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CMS offers step-by-step guide to Physicians Quality Reporting Initiative (PQRI)

May 11, 2009

CMS 2009 Incentive Programs: Physician Quality Improvement Initiative (PQRI) & E-Prescribing: Implementation Advice for the Office Manager
by Michael T. Rapp, MD, JD, FACEP, Centers for Medicare & Medicaid Services.

The Physician Quality Reporting Initiative(PQRI) is a voluntary individual reporting program that provides an incentive payment to identified eligible professionals (EPs) who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B beneficiaries (including Railroad Retirement Board and Medicare secondary payer claims).  For 2009, the incentive is 2% of the eligible professional’s estimated total Medicare Part B Physician Fee Schedule (PFS) allowed charges.  

PQRI is now in its third program year. The program has expanded the number of measures and number of reporting options over time to facilitate quality reporting by a broad array of eligible professionals.

We at CMS are also working on the first year of the E-Prescribing Incentive Program. This program works similarly to PQRI: eligible professionals indicate on their claims, through special G-codes whether they take advantage of the benefits of a qualified e-prescribing system.

It is not too late to participate in the 2009 PQRI and E-Prescribing Incentive Programs.  There is still time to qualify for both the 2009 PQRI and e-prescribing incentives. This article is intended to help you navigate the information on the CMS PQRI and E-Prescribing Incentive Program websites so that you can get started.

2009 PQRI
For 2009 PQRI you can report the quality measures through claims or through a qualified registry. In addition, you can report on individual quality measures or on measures groups.

You can read about the multiple options, their reporting periods, and the criteria for satisfactorily reporting under these options in the “CMS Fact Sheet: What’s New for 2009 PQRI?” available online.

How to Get Started
If you are new to PQRI, the fact is that participation in the PQRI is pretty straightforward.

The first step is to understand the PQRI measures and how to report them.  This may require you to establish an implementation team to ensure that your practice’s billing software and/or clearinghouse can capture the PQRI quality data codes for the selected measures. 

How to get started? Review the 2009 PQRI Implementation Guide. This Guide tells you how to prepare to report individual measures through claims, it includes the reporting principles you need to know, provides a sample claim illustrating how to report several measures. You can find the Guide here.

The second step is to print the list of quality measures, which you can find here. Go over the list with your doctor and pick three or more measures that seem appropriate for your practice. There are several measures available that are broadly applicable to many practices. Many measures require only one time reporting per patient per eligible professional per reporting period and you can find these “one-time-only” measures (also referred to as Patient-Level Measures) here.

Once you’ve selected the measures, print the detailed coding specifications for those three measures, which you can find here. Don’t print the entire 2009 PQRI specifications manual, just the few pages that have to do with your three measures.
As you read through the specifications and reporting instructions, you’ll notice that each of the measures has a quality data code (CPT II code or G-code) associated with it, and several CPT II modifiers: generally 1P, 2P and 3P. To qualify for the incentive, the correct quality data code will need to be reported on at least 80 percent of the claims that are eligible for each selected measure. A claim is “eligible” when the ICD-9-CM diagnosis and the CPT1 service codes match the diagnosis and CPT1 codes listed for the measure denominator. 

An alternative to reporting three individual measures is to report a measures group. There are 7 measures groups available for 2009.  The CMS website has 3 documents that will provide you with the necessary information about reporting a measures group:

An alternative to reporting quality data codes through claims is to report the data through a qualified registry.  Both individual measures and measures groups may be reported through a qualified registry.  A list of qualified registries is available from the Reporting section of the PQRI website.

Select the reporting option that best suits the practice.

Ensure your billing software/clearinghouse can report the measures on the claim to the carrier/AB MAC.  Also ensure that you and your physician communicate clearly so that you can report the measures accurately on eligible claims.  Some practices have added the quality data codes to their super bill with a descriptor so that their clinicians will know what the code represents.  Others have used a data collection worksheet or created their own worksheet.  Data collection worksheets are available from the American Medical Association here.

After you have submitted your claim to the carrier/AB MAC with the diagnosis, CPT 1 service codes related to the encounter and corresponding quality data code(s) on it, you will receive a Remittance Advice (RA) from your carrier/AB MAC.  Line items containing a quality data code are submitted with a zero dollar amount and will be denied for payment, but are then passed through the claims processing system for PQRI analysis. The RA associated with the claim containing the quality data code line-item will include a standard remark code (N365) and a message that confirms that the QDCs passed into the National Claims History (NCH) file. N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.” The N365 remark code does not indicate whether the QDC is accurate for that claim or for the measure the EP is attempting to report.

Contact your carrier/AB MAC or questions you may have or you can contact CMS at Also I would encourage you or a member of your office staff to participate in the monthly PQRI National Provider Calls.  You can get the information you need about this and other PQRI-related calls sponsored by CMS.

2009 E-Prescribing Incentive Program
The new 2009 E-Prescribing Incentive Program is a voluntary claims-based reporting program that allows individual eligible professionals to qualify to earn an incentive of 2% of the professional’s estimated total Medicare Part B PFS allowed charges, if the professional is a successful e-prescriber.  To be considered a successful e-prescriber for 2009, you must report an e-prescribing measure on at least 50% of Medicare Part B claims for services furnished during the 2009 reporting period.

Also, to qualify to earn the incentive, at least 10% of your total Medicare Part B PFS allowed charges for the 2009 reporting period must be for services listed in the e-prescribing measure’s denominator. 
The steps to participating in the E-Prescribing Incentive Program are similar to the steps for reporting individual PQRI measures through claims.  You can read all about this incentive, how the measure is specified, and how to report the G-codes, including a sample CMS-1500 claim, on the CMS e-Prescribing Incentive website