Medicare Compliance & Reimbursement

The Physician Quality Reporting Initiative (PQRI) has already begun for 2008. To be sure you're on the right track, you need to know what this means for you as a coder and how PQRI can affect your bottom line.

Your physicians don't need to enroll or file intent to participate in the PQRI. They can participate by reporting the appropriate quality data codes on claims submitted to your Medicare claims processing contractor.

These measures should always be reported with the appropriate ICD-9 and CPT codes.

For more information, the PQRI coding handbook is online at http://www.cms.hhs.gov/PQRI/Downloads/2008PQRICodingforQualityHandbook.pdf.

Watch for: "The PQRI code will only be counted and recognized when it is billed on the same claim with the specified CPT codes," says Joyce Matola, billing manager for the Center for Cancer and Hematologic Disease in Cherry Hill, NJ. "All PQRI Category II codes for the PQRI measures must be reported on the same claim with the CPT codes as outlined in the Coding Specifications."

You'll be able to find these codes and much more on the CMS Web site at http://www.cms.hhs.gov/PQRI/.

You only 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.

When there are four or more applicable measures, you need to meet the 80 percent threshold on at least three of the measures reported.

Important reminder: Matola notes that all PQRI claims must be reported with the provider's National Provider Identifier (NPI) number.

Know the modifiers: You have to learn to use four new modifiers to explain the specific action involved with the PQRI measure you've coded. These modifiers are:

• 1P -- Exclusion modifier due to medical reasons

• 2P -- Exclusion modifier due to patient reasons

• 3P -- Exclusion modifier due to system reasons

• 8P -- Reporting modifier -- action not performed, reason not otherwise specified

Remember: Use these modifiers with PQRI Category II codes -- not with G codes.

Financial benefit: If a physician is eligible, and if you successfully report from the designated set of quality measures, you can receive reimbursement for up to 1.5 percent of all of your Medicare billings -- the same rate you saw in 2007 -- during that period.

To receive the bonus, providers will have to report on up to three measures per claim for covered services payable under the Medicare Physician Fee Schedule.

The bonus will apply to all allowable charges, including deductibles and copayments.

Bonus calculations won't include physician laboratory or physician-administered drug charges, and there will be no beneficiary co-insurance requirement for quality measures you report.

The 2008 PQRI reporting period runs from Jan. 1 to Dec. 31, 2008. If you report 2008 measures successfully, you'll receive your 2008 incentives in mid-2009.

Tip: For more information on PQRI, visit the CMS Web site at http://www.cms.hhs.gov/pqri/.

You can also find a listing of the quality measures on the AMA Web site at http://www.ama-assn.org/ama/pub/category/17493.html. This includes descriptions of each measure, coding specifications and a data collection sheet to help you with documentation.