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For additional questions, please search the CMS Find Answers Page.
What is PQRI?
PQRI is the “Physicians Quality Reporting Initiative,” formerly known as the “Physician Voluntary Reporting Program” (PVRP). In December, President Bush signed the Tax Relief and Health Care Act of 2006, mandating establishment of a physician quality reporting system and authorizing a payment incentive for voluntary participation.
Is participation in PQRI mandatory as a condition of payment under Medicare?
No, participation in PQRI is strictly voluntary.
What is the incentive for physicians to participate in PQRI?
Physicians who report quality measures for care delivered to Medicare beneficiaries during the period of July 1 – December 31, 2007, may receive an additional 1.5 percent incentive payment.
How do I register to participate in the program?
Registration is not necessary. However, those who decide to participate in the program must begin reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor on July 1, 2007. Analysis is expected to be performed at the individual physician level; therefore, accurate and consistent use of individual National Provider Identifier (NPI) on claims is required.
Who is eligible to participate in the program?
All Medicare-enrolled eligible professionals may participate, regardless of whether they have signed a Medicare participation agreement to accept assignment on all claims. Eligible professionals include physicians and other practitioners described in Social Security Act (SSA) Section 1861(r) and Section 1842(b)(18)(C) who provide professional services that get paid under the Medicare Physician Fee Schedule. Services which are paid under the MFS are eligible for the incentive payment.
What measures are available for hematologists to report in 2008?
Four measures developed by ASH’s Pay-for-Performance Task Force are included in the 74 measures for 2007. ASH is asking hematologists to report on these Physician Consortium for Performance Improvement (PCPI), NQF-endorsed measures, which include at this time:
In addition, two health information technology measures are available that hematologists may find useful:
The specifications for all 119 measures are posted.
How will physicians report measures?
Reporting is claims-based. CPT Category II codes (or temporary G-codes where CPT Category II codes are not yet available) will be used for reporting quality data. Quality codes, which supply the measure numerator, must be reported on the same claim as the payment codes, which supply the measure denominator. Physicians must continue to report appropriate CPT procedure or E&M codes and ICD-9_CM diagnostic codes for patient encounters for which quality measures are relevant. In addition, practices should consider adding the appropriate CPT Category II codes to their superbills.
What are the reporting requirements?
To be eligible for the incentive payment, an eligible professional must report on at least three quality measures. Of those three measures, reporting must occur on at least 80 percent of the cases for which that measure is reportable. If it is determined that reporting occurred less than 80 percent of the time for any one of the measures, the professional would be ineligible for the incentive payment.
What happens if there are not three measures that reflect the types of services that I provide in my practice?
Those professionals who identify only one or two applicable measures will be asked to report on those measures at least 80 percent of the time. However, those professionals will be audited to determine whether additional measures COULD HAVE been reported based on a sample of the provider’s patient population. CMS will then determine whether the one or two measures reported by the professional were in fact the only measures appropriate to be reported. If it is determined that there will be additional appropriate measures, the professional would be deemed ineligible for the incentive payment.
How will the incentive payments be calculated and paid?
Participating eligible professionals who successfully report may earn a 1.5 percent bonus, subject to a cap. The 1.5 percent bonus calculation is based on total allowed charges during the reporting period for professional services billed under the Physician Fee Schedule. Claims must reach the National Claims History (NCH) file by February 29, 2008.
The cap may apply when relatively few instances of quality measures are reported. The cap calculation is based on the following calculation:
Individual’s instances of reporting quality x (multiplied by) 300% x
National average per measure payment amount
What is the “average per measure payment” as outlined in the formula to determine the cap?
The “average per measure payment” has not yet been estimated by CMS and is not likely to be estimated prior to implementation of the program. The “average per measure payment” will be calculated using the following formula:
National charges associated with quality measures / (divided by) National instances of reporting
Can I calculate whether my incentive payment would be subject to the cap?
Because the “average per measure payment” is not likely to be estimated prior to the implementation of the program, it will be difficult for physicians to determine in advance whether their incentive payment will be subject to the cap. The best estimate is to determine 1.5 percent of one’s total allowed charged for the time period of July through December 2006.
When will I receive the incentive payment?
Incentive payments for 2007 will be paid in a lump sum likely sometime in mid-2008 for data reported in 2007. At this time, the payment structure for 2008 has not been determined.
How will the incentive payment be received?
CMS will use the taxpayer identification number (TIN) as the billing unit, so any bonus incentive payments earned will be paid to the holder of the TIN. Both the NPI and the TIN must be furnished on the claim.
Once the measures are reported, how will the data collected be used by CMS?
Confidential feedback reports will be available at or near the time of the bonus payments in 2008. Reports are expected to summarize reporting and performance areas.
What are some of the factors that I should consider before determining whether to participate in 2007?
Some of the issues you might want to consider include the proportion of your patients for whom the ASH-developed measures are applicable, necessary changes in coding and billing processes, potential changes in billing software, and physician training. On the benefit side of the equation, you will want to think about not only the relatively small bonus payment but also the opportunity for your practice to gain experience with the performance measure reporting and the chance to help shape the direction of future quality reporting.
What should I do right now?
- Get your NPI.
- Bookmark ASH’s PQRI resources page.
- Bookmark CMS’s PQRI page.
- Check it often.
- Understand the measures.
- Educate staff.
How can I submit the no-charge PQRI Healthcare Common Procedure Coding System (HCPCS) codes when my carrier says that CMS does not allow them to accept claims with a total charge of $0?
Your carrier is correct that the CMS claims processing systems cannot accept an entire claim with a total charge of $0. The CMS claims processing system requires at least one non-zero-charge line item. The PQRI quality-data code must always be a line item within the same claim as the patient diagnosis and service or procedure to which the quality-data code applies. Claims submitted with only PQRI quality-data codes will not be counted in the analysis of reporting or performance rates.
Do I need to change my practice management system to participate in PQRI?
If your practice management software does not allow entry or submission of zero-dollar line items, you need to change this edit for your Medicare claims for covered professional services on which you submit quality-data codes. You or your staff may be able to accomplish the edit in-house, or you may need to work with your billing service or your software vendor. A nominal non-zero charge value associated with the PQRI code can be submitted until your software vendor resolves the billing software edit. In either case (a charge of $0.00 or an amount greater than $0.00 is billed), the PQRI code is denied, tracked, and included in the PQRI analysis.
What happens if only one eligible professional in a group practice submits data for PQRI?
CMS must use the Taxpayer Identification Number (TIN) as the billing unit for the 2007 PQRI, so any bonuses earned will be paid to the TIN holder of record. Though the analysis of satisfactory reporting will be performed at the individual eligible professional level using individual-level NPI data, bonuses will paid to the holder of the TIN, aggregating individual bonuses for groups that bill under one TIN.
I have assigned my Medicare Part B Physician billing to another entity. Can I report and be eligible for the bonus under PQRI?
If a professional or group has assigned Medicare Physician Fee Schedule billing to an employer or facility, such as a hospital, the eligible professional may participate. The entity can submit the PQRI clinical measure CPT Category II codes or G-codes on Part B professional services claims and pursue the bonus. In situations where eligible professionals who are employees or contractors have assigned their payments to their employers or facilities, any bonus payment earned will be paid to the employers or facilities.
CMS has stated that to participate in PQRI, I need an individual National Provider Identifier (NPI). What if I don’t have one, can’t get one, or my Medicare carrier won’t accept it?
If your claim does not include your individual NPI at the line item level, it will not be included in the analysis of satisfactory reporting for PQRI and the bonus payment calculation will not include it. Getting an NPI is easy and free. Over 2 million providers have already applied for and received them. Go to www.cms.hhs.gov/NationalProvIdentStand to learn about NPI, and go to https://nppes.cms.hhs.gov/NPPES to apply for an NPI. Medicare carriers do accept NPIs on claims right now and have done so since January of 2006.
Does ASH support the PQRI program?
While not perfect, ASH supports PQRI as a starting point for testing the feasibility of a claims-based quality self-reporting alternative. ASH will continue to work closely with CMS and Congress this year to improve the program.
Who can I contact for help at ASH?
Carol Schwartz, Senior Manager, Policy and Practice
202-776-0544 or cschwartz@hematology.org
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