Physician Quality Reporting System: There’s still time to avoid penalties in 2015


All eligible providers who do not participate in PQRS in 2013 will be subjected to a 1.5% penalty in 2015 and 2% penalty in 2016 and beyond. As you may be aware, there are many ways to participate in PQRS to avoid the 2015 penalty.

I am in solo practice, and I have not been collecting Physician Quality Reporting System (PQRS) data. Is there any way I can prevent the penalties that will start in 2015?

This is a very timely question. All eligible providers who do not participate in PQRS in 2013 will be subjected to a 1.5% penalty in 2015 and 2% penalty in 2016 and beyond. As you may be aware, there are many ways to participate in PQRS to avoid the 2015 penalty. Unfortunately, at this late date you have eliminated most options.

Based on your question, we will assume that you have not reported PQRS codes (eliminating the claims-based reporting options) and that you are not using a qualified EHR program.

This leaves you with two main options:

  • Meet the requirements for satisfactory reporting for incentive eligibility as defined in the 2013 PQRS measure specifications or report at least one valid measure for PQRS using a registry before the end of February 2014. (This requires that you obtain the services of a data registry and that you have been providing PQRS-compliant care.)

  • Elect to participate in the Centers for Medicare & Medicaid Services-calculated administrative claims-based reporting mechanism.

Although this program is not entirely new, it is newly opened to PQRS for most providers. Details are a bit sketchy, but it appears that all you have to do on your part is elect to participate in the CMS-calculated administrative claims-based reporting mechanism. You have to choose this option by Oct. 15 by signing up. This is a two-step process. Step one is to register for a CMS (Individuals Authorized Access to the CMS Computer Services) account at Step two is to register for the program online at

This option is available to all group practices as well as individual practitioners. Even if you have signed up for the PQRS program but think that you might not have successfully met the requirements, you can choose to switch to this program, which will not provide you the bonus this year or next, but will prevent the penalty in 2015. We have turned the program upside down and sideways looking for the major drawbacks to participation. We have yet to find one as long as the participation at this point is for PQRS.

Could you please clarify your answer regarding using modifier 59 when billing out for procedures performed on two separate lesions? Does this mean two only? If the physician removes four stones from the kidney and they are all in different compartments, could I bill out for four stone removals and get payment for all four?

The short answer is yes. If there are four totally separate “lesions” or stones, then you should be able to bill for each one separately using the –59 modifier. In essence, the concept of a separate “lesion” is not limited to a single additional lesion. If the Medicare contractor follows Medicare rules as currently published, they should pay for all four. Remember, when billing endoscopy procedures, all procedures are paid based on the “family of codes” payment reduction. Procedures two, three, and four will not be paid at 50%; they will be paid at a reduced rate.

For instance, a ureteroscopy with lithotripsy will be paid only about $90 more for each additional procedure. However, we caution you that payers are very likely to review documentation for these cases. Make certain that your documentation clearly supports the preoperative diagnosis and the separate efforts that were required to remove the additional stones.

However, “the rest of the story” would include the caveat that this may or may not work. We have seen creative interpretation on the part of Medicare, and other payers, to avoid paying us for work performed.

As we continue to explore this issue with Medicare directly in partnership with the AUA, we are in need of some redacted operative notes supporting the work effort in the treatment of multiple stones. If you have documentation for a case demonstrating treatment of multiple stones during the same session, please send it to Mark Painter at


National Correct Coding Initiative (CCI) edits appear to bundle 51720 when coded with 52234-52240 (transurethral resection of a bladder tumor). Our physicians frequently instill mitomycin after the resection for our day surgery patients. The American Hospital Association coding clinic for Healthcare Common Procedure Coding System indicates this is appropriate. But this doesn’t seem to meet the Medicare definition of separate site, lesion, injury, or encounter. Is modifier 59 appropriate?

You have noted correctly the bundling issues as they exist in the CCI. We feel that the use of the –59 is appropriate for these cases. The instillation of the mitomycin or another anticarcinogenic drug following a TURBT is provided to patients as ongoing treatment of the disease and not a part of the excision of the tumor per se, and you should be paid separately from that procedure.

We have also noted that many physicians wait to instill the anticarcinogenic drug until they are in the recovery room. If that’s the case, the different “encounter” definition has been met.

In either case, this is another instance where the CCI has pursued a payment policy that is inconsistent with treatment and/or proper coding in the interest of saving Medicare a few cents. Expect more of these bundling pairs to appear in the CCI. We would encourage each of you to write to the AUA or directly to CCI with clear reasoning as to why in fact code pairings like this should not be included in CCI.

With the number of issues faced by urology today with health care reform, implementation of ICD-10, code bundling, and value changes, the AUA has its hands full, and all urologists will need to get involved in changing the rules to help protect patient treatment. Get in the game; if you do not protest, you will be restricted.UT

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