Sunday, June 28, 2009

Becoming a Medicare Qualified PQRI Patient Registry

This will be the first of a series of posts describing MDinteractive's experience of becoming a Medicare Qualified PQRI Registry.

General Introduction

To improve quality of the healthcare in the US, Medicare has a innovative program called Physician Quality Reporting Initiative that rewards physicians for reporting quality measures like checking cholesterol levels on diabetics patients, doing mammograms, giving smoke cessation advice, etc.

This is part of a movement to slowly change the way the system rewards physicians - right now with a fee-for-service payment system, healthcare professionals are paid more for "doing things" to patients and not for keeping patients healthy.

With the PQRI incentive program, physicians can earn an incentive payment of 2% above the regular Medicare Physician Fee charges.

The 153 PQRI Quality measures can be found here:

Examples of PQRI Measures:

How to Report PQRI

There are basically two main options to report PQRI options:

- Claims Based Reporting
- Registry Reporting

Claims-Based Reporting:

In this case, a physician will need to report at least 3 PQRI Quality Measures for at least 80% of applicable patients.

For example, a pulmonary specialist would report 3 measures from all Medicare patients seen with the diagnosis of community acquired pneumonia(measures 56, 57 and 58).

Measure 56 - Community-Acquired Pneumonia (CAP): Vital Signs
Percentage of patients aged 18 years and older with a diagnosis of
community-acquired bacterial pneumonia with vital signs documented and

When the doctor treats someone with the diagnosis of pneumonia (ICD-9 code 481), and a CPT code for a office visit like 99204 then she/he will also add the CPT II code 2010F in the same CMS-1500 billing form. This code means that vital signs like temperature, pulse, respiratory rate, and blood pressure were documented and reviewed.

The worksheet for these measures can be seen at the AMA website:
Participation Tools: Individual Quality Measures for 2009 PQRI and more specifically here for measure #56

On the same CMS-1500 claim form he also enter quality codes for measures #57 (Assessment of oxygen saturation - code 3028F) and for measure #58 (Assessment of mental status - code 2014F).

Each one of the quality codes must be submitted with a line-item charge of $0.00. Charge field cannot be left blank.

At the end of the year, if the above pulmonary specialist saw 10 Medicare patients with community-acquired pneumonia and reported measures #56, #57 and #58 on at least 8 of those patients will receive a 2% bonus over all her/his Yearly Medicare Part B Fee-for-Service revenues.

We should note that the 2% applies to all the Medicare Part B fees charged for all the Medicare patients seen by the doctor and not only to the patients with community-acquired pneumonia. For example if the the yearly revenues were $100000, the bonus would be $2000.

In the next post, we will describe an Alternative Reporting Method using a Qualified Medicare Registry like MDinteractive.