Internal Medicine Coding Alert

Published on Thu Apr 24, 2008 PDF

Surprise: 'No action' still counts toward PQRI total

To successfully participate in the Physician Quality Reporting Initiative (PQRI), you must include Category II codes to represent the quality measure that the physician performed. But what should you do if the physician does not perform the specified quality measure on a patient whose encounter qualifies for PQRI?

You should still report the visit as you would any other PQRI encounter -- just remember to include the appropriate modifier to explain why the physician did not perform the measure, says Sandra Pinckney, CPC, coder at CEMS in Grand Rapids, Mich. Medicare will count these encounters toward your practice's PQRI total, Pinckney says.

To explain the specific action involved with the PQRI measure, you have to learn to use four new modifiers:

• 1P -- Exclusion modifier due to medical reasons. Examples include not indicated (absence of organ/limb, already received/performed) and contraindicated (patient allergic history, potential adverse drug interaction).

• 2P -- Exclusion modifier due to patient reasons. Examples include patient declined for economic, social or religious reasons.

• 3P -- Exclusion modifier due to system reasons. Examples include resources to perform the services not available, insurance or coverage/payer-related limitations and other reasons attributable to healthcare delivery system.

• 8P -- Reporting modifier -- action not performed, reason not otherwise specified. You should reserve modifier 8P for when the physician does not perform an action described in a measure and does not specify the reason. Modifier 8P indicates that the patient is eligible for the measure but the record contains no indication that the physician performed the action described in the measure, nor did he document a reason attributable to the exclusion modifiers.

Example: You are reporting on "Measure 7: Beta-Blocker Therapy for Coronary Artery Disease Patients With Prior Myocardial Infarction (MI)," which reflects the percentage of patients 18 and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy.

The physician provides a level-four E/M for an established patient who had AMI of the anterolateral wall and has postmyocardial infarction syndrome. However, due to patient allergies, the internist does not administer beta-blocker therapy.

This scenario fits PQRI Measure 7, even if the physician did not perform beta-blocker therapy. To qualify this encounter for PQRI, report the following:

• 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M

• 410.00 (Acute myocardial infarction of anterolateral wall; episode of care unspecified) linked to 99214 to represent the MI

• 411.0 (Postmyocardial infarction syndrome) linked to 99214 to represent the underlying condition

• 4006F (Beta blocker therapy, prescribed) to represent the PQRI measure

• modifier 1P linked to 4006F to show that the physician did not meet the quality measure due to a medical reason.