The Centers for Medicare and Medicaid Services (CMS) launched its Physician Quality Reporting Initiative (PQRI) July 1. This program, voluntary in 2007, rewards physicians for reporting a designated set of quality measures. Physicians who successfully report these measures under established criteria earn a bonus payment, subject to a cap, of 1.5% of their total allowed charges for covered services paid under the Medicare physician fee schedule.
Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.
To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.
How do I report an intervention?
Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:
- Select the quality measures that apply most often to your practice (see the TABLE)
- Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
- There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
- Apply any applicable allowed modifier that explains why the quality measure was not assessed:
- Measure title
- Description
- Instructions on reporting, including frequency, time frames, and applicability
- Numerator coding
- Definition of terms
- Coding instructions
The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.
TABLE
The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007
| MEASURE | CONSTRAINTS AND COMMENTS | ||
|---|---|---|---|
| #20 Perioperative care: Timing of antibiotic prophylaxis—ordering physician |
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| #21 Perioperative care: Selection of prophylactic antibiotic—first- or second-generation cephalosporin |
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| #22 Perioperative care: Discontinuation of prophylactic antibiotic (non-cardiac procedures) |
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| #23 Perioperative care: venous thromboembolism prophylaxis (when indicated in all patients) |
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| #39 Screening or therapy for osteoporosis for women 65 years and older |
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| #41 Osteoporosis: Pharmacotherapy |
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| #42 Osteoporosis: Counseling for vitamin D and calcium intake, and exercise |
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| #48 Assessment of presence or absence of urinary incontinence in women aged 65 years and older |
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| #49 Characterization of urinary incontinence in women aged 65 years and older |
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| #50 Plan of care for urinary incontinence in women aged 65 years and older |
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