Mind your PQRI: Participating can mean a bonus for you

June 1, 2007

The Physician Quality Reporting Initiative (PQRI) is a program established at the end of last year to provide incentive funding for physicians to begin submitting data that will be used to make Medicare a smarter purchaser of health care.

Medicare is preparing to change its approach to health care payments. For years, the Centers for Medicare & Medicaid Services has considered itself a passive payer for health care services, which allowed it to essentially establish and control how much it will pay for various services. Over the years, it has placed restrictions on the number of times a service will be paid and on payment for services for treatment for particular medical problems. Medicare payment policies have rarely addressed which service is the most effective for treatment of a given disease (one notable exception being the least costly alternative policies for LHRH drugs).

The incentive for participating in the program is a 1.5% bonus for each physician meeting certain participation levels. The bonus will be calculated on the aggregate approved allowed amount for all claims submitted by each qualified provider during the data collection period. The approved allowed amount is the amount paid by Medicare and the recipient, including deductibles and co-payments for services provided to Medicare beneficiaries. The bonus is subject to a cap established by a formula we have yet to figure out and will be paid in a lump sum in 2008. To be eligible for the bonus, you must submit the required coding on at least 80% of three measures selected by the office that are applicable to your patients.

Each measure identifies circumstances that require additional reporting by ICD-9 and/or CPT codes (denominator). The required CPT category II codes or G codes that are to be reported on claims for these patients with a charge of $0.00 (or $0.01 if your system will not process $0.00 charge claims) are listed in the measure (numerator). In addition, there are four modifiers that can be appended to the category II codes or G codes describing circumstances that caused the patient to not receive the measure. Each measure description will also identify the allowed modifier for the measure.

All of this may sound a bit foreign, so we will break down measure 23, reporting on venous thromboembolism (VTE) prophylaxis.

First, see the list of CPT codes in the box ("Example CPT codes") below for all patients receiving a service from this list.