI measure is not met:

• 1P-- Performance measure exclusion modifier due to medical reasons

• 2P-- Performance measure exclusion modifier due to patient reasons

• 3P-- Performance measure exclusion modifier due to system reasons

• 8P-- Performance measure reporting modifier -- action not performed, reason not otherwise specified.

Example: A patient presents with an acute myocardial infarction (AMI), but has a history of anaphylaxis from aspirin. The physician documents clinical decision making related to withholding aspirin during the MI due to the history of severe allergic reaction.

If your ED is tracking measure 28 (Aspirin at arrival for acute myocardial infarction), this is a PQRI scenario you should report. For this encounter, you would report:

• 4084F (Aspirin received within 24 hours before emergency department arrival or during emergency department stay [E/M]) with modifier 1P, along with the proper diagnosis and CPT codes based on encounter specifics.

8P caveat: You can use modifier 8P to receive credit for satisfactory reporting -- but use the 8P reporting modifier judiciously, warns Caral Edelberg, CPC, CCSP, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

"The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice's quality improvement goals," she says.