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Medical Coding News Archives

July Starts New Reporting Period for PQRI

June 23, 2009:

The second six-month reporting period for Medicare’s Physician Quality Reporting Initiative(PQRI) begins July 1. This reporting period runs through December 31, 2009, and gives providers who have not already started a chance to meet the PQRI reporting criteria for 2009 and receive an incentive payment when reporting thresholds are met.  

In 2007, the Centers for Medicare and Medicaid Services (CMS) developed PQRI in an effort to establish a financial incentive for eligible professionals (EPs) to participate in a voluntary quality reporting program. Eligible professionals include:

Medicare physicians

  • Doctor of Medicine
  • Doctor of Osteopathy
  • Doctor of Podiatric Medicine
  • Doctor of Optometry
  • Doctor of Oral Surgery
  • Doctor of Dental Medicine
  • Doctor of Chiropractic


  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
  • Certified Nurse Midwife
  • Clinical Social Worker
  • Clinical Psychologist
  • Registered Dietician
  • Nutrition Professional
  • Audiologists (as of 1/1/2009)


  • Physical Therapist
  • Occupational Therapist
  • Qualified Speech-Language Therapist

Federally qualified health centers (FQHC), rural health centers (RHCs), independent diagnostic testing facilities (IDTFs), independent laboratories (ILs), and other providers are not considered eligible. These entities are not defined as EPs in the Tax Relief Health Care Act of 2006 or the Medicare Improvements for Patients and Providers Act of 2008 and are paid under a different fee schedule. As a result, they do not qualify for the incentive.

EPs who successfully report a designated set of quality measures on claims for defined reporting periods may earn a bonus payment of 2.0 percent of the total allowed charges for covered Medicare physician fee schedule services. Services not paid under the MPFS are, therefore, ineligible for the bonus payment. This includes laboratory services paid under the clinical laboratory (CLAB) fee schedule, durable medical equipment, as well as drugs and biologicals.

CMS has adopted 153 individual quality measures and seven measure groups. The quality measures data are reported using CPT category II codes and CPT category II modifiers or HCPCS Level II G codes and CPT category II modifiers when there is no CPT category II code available. HCPCS Level II codes G8006–G9140 are temporary codes developed by CMS for reporting quality measures. CMS states that these codes are to be used when there is no CPT category II code available or when the category II codes do not collect the type of information CMS wants.

CMS also established “measure groups,” which are reported by submitting group-specific G codes to indicate intent (e.g., submit G8485 on first diabetic patient to begin reporting diabetes measures group). The individual measures within the selected group are then reported on the claim.

To report the quality information, a provider indicates the appropriate quality code (a CPT category II or HCPCS Level II code) or numerator for applicable patients. Patient eligibility is determined by the presence of a defined condition, as indicated by an ICD-9-CM code or a service or procedure as defined by a CPT or HCPCS Level II codes. These conditions or services are called the denominator. There are also CPT category II modifiers that indicate whether a patient should be excluded from the measure for a specific reason. The numerators, denominators, and applicable exclusion modifiers associated with the individual quality measure are defined in the quality measures specifications created by CMS.

There are two methods of submitting the PQRI data: claims-based or registry based. The claims-based reporting system enables the provider to report the quality measures on either the paper CMS-1500 claim form or 837p electronic equivalent. The registry-based reporting method allows providers to submit the quality measure codes, electronically, through an approved registry. The quality measure specifications and a list of the approved registries can be found at: www.cms.hhs.gov/pqri.

Quality codes are to be reported with a $0.00 amount as there is no charge associated with quality codes. If a billing software program does not accept a $0.00 charge, a small amount, such as one cent, can be substituted. Remember, this amount should be adjusted off the patient’s account upon receipt of the remittance advice. Quality codes must be reported on the same claim as the related diagnosis and procedure code described in the measure specifications. Reporting quality codes (numerators) and diagnosis and procedure codes (denominators) together is required so that CMS can analyze the quality measure, calculate individual provider performance, and determine whether the provider has achieved the 80 percent minimum reporting threshold.

There are a number of reporting options that can be selected. The threshold that must be met to qualify for the bonus payment depends on the method selected.

Claim-Based Reporting Option
When fewer than three measures are applicable to the providers practice, there is only one reporting option. The provider must report each measure for 80 percent or more of the applicable patients for the 12-month reporting period.

If three or more measures apply, there are two options the provider can choose from. The first is to report three or more measures for 80 percent of eligible patients during the 12-month reporting period. The second and third options are to report measure groups for the six-month reporting period using either the 80 percent criteria or by reporting 100 percent of 15 consecutive eligible patients, anytime, within the six-month period. Consecutive patients are defined by CMS as next in order. Patients are considered consecutive without regard to gender even though some measures in a group (preventive care measures) may apply only to male or female patients.

Registry-Based Reporting
When the provider elects to report the quality data using a registry, there are six reporting options. The provider may elect to report data on at least three measures for 80 percent or more of eligible patient encounters during either the six- or 12-month reporting period. Or there are four registry reporting options, which entail reporting measures groups using either the consecutive or 80 percent thresholds for either a six- or 12-month reporting period.

Since these last options involve the reporting of measure groups and are not applicable to physical therapists, no further information will be provided at this time regarding these methods.

Deborah C. Hall
Clinical/Technical Editor


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