Medicare Compliance & Reimbursement

Here's how to navigate the new quality measures-based system.

Starting July 1, a chunk of your reimbursement will depend on a program that nobody understands yet. 

Bonus payment: Congress passed a law telling Medicare to pay you an extra 1.5 percent for all your physician claims for the second half of the year. But you get the money only if you report on quality measures.

Many details about the program remain up in the air, but the Centers for Medicare & Medicaid Services (CMS) answered some of your toughest questions about the new Physicians Quality Reporting Initiative (PQRI) at a Jan. 23 physicians Open Door Forum.

1) How do you get the extra 1.5 percent? It will be a lump sum bonus payment in early 2008, based on 1.5 percent of your total Part B physician billings from July through December.

2) Is it 1.5 percent of all Part B billings? No, just physician services--not drugs, lab costs or non-assigned claims. And it may be subject to a cap, CMS officials said.

3) What measures does the PQRI include? The 66 measures already agreed on, plus--maybe--a few others. You can see the list online at www.cms.hhs.gov/pvrp.

4) Will the bonus payment "count" for figuring out how much Medicare spent on physician services for next year's Part B cut? No, it will be separate.

5) Will it be 1.5 percent of what Medicare paid, or the total allowable? You'll receive 1.5 percent of the total amount Medicare covers, including copayments and deductibles.

6) How will you submit your quality indicators? You'll either use G codes or Category II codes, depending on which are available. CMS will soon address whether these codes need to be on the same claim as the service they relate to.

7) Do you have to submit the applicable quality measures in every single instance? No. As long as you submit quality information in 80 percent of cases, you'll receive the total bonus. And if four or more quality measures apply to one case, you only need to report at least three of them.

8) Can rural health clinics take part in the PQRI, for claims where their physicians bill Part B? It's not clear yet. CMS will explain in an FAQ later.

9) What if a patient has a chronic condition but comes in for an unrelated reason? Should you report the quality indicator that relates to that condition? Probably not, unless the doctor did something about the chronic condition. The reporting should be "specific to the service it is linked to," one CMS official said.

10) Can these measures be linked to an inpatient service? Yes, if it's a surgical service, or some other Part B service billed in the hospital.

11) Do you need to enroll or apply to join the program? No, just start submitting the quality measures on July 1.

12) What if three different doctors treat the same heart-attack patient in the emergency department? Should all three doctors submit a quality indicator for whether they administered a beta blocker? CMS will address this in an FAQ soon.

Quality Measures Could Hurt Patients, Provider Says

CMS should have some way of culling out quality measures that turn out to have nothing to do with making patients healthier, insisted one caller, Mary Peterson with Mile Bluff Clinic in Mauston, WI. Also, some doctors who treat a number of low-income patients could end up looking worse according to the quality measures because those patients might not comply with medication orders as much or get their diabetes under control.

Your quality measures won't be reported publicly, CMS officials responded, so it doesn't matter if the measures unfairly make a particular provider look bad. Also, CMS is still learning about the validity of the quality measures. The agency will evaluate all the data that comes in to decide whether some of the measures are useless.

But Peterson argued the PQRI "has the potential to be very dangerous in interfering in patient-centered care" by making providers jump through extra hoops.