Physician Quality Reporting Initiative (PQRI) Letter to Medicare Beneficiaries
The Centers for Medicare & Medicaid Services (CMS) has posted a letter to Medicare beneficiaries with important information about the Physician Quality Reporting Initiative (PQRI) at http://www.cms.hhs.gov/PQRI 
on the CMS Website. The letter is from Medicare to the patient explaining what the program is, and the implications for the patient. Physicians may choose to provide a copy to their patients in support of their PQRI participation.
To access the letter, visit http://www.cms.hhs.gov/PQRI on the CMS Website. Once on the Overview page, scroll down to the "Downloads" section.
PQRI Questions of the Week
Q: If a Physician Quality Reporting Initiative (PQRI) quality-data code is not listed on a line adjacent to the correct Current Procedural Terminology (CPT) Category I code, will the quality-data code be accepted?
A: Yes, the PQRI analyses will match PQRI quality-data codes to the Current Procedural Terminology (CPT) Category I codes that appear on any non-denied service line on the claim, regardless of the order in which the various line items appear.
Q: If I report a modifier to a Physician Quality Reporting Initiative (PQRI) quality-data code on a claim, when use of that modifier is not specifically allowed per the PQRI Measure Specifications document, will I get credit for reporting?
A: No. In order to be considered an instance of appropriate quality data submission, PQRI quality-data codes should be accurate and reflect valid modifiers as in the measure specifications. Invalid codes will not be included in reporting or performance rate calculations.
Q: I have questions about which PQRI measures are most applicable to my specialty and practice, and how best to implement PQRI in my practice. Where can I get more information and advice on these topics?
A: For specialty- or practice-specific questions, please contact your professional organization or specialty association for guidance. In many cases, these organizations have information and tools to enable successful reporting of PQRI measures available on their Websites.
Q: The 1.5% bonus is subject to a cap. How and when will CMS calculate the cap for an individual eligible professional?
A: The bonus cap calculation is defined as follows: (the individual's instances of reporting quality data) multiplied by (300%) multiplied by (the national average per measure payment). The third factor, the "national average per measure payment amount" can only be calculated after the reporting period ends because it is equal to (the total amount of allowed charges under the Physician Fee Schedule for all covered professional services furnished during the reporting period on claims for which quality measures were reported by all participants in the program) divided by (the total number of instances where data were reported by all participants in the program for all measures during the reporting period.)
Because the "national average per measure payment amount" is not yet available, the following is a hypothetical example:
Example:
Dr. Smith had $400,000 in allowed charges during the PQRI reporting period.
The 1.5% potential bonus is $6000.
Dr. Smith reported quality data codes in 500 instances.
The national average per measure payment amount for 2007 was calculated in CY 2008 and turned out to be $100 ($100 M total national allowed charges claims submitted from July through December, divided by, 1 million instances of PQRI quality data codes being reported in the same time period).
The cap for Dr. Smith is $150,000 (500 x 3 x $100).
The bonus paid to Dr. Smith in early CY 2008 is $6,000.
For a complete listing of all questions and answers about the 2007 PQRI, visit our Website at
http://www.cms.hhs.gov/PQRI and click on "All PQRI FAQs" available on any page.
Page Last Updated: Monday, 09-Jun-2008 13:34:31 CDT
