Medicare Compliance & Reimbursement

Learn the PQRI ropes now--or get tied in knots.

It's crunch time: If you don't start reporting quality indicators on July 1, then you can probably kiss Medicare's 1.5-percent bonus goodbye.

How it works: You don't have to register for the Physician Quality Reporting Initiative (PQRI), experts say.  Instead, you just have to start reporting special category II codes on your claims. The category II codes should be on the same claim as the visit they apply to.

For example: Let's say your practice sees a lot of patients with community-acquired bacterial pneumonia (CABP) and therefore decides to report on measures 56 through 59.  

Then, every time a patient comes in with CABP, you will examine the documentation to see whether your physician checked the patient's vital signs. If the physician did, then you will add CPT code 2015F to the claim. If the physician didn't check the vital signs, you will still report 2015F, but you'll also attach a modifier explaining why not. (For example, modifier 1-P means the doctor didn't record the patient's vitals for medical reasons.

Similarly, you will report 3028F, with or without a modifier, to note whether the doctor checked the patient's oxygen saturation results. And you'll report 2014F for whether the doctor checked the patient's mental status and 4045F for whether the doctor prescribed an "appropriate empiric antibiotic."

Bonus: If your quality reporting meets standards, you get an extra 1.5 percent of all your Medicare billings from July 1 to Dec. 31. To receive the bonus, your doctor must report on up to three measures per claim.

Also, Medicare will look at all the claims for patients with pneumonia, and see whether your doctors reported on their chosen measures for them. "If at least 80 percent of the qualifying records had these [measures] included, the providers will be eligible for the bonus," explains Robert La Fleur, an emergency medicine physician and resident of Medical Management Specialists in Grand Rapids, MI.

Cap: There's a cap that might reduce the amount of your bonus, if your doctor meets the 80 percent requirement but doesn't report measures very often.

For emergency medicine physicians, the measures that apply most are acetylsalicylic acid (ASA) for myocardial infarction, electrocardiogram (EKG) for chest pain, EKG for syncope, and the pneumonia measures, says La Fleur.

Important: Remember that it doesn't matter how many measures may apply to your patients, La Fleur points out. You just have to have three measures per claim, at least 80 percent of the time. And, for now at least, the PQRI has nothing to do with performance. You get paid whether or not your doctor actually performed the measures you're reporting on.