Physician Quality Reporting System: Tips That Boost Your Practice’s Revenue


Medicare’s incentive-driven physician quality reporting system is aimed at tracking quality metric or patient care services that physicians provide. When the practice treats enough patients in the same category, some PQRS dollars might be only a few codes away.

Who are the EPs? EPs refers to the eligible professionals by CMS. And there is a list that it's available on a website where you can see which providers are eligible. Bottom line, we're looking at physicians, practitioners and therapists. So, you know, if you're a doctor of Medicine, doctor of  Osteopathy, Podiatric Medicine, Optometry, et cetera, you can go to the website CMS and may have a list of all those providers that are eligible to participate in this program. Pretty much, if you are submitting a Part B claim, you're eligible.

Is there a registration necessary? Bottom line, you have to be enrolled in Medicare. There's no participation agreement necessary. The only thing you are required to do is to submit an NPI number basically on your claim form so that they can identify the provider because that's how they measured as it’s on the individual provider level. And then they group together those individual providers and they pay a bonus to the tax ID number, the group tax ID number. So, that's how that operates.

For this year, there are now a total of 175 - actually 179. There are175 individual measures and then there are four back pain measures that cannot be reported individually. It must be reported and they measure it as a group.

Each of these PQRI (now PQRS) measures, they all contain a measure specification document. This is a very important document and it has the critical information that you need to be aware of. For each of these measures, you have this document that has the title of the measure, the description, all of the instructions on how to report -- frequency, time frames, when they're applicable.

You have some key concepts -- numerator, denominator codes.The calculation method that they used in this program is basically, it's a percentage of a defined patient population that received a particular process of care. And what they're doing is they're looking at your claims. And when you submit a CPT code and a diagnostic code, that is denominator criteria. Also place of service and age are our other denominator criteria. And what they do is they indicate when there's an eligible case for a quality data measure to be reported.

Basically, when you submit your claim, you've got your CPT code and your ICD-9 code. And that indicates, “Hey, we need a quality data measure reported here.”

The numerator is the actual clinical action that was taken by the provider. And those are submitted as subsequent line items on the claim form where you are submitting a Category II code, one of these tracking codes. And in some cases, there may be a temporary G-code if there is no Category II code available. And those are then submitted as subsequent line items on the claim form as well.

And here you see an example from the PQRI (now PQRS) measure specification document where you have the denominator listing, you see the denominator criteria. In this case, this is for aspirin at arrival for acute myocardial infarction. We use this measure in the emergency department. And you see all of the diagnoses that would indicate this measure. And then, of course, you see the range of CPT codes that would indicate also the same thing.

And then there is a place of service. And so, a place of service 23 indicates the emergency department. So, this particular measure is only applicable in the ED, in the Emergency Department and only by those providers who submit ED codes. But obviously there are measures out there, quality measures that will be applicable to your specific specialty practice depending on what that might be.

Here's an example of the numerator for the same measure, the aspirin at arrival. You can see that they were looking for a CPT code to be submitted that would indicate either that aspirin was received for that patient within 24 hours of arriving at the ED or during their ED stay.

And then, there are some other options where you have the Category II codes submitted with a modifier. So, you know, a -1P would indicate that, “Hey, there was a problem. The hospital ran out of aspirin. We couldn't...” whatever the case maybe. If there's a medical reason the patient said, “Nope, I'm not going to take the aspirin. It's against my beliefs,” whatever the reason is. But it indicates that the provider tried to perform that quality measure but there is a reason why he or she was unable to perform it.

This QDCs or quality data codes once again, they're Category II. There are temporary G-codes you need to be careful when you look at the specification document to see which codes that you are going to have to submit. In some cases, you have multiple codes that have to be submitted. So, you need to pay close attention to that PQRS measure specification document.

Here we see the list of the modifiers that are applicable -- -1P is a medical reason, 2P would indicate a patient reason, and 3P would indicate some system related reason why you could not perform the measure.

There is an additional modifier called an -8P modifier. And this is basically are carried for all the providers out there just to participate in this program. If there was no performance whatsoever and no reason given why you didn't perform a quality measure, it allows you to still say, “Hey, we didn't do anything. And we're going to submit this -8P and you'll still get credit.” You'll still get credit for successfully reporting the measure because remember, this is a reporting program. It's not a performance program as yet.”

So, the potential is that there might be some over utilization where you're not really caring about the measures, you're just submitting these -8Ps. Obviously that's not the goal of the program, the overall goal is quality improvement.

For more information on PQRS measures, visit our Physician Quality Reporting System page.