Medicare Compliance & Reimbursement

Don't forget modifiers for measures that don't fit the facts.

You may just be starting to submit your claims for early July, which means it's your last chance to untangle your Physician Quality Reporting Initiative (PQRI) coding dilemmas. Here are some more answers to your PQRI questions:

Q: If a claim consists of just an evaluation and management visit plus a category II code for the PQRI, do we need to attach the 25 modifier to the E/M code?

A: No. Since these are assessment codes and don't actually describe a "procedure," you don't need to add the 25 modifier, says Kevin Arnold, business manager for emergency medicine with Norwalk Hospital.

Q: If only one measure applies to a visit, should you just report that measure, or find some other measure that also applies?

A: Just report the measures that pertain to the visit, advises Arnold. Also, if more than one provider takes care of the same patient during a visit, you can report the same measure for more than one provider per visit.

Q: Measure #30 (Timing of prophylactic antibiotic) says that the doctor must provide the antibiotic within two hours of the start of surgery. So if the doctor provides an antibiotic later on, should we simply not report this code?

A: This measure only applies when the physician gives the order for an antibiotic within the one- to two-hour window before the incision is made, says Arnold. So if the patient doesn't receive the antibiotic during that timeframe, but the physician gave the order, you should report the measure. But you should add the appropriate modifier (1P, 2P, 3P,or 8P) to explain why the staff didn't administer the antibiotic within the required timeframe.

Note: The American Society of Anesthesiologists says measure #30 is "the PQRI item applicable to anesthesiology."