Medicare Compliance & Reimbursement

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, MI. 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.