Friday, 7 September 2012

Physician Quality Reporting System - PQRS

Let me just summarized the information which i understood clearly about PQRS . The following information are taken from different websites and some of them of my own question and answer Eye rolling smile. And also I just want to have a reference about this, so that when I get chance to implement this, I can always come and refer here. At the end, I just summarized my thought on how we can implement in the EMR PMS Application.

  1. What is the Physician Quality Reporting System?
    The Physician Quality Reporting System, formerly known as PQRI, is a program developed by the Centers for Medicare and Medicaid Services (CMS) to provide a financial incentive bonus to physicians who volunteer to report on best practice quality measures for the Medicare patients they treat.

    Prior to 2015 PQRS was simply an incentive program (known as PQRI).  But in 2015 it will become a penalty program.  Physicians who do not report performance measures using PQRS will be faced with a 1.5% penalty in 2015 and a 2% penalty in 2016.  Even though the penalty program doesn’t start until 2015 the penalty is based on reporting done in 2014 so in order to avoid the penalty providers must be reporting performance measures now.

    The PQRS program is for Fee-For-Service Medicare patients.  It does not include patients who are enrolled in Medicare Advantage Plans, or Part C Medicare.
  2. Do Physician has to sign up or Register with CMS for PQRS ?
    Individual eligible professionals do not need to sign-up or pre-register in order to participate in the Physician Quality Reporting.

  3. Who are eligible to participate in this?
    You can check CMS Link here

  4. Does physician can get incentive for both PQRS and ERX ?
    Yes. This incentive program is separate from and in addition to any incentive payment that physicians may earn through the Physician Quality Reporting System (PQRS)

  5. Sometimes, multiple different providers in a practice will treat a single patient. Who should report that patient?
    A physician will report a patient only if that patient is billed under his or her individual NPI. If the physician’s individual NPI is not on the Medicare claim, then the patient should not be entered into the registry for that physician.

  6. I understand that this program only applies to Medicare patients, but what if Medicare is a secondary or tertiary payer for this patient’s care?
    Patients who have Medicare as a secondary or tertiary payer should be included in your submission.

  7. What are the PQRS reporting periods for 2012?
    There are two reporting periods available for eligible professionals: a) 12-month reporting period from January 1 through December 31 OR b) a 6-month reporting period from July 1 through December 31. The 6-month reporting period only applies to registry submission of measures groups, which don't typically apply to the ED.  ED providers usually submit individual measures and the reporting period is 12 months for both claims and registry

  8. What are the reporting options for 2012?
    a.
    Claims Reporting Method:
    This requires providers to add specially created CPT II and/or G Codes to their claims at the time of billing.

    b. Registry Reporting Method:
    This requires providers to select a registry which has been approved by CMS as a qualified registry, such as Outcome, for data collection. This method is expected to become the preferred method for many providers since they can review the data and add key clinical information regarding the patient at any time. The data is only submitted once at the end of the reporting period. Additionally, providers DO NOT need to report CPT II or G Codes for registry reporting since the registry performs the measure calculations and performance data is submitted separately from the billing process.

    c. Group Reporting Method (GPRO):
    This requires a practice to apply and be selected by CMS directly for participation. For 2012, all applications were due on January 31st, 2012.

    d. EHR Reporting Method:
    This requires your EHR to be certified by CMS to accept PQRS data. You will want to contact your EHR to see if they are CMS certified.
  9. Please give me an example of how to report one of the PQRS measures.

Suppose you treat a patient with AMI(Acute Myocardial Infarction) in the ED. If you order aspirin for the patient – and you document it on the medical record – your biller should give you credit for Quality Measure #28 (Aspirin at Arrival for Acute Myocardial Infarction). But if for some reason you don’t order aspirin, e.g., because of an aspirin allergy or patient refusal, and you likewise document it, you would also get credit for reporting on Quality Measure #28. And if you do this for 50% of the AMI patients you treat and duplicate this 50% performance level for at least two other quality measures, you become eligible for a bonus payment under PQRS.

Scenario 1: Aspirin received or taken within 24 hours before emergency department arrival or during emergency department stay

PQRS assigned code: 4084F

OR

Scenario 2: Aspirin not Received or Taken 24 hours Before Emergency Department Arrival or during Emergency Department Stay

PQRS assigned code: 4084F, with one of the following modifiers:

  • 1P: Documentation of medical reason(s) for not receiving or taking aspirin within 24 hours before emergency department arrival or during emergency department stay
  • 2P: Documentation of patient reason(s) for not receiving of taking aspirin within 24 hours before emergency department arrival or during emergency department stay
  • 8P: Aspirin was not received within 24 hours before emergency department arrival or during the emergency department stay, reason not otherwise specified.

[Of note, the 3P modifier is not eligible to append to the aspirin for AMI measure. 3P is available for other measures to describe system reasons that justify why a measure may not have been satisfied.]

Psychologist Dr Jones sees a patient for the first time and diagnoses the patient as having Major Depressive Disorder.  He performs an assessment of the severity of the Major Depressive Disorder during the initial visit.  The claim for the initial visit could be coded as follows:
1.    09/04/2014        90791        $225.00
2.    09/04/2014        G8930        $    0.00

LCSW Mary Smith sees a patient that she has been seeing fairly regularly for the past 12 months.  The patient missed the past couple of scheduled appointments and Mary sees some changes in the patient so she decides to screen the patient for clinical depression.  After completing the screening she determines that the patient is not clinically depressed.  The patient was seen for a 45 minute session and may be coded as follows:
1.    09/04/2014        90834        $125.00
2.    09/04/2014        G8510        $    0.00

The most common reporting method is claims based reporting. Claims based reporting is done by adding a G-Code or a CPT II code to the claim. Once the appropriate code is selected it is billed on the same claim as the services. The code must be entered with either a $0.00 or a $0.01 charge. (Nothing is paid on the code. Some systems will not allow it to be entered with a $0.00 charge so a $0.01 charge must be used. It will depend upon the system being used to create the claim.)


  1. What is the methodology for PQRS scoring?

    CMS has defined a numerator and a denominator that permit the calculation of the percentage of patient visits that achieve appropriate reporting of quality measures.

    There are 4 elements that must be extracted from the record to determine if the encounter qualifies for a PQRS measure: insurance status, patient age, ICD-9 code(s) and CPT code(s). The following is the step-by-step process that your biller would use to document Quality Measure #28 on the CMS 1500 billing form. First, the biller would determine the insurance status and age of the patient. Then check for documentation on the medical record that supports one of the ICD-9 Acute MI diagnostic codes for the measure for example:

    ICD 9 Description
    410.01 AMI Anterolateral
    410.11 AMI Other Anterior
    410.21 AMI Inferolateral
    410.31 AMI Inferoposterior
    410.41 AMI Other Inferior
    410.51 AMI Other Lateral
    410.61 AMI True Posterior
    410.71 AMI Subendocardial
    410.81 AMI Other Sites
    410.91 AMI Unspecified Site

    Then, the biller would check for documentation that supports the correct CPT service code (99281-99285 or 99291). Assuming the above criteria were met, the biller would then report on your PQRS quality measure based on your documentation. Conversely, if the patient’s diagnosis was chest pain or acute coronary syndrome, the encounter would not meet the measure specifications for measure #28 and the PQRS code would not apply.

    A threshold of 50%, i.e. reporting the appropriate quality measure codes for 50% of qualifying cases that are eligible for the quality measure, is required for each of three measures to be able to receive the 0.5% PQRS bonus for 2012.

  2. What happen if i am not participating in the PQRS.
    As per Patient Protection and affordable care act, from 2015, 1.5 % will be penalty.

  3. What is the extent of the bonus for participation in PQRS?
    Incentive payments are available until 2014.  Beginning in 2015, physicians who do not satisfactorily report PQRS measures will be subject to negative payment adjustments.  Incentive payments and negative payment adjustments are based upon the physician's total allowable Medicare charges for a given year.  Physicians who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2012- December 31, 2012, will earn an incentive payment of 0.5% of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished during that applicable reporting period.  This includes all deductibles and co-pays. Additionally, where Medicare is the secondary insurance, PQRS bonuses are based on overall charges, and not limited just to the portion paid by Medicare.

  4. When can I expect to receive my incentive payment?
    CMS states that checks will be issued in the fall of 2013.

  5. How much will my incentive payment be?
    If participants successfully meet the criteria of the Physician Quality Reporting System program and accurately report all applicable measures, they will receive a bonus of 0.5% of total allowed Medicare Part B charges to CMS for the calendar year.


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