Medicare Compliance & Reimbursement

If all of your physicians are gung-ho about participating in PQRI except one holdout who is tentative about the program, you can still go ahead and participate without that practitioner. That's the word according to a June 22 CMS-sponsored PQRI conference call.

Suppose your practice employs four physicians, three of whom are happily plugging along with the Physician Quality Reporting Incentive (PQRI) program, and one who isn't interested in participating. You can still collect PQRI bonuses for the three who participate.

"Each one is separately and individually analyzed for qualification," said Michael Rapp, MD, director of CMS's quality measurement and health assessment group. "That fourth person, however, their charges will not be counted toward the bonus," Rapp said. The Physician Fee Schedule charges for the three participating physicians will count toward the bonus, and the fourth physician's charges won't, he said.

Upcoming bonuses: CMS officials addressed the fact that many practices are eager to receive their bonus payments for 2009, noting that e-prescribing incentive payments will be issued beginning in September, while PQRI payments will begin in October, Rapp said during the call.

Feedback reports: If you're looking for your PQRI feedback report, get to know the request process. "CMS has created an alternative feedback report request process for those eligible professionals requesting PQRI feedback reports based on their national provider NPI," said CMS's Jacquelyn Kosh-Suber during the call.

"It's not necessary for eligible professionals requesting feedback reports on their NPI to register on the Individual Authorized Access to CMS Computer Services (IACS) system to use the  alternative feedback report process," she added. "If you're seeking the NPI-level feedback report, you can request them from your carrier or MAC, who will verify that a 2007 rerun or a 2008 PQRI feedback report is available for the requested NPI." You'll receive the report via email within two to four weeks from the CMS system, Kosh-Suber added.

Keep in mind: If you request feedback reports related to the TIN, or the tax identification number, you'll still have to register in the IACS system and access your reports via a secure Web site through IACS.

CMS reps also dispelled confusion during the call regarding whether you must report measures groups consecutively, and fortunately, the answer was that you need not do so. One caller noted that her practice was just getting started with PQRI this year, and reported the preventive care measures group (G8486) on a claim for a patient who told the practice that he had Medicare, but the practice later discovered that the patient did not. Because this was the practice's first attempt to report a claim with G8486 and it turned out to not be applicable to the program, the caller wasn't sure whether they would need to re-start their PQRI efforts all over again, or if CMS would still count the 25 additional patients that were reported through PQRI after that first one. However, Rapp told the caller that she could just report the measures group again on subsequent claims without a problem.

"The original reason for that code was to know the first patient that you were reporting on, but when we switched to not having the requirement of consecutive patients, it basically indicates that you want to report on a particular measures group, so you can go ahead and report that code again." The 25 PQRI claims that the practice submitted after the erroneous one will still be counted by CMS toward the practice's PQRI eligibility, Rapp said.

Get to know big practice specs: If your practice has 25 residents and 12 faculty doctors seeing patients, you still only report to PQRI per-physician, CMS reps indicated after a caller asked about this issue. "We do have a group reporting option for large groups that signed up to be treated that way, and in that case, they're analyzed as a group," Rapp said. "But otherwise, all PQRI from the beginning is analyzed at the individual practitioner level, so even if you have a group of 1,000 doctors, each one has to individually qualify, and the fees for that doctor is what determines the bonus."

One caller whose practice works under a group NPI noted that she employs clinicians (such as social workers) who cannot prescribe medications, but questioned whether those practitioners would qualify for an e-prescribing bonus incentive since they do participate in PQRI. But CMS officials responded that although many eligible professionals (including some that cannot prescribe medications) are eligible for PQRI, only those practitioners that can prescribe medication are able to collect the e-prescribing incentive payment.

"If you can't prescribe, obviously, you can't indicate that you did e-prescribe," Rapp noted. "Basically, for the e-prescribing incentive program, the analysis is done at the individual NPI level, so on the claim or registry, one has to indicate to us what the individual NPI is."

Make sure G codes are on initial claims: One caller indicated that his practice submitted several claims to Medicare but inadvertently left out the e-prescribing G codes on the claims. He asked whether he could resubmit the claims with just the G codes on them to count the claims toward the bonus program, but learned that he was out of luck. If you resubmit the claim only for the  urpose of adding the G code, CMS can't "allow resubmission of claims solely for that purpose, purely because of the administrative cost" that it would require, Rapp said.

Get annual updates: CMS staffers reminded practices to check in with the PQRI measures and program materials every year, because they are updated annually.

(Editor's note: To determine whether your practitioner is considered an "eligible professional" for the PQRI program, visit the CMS Web site at: www.cms.gov/PQRI/Downloads/EligibleProfessionals.pdf.)