Gastroenterology Coding Alert

Experts warn that learning modifiers might be the trickiest part

If your gastroenterology practice wants to participate in the Physician Quality Reporting Initiative (PQRI), then you'll need to know what category II codes to report--and when.

See how other practices are preparing, and what you should do to make certain you receive that extra Medicare reimbursement. How It Works PQRI is a voluntary program that will provide a financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the Medicare Physician Fee Schedule between July 1 and December 31, 2007.

Common misconception: You don't have to register for the 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 they apply to.
 
For example: Your practice sees a lot of patients with gastroesophageal reflux disease (GERD) and therefore decides to report on measures 60-63.

Then, every time a patient comes in with GERD, you will examine the documentation to see whether your
physician checked the patient for alarm symptoms (such as involuntary weight loss, dysphagia and GI bleeding). That's measure number 60.

If the physician did, you will add CPT code 1070F (Alarm symptoms [involuntary weight loss, dysphagia, or gastrointestinal bleeding] assessed; none present) or 1071F (... one or more present) to the claim.

If the physician didn't check the alarm symptoms, you will still report 1070F or 1071F, but you'll also attach a modifier (1P, Documentation of medical reason[s] for not documenting presence or absence of alarm symptoms) to the F code.

Result: 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.

Recipe for success: Remember that how many measures may apply to your patients doesn't matter, says Robert La Fleur, an emergency medicine physician and president of Medical Management Specialists in Grand Rapids, Mich. What's important: You just have to report on three measures per claim at least 80 percent of the time when that measure applies to any patient seen by the physician. And, for now at least, the PQRI has nothing to do with performance. You get paid regardless of whether your doctor actually performed the measures you're reporting on.

Keep in mind: 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. The cap is designed to reduce the bonus for providers who meet the requirements but still don't report on quality measures often enough. That [...]