Coding and Reporting Updates for the PQRI and E-Prescribing Programs

A recent CMS Manual Transmittal provides a high-level overview of claims-based reporting for the 2009 physician quality reporting initiative (PQRI) and the E-Prescribing Incentive Program.

For 2009, PQRI submission of quality data may be performed via claims or via a qualified registry. Multiple reporting options are available for each method of submission, including the option of reporting on individual quality measures or on measures groups.

When reporting data for the PQRI incentive program, CPT Category I codes can be reported with or without CPT Category I modifiers. If a procedure is billed by an assistant surgeon using modifiers 80, 81, or 82 that data will be excluded from the PQRI results since the primary surgeon, not the assistant, is responsible for performing and reporting the quality actions. If two primary surgeons bill for the same surgery, the procedure code should be reported with modifier 62 and both surgeons will be held accountable for the quality actions. Both surgeons participating in the PQRI will be fully accountable for the quality action(s) described in PQRI measure(s).

CPT Category II codes are used for performance measurement and serve to encode the quality action(s) described in a measure’s numerator; whereas the Category I codes service as the measure's denominator. PQRI measure specifications do not encompass all published Category II codes; only a subset of codes that are selected by the measure developer for use in PQRI. Category II codes are not modified or updated during the reporting period and remain valid for the entire program year as published in the measure specifications manuals and related documents for PQRI.

A new incentive program for EPs who are successful electronic prescribers is separate from and in addition to the PQRI. To be considered a successful e-prescriber for 2009, an EP must report an e-prescribing measure in at least 50 percent of reportable cases. For 2009, the e-prescribing measure may be reported via claims only. EPs may submit multiple codes for more than one measure on a single claim.

When submitting a claim for the e-prescribing incentive program it is important to include one of the following HCPCS codes: G8443, G8445, or G8446 to indicate whether a provider has access to a qualified e-prescribing system. Further requirements for filing CMS-1500 to receive the e-prescribing incentive, go to E-Prescribing Incentive website http://www.cms.hhs.gov/ERXIncentive. Background on the PQRI is posted on the CMS website at http://www.cms.hhs.gov/PQRI/. One-Time Notification Manual, Pub. 100-20, Transmittal No. 513, July 2, 2009.