pqri measure coding and reporting principles - Indiana Academy of ...

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8P modifier to receive credit for successful reporting but will not receive credit for performance. For example, a patient with diabetes may present to a clinician for reasons that do not involve glycemic control, hypertension, or cholesterol management. However, the claim for services for that encounter will contain ICD-9 and CPT codes that will draw the patient into the diabetes measures’ denominator during analysis. The 8P modifier serves to include the patient in the numerator when reporting rates are calculated for PQRI. Reporting Frequency and Performance Timeframes Each measure includes a reporting frequency requirement for each denominator-eligible patient seen during the reporting period. The reporting frequency is described in the instructions: • Report one-time only • Report once for each procedure performed • Report once for each acute episode A measure’s performance timeframe is defined in the measure’s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the clinical action described in the numerator may be accomplished. Performance timeframes may be stated as “within 12 months,” or “most recent.” This means that: 1. The clinical action in the numerator need be performed only once during a 12-month period for each patient seen during the reporting period 2. The quality code need be reported only one time for each patient by each eligible professional caring for the patient who has chosen to report that measure during the reporting period If the measure calls for a clinical test result, then the most recent test result only needs to be obtained, assessed, and reported one time per reporting period. A test does not need to have been performed within the reporting period, nor does it need to have been performed by the same eligible professional. Performance timeframes may also be tied to a specific clinical event that requires reporting each time the event occurs within the reporting period. The following are examples of measures reported each time the clinical action described by the measure numerator is taken: • Procedure-related measures require reporting each time the procedure is performed and have distinct performance timeframes tied to them. The date of service is the date that is used to report the measure. Examples are perioperative care or imaging measures. • Chronic care measures, such as those that call for prescribing a medication, require the eligible professional to verify whether the medication is current and being taken by the patient. A new prescription is not required to meet the measure requirement unless it is clinically indicated. • Acute care measures are tied to specific episodes of acute care and require reporting each time an acute event occurs. Examples are measures related to hospitalizations, fractures and osteoporosis management, or stroke measures. Claims-Based Reporting Principles The following principles apply to the reporting of quality-data codes for PQRI measure • The CPT Category II code, which supplies the numerator, must be reported on the same claim form as the payment codes, usually ICD-9 and CPT Category I codes, which supply the denominator. • Quality-data codes must be submitted with a line item charge of zero dollars ($0.00) at the time the associated covered service is performed. ! The submitted charge field cannot be blank. *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc. 5-2
! The line item charge should be $0.00. ! If a system does not allow a $0.00 line item charge, use a small amount such as $0.01 ! Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00) ! Quality data code line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. • Multiple eligible professionals’ quality-data codes can be reported on the same claim. • Multiple CPT Category II codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim. • The individual NPI of the participating eligible professional(s) must be properly used on the claim. Timeliness of Quality Data Submission Claims processed by the Carrier/MAC must reach the national Medicare claims system data warehouse (National Claims History file) by February 29, 2008 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add quality-data codes will not be included in the analysis. Successful Reporting The 2007 PQRI incentive payment is an all-or-nothing bonus (subject to cap) based on successful reporting. Eligible professionals need not enroll or file an intent to participate for the PQRI. Eligible professionals can participate by reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor. In order to satisfactorily meet the requirements of the program and receive the bonus payment, certain reporting thresholds must be met. When four or more measures are applicable to the services provided by an eligible professional, the 80% threshold must be met on at least three of the measures reported. Good news for those physicians practicing in a group practice, not all physicians in the group must participate in PQRI to be eligible for the bonus payment. Individual analysis will be done using the individual physician’s national provider identifier (NPI) to determine satisfactory reporting and the bonus payment calculation. Thus, physicians must bill with an NPI to participate in PQRI. The potential 1.5 percent incentive payment will be paid in mid-2008 as a lump-sum bonus payment made to the practice at the Taxpayer Identification Number (TIN) level. According to the CMS website, the NPI is the only unique provider enumerator that can be used by the CMS PQRI analysis contractor to properly identify eligible physicians at the individual-physician level. The performing professional’s NPI must be used for the quality-data codes and related services. For claims submitted via the ASC X12N 837 professional health care claim transaction, the group practice NPI is placed in the provider billing segment, loop 2010AA, and the performing professional’s NPI is placed in loop 2420A. For claims submitted via the CMS 1500 form, the performing professional’s NPI is placed on the individual line item. Placing the performing eligible professional’s NPI on the individual line item will allow the analysis of successful reporting and the bonus payment calculation to be performed at the individual level, though payment will be made at the TIN level. Bonus Payment Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap. The potential 1.5% bonus will be based on allowed charges for covered professional services: *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc. 5-3
Page 1: PQRI MEASURE CODING AND REPORTING P
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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