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Medicare Compliance & Reimbursement

PQRI:

Look For Instances Of Your Doctors Providing Care Outside Their Specialties

Published on Mon Apr 16, 2007

You won't know if you're meeting PQRI requirements, but you can prepare.

It's confusing and over-complicated, but your practice's financial health may depend on it. The Physician Quality Reporting Initiative (PQRI) starts in just over a month, and you'll need to know how to bill enough category II quality codes to receive the 1.5-percent bonus from Medicare.

Here are some more PQRI tips that Centers for Medicare & Medicaid Services (CMS) officials spilled during a recent physician open door forum and a PQRI conference call in April:

· When you're figuring out which claims to match up with the quality reporting codes, you should look at both primary and secondary ICD-9 diagnosis codes, CMS officials said.

· You'll have no way of knowing if you're reporting quality measures at least 80 percent of the time during the program. You'll just have to put your systems in place and try to identify the patients who qualify for some quality measures before July 1, and then hope for the best.

· If you have a new physician fresh out of residency, and he starts this fall, chances are he may not have a national provider identifier (NPI) in time to participate in the program for 2007, CMS officials admitted.

· You will report quality measures related to laboratory tests when your doctor reviews the test results with the patient, not when the doctor orders them.

· For measures that you're supposed to report once per year, you will suffer no penalty for reporting them more than once by mistake.

· If you pick three quality measures that you report on only infrequently, then you risk coming under the "cap" on bonus payments. That would mean you wouldn't receive the full 1.5 percent bonus payment. So you should choose measures that will effect your practice's quality improvement greatly. "You really want to pick something that will have an impact on a lot of people you provide services for," one CMS official said.

· CMS hasn't figured out yet what to do with Medicare secondary payor claims. If you submit a claim to a commercial carrier and include a quality-reporting code for when it crosses over to Medicare, the commercial carrier may hold up the claim, providers worried.

· If another physician provided a service that satisfies one of the quality measurements, then your practice can use the 8P (unspecified) modifier to indicate that you're not taking credit for that service.

· You should report on only quality measures that fit with your specialty and your patients. But if your doctors provide care outside of their specialty, such as managing a patient's other problems, then you can report other quality measures.

· Your patients will see a "denial" on their explanation of benefits (EOB) forms for the quality codes that have zero reimbursement. But the denial will make it clear those codes are just for quality reporting, not for denied services, CMS officials said.

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