PQRI Program Begins July 1
Use ACR’s New Reporting Guidance Tool to Earn Bonuses
CMS’ new "pay-for-reporting" program, the Medicare "Physician Quality Reporting Initiative" (PQRI), will operate during the last six months of 2007, paying physicians and other eligible providers up to 1.5 percent of their total allowable Medicare billings for reporting quality measures (QMs). To make it easier for members to participate in the PQRI, the ACR has prepared the 2007 PQRI Guidance for Reporting. This guidance contains specific CMS coding requirements for all quality measures referenced below.
Additionally, use the following links to access data-collection tools created by CMS in collaboration with the American Medical Association (AMA), Mathematica Policy Research, Inc, and the National Committee for Quality Assurance (NCQA). These simple tools contain easily understood instructions and data collection worksheets to help you through the process.
Data collection worksheets for Measures 10, 11, 71 and 74 can be downloaded by clicking the links below:
PQRI Data Collection Worksheet for Measure #10
PQRI Data Collection Worksheet for Measure #11
PQRI Data Collection Worksheet for Measure #71
PQRI Data Collection Worksheet for Measure #74
Data collection tools for all 74 PQRI measures are also available on the AMA and CMS PQRI Web sites.
AMA Data Collection Tools
CMS Data Collection Tools
Key things ACR members should know about the PQRI:
- Participation is voluntary; no enrollment is required.
- Physician performance is not being measured; the bonus is paid simply for reporting a practice's appropriate QMs (even in cases where all or some of a QM's clinical requirements have not been met).
- The size of your bonus payout depends on the volume of valid Medicare PQRI-related claims submitted to your carrier (subject to a statutory cap). To maximize the PQRI bonus, radiologists should maximize the number of valid PQRI claims they submit.
- Participating diagnostic radiologists must report on both of two stroke-related imaging QMs; participating radiation oncologists must report on both of two measures related to treating breast cancer patients.
- To qualify for the bonus, each applicable measure must be reported for 80 percent of all eligible patients for the period from July 1 through December 31, 2007.
Additional PQRI Details
No registration or enrollment required — You need not enroll with CMS to participate in the PQRI; the program is strictly voluntary. Your participation is triggered when you submit a Medicare claim with appropriate PQRI codes. The 74 program-eligible QMs and their related detailed coding specifications can be found on the CMS Web site.
Reporting, bonus payment, and feedback are calculated at the individual physician level — CMS will require each physician or other eligible provider to include a national provider identification (NPI) number on claims submitted for PQRI reporting. The NPI is necessary in addition to your tax ID. While QM reporting and feedback is performed at the individual physician level, all CMS bonus payments are made to the holder of the tax ID. CMS will provide PQRI participants with feedback reports profiling their individual QM reporting patterns. CMS will send these reports, as well as bonus payments, in mid-2008.
Minimum requirements to qualify for a PQRI reporting bonus — CMS will require all physicians reporting a PQRI measure to report the QM for at least 80 percent of all QM-applicable patients. CMS will also require that a minimum of three QMs be reported at this 80 percent level if four or more QMs are available for your area of practice. If there are three QMs or less, you must report on all that apply to your area of practice. Specific minimum QM reporting requirements to qualify for a PQRI bonus are provided below for radiologists specializing in diagnostic imaging, radiation oncology, and interventional procedures.
Diagnostic imaging radiologists — Measures applicable for radiologists include two stroke-related imaging measures: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports and Carotid Imaging Reports (numbers 10 and 11 on the CMS-published QM list). Both of these two measures must be reported for 80 percent of all eligible patients (based on qualifying ICD-9 and imaging procedure CPT® codes) to qualify for the bonus.
Radiation oncologists — There are two QMs for radiation oncologists: Hormonal Therapy for Stage IC-III, ER/PR Positive Breast Cancer and Radiation Therapy Recommended for Invasive Breast Cancer Patients Who Have Undergone Breast Conserving Surgery (numbers 71 and 74 on the CMS QM list). Both QMs must be reported at this 80-percent level to qualify for the bonus (based on qualifying ICD-9 and initial radiation therapy consultation E/M CPT codes).
Interventional radiologists — Interventional radiologists should be aware that there are a few quality measures potentially applicable to their practices that could be reported in addition to measures 10 and 11. For example, perioperative measures 20-23 could be applicable. Since most interventional radiologists will already be reporting on both numbers 10 and 11, qualifying for the bonus may only require reporting on one additional quality measure (and then only if a minimum of 50 Medicare patients were seen for a condition specific to any of the applicable measures).
Amount of bonus payment depends on volume of quality measures reported — While the PQRI pays up to 1.5 percent of all allowable Medicare billings, receiving the full 1.5 percent bonus is contingent on the volume of QM reporting. For physicians reporting on three QMs or fewer, as is the case with radiologists and radiation oncologists, the total bonus payout may be below the 1.5 percent maximum due to a statutory cap based on the total volume of QM reporting. CMS will pay the lower of the 1.5 percent or the capped bonus amount. The formula for calculating the capped bonus amount is as follows:
Total bonus payout under cap = Total instances of reporting QMs × 300 percent × national average per measure payment amount (NAPMPA)*
Note: *CMS will not be able to calculate the NAPMPA until mid-2008. This average is calculated by dividing the national aggregate cost of covered Medicare Physician Fee Schedule services appearing on all claims containing QMs by the total number of instances of QM reporting under the PQRI. This amount will be a single dollar value that will be applied to all submitted claims containing a QM that is subject to the cap. EXAMPLE: A radiologist meets the 80 percent reporting threshold and submits a total of 10 claims with QMs. The NAPMPA is set at $50. Multiplying these two figures times 300 percent produces a total PQRI payout of $1,500. This cap amount will be paid only if it is less than the full 1.5 percent bonus.
Important Notes on the New PQRI Program
The ACR plans to expand the number of reportable QMs beginning in 2008 to allow more members to participate. For a comprehensive ACR overview of Pay for Performance, click on the link below.
The deadline for submitting PQRI-eligible claims (dates of service between 07/01/07 and 12/31/07) is February 29, 2008. The ACR welcomes all member inquiries about the PQRI. Please submit your questions to P4Pquestions@acr.org. Also, CMS has extensive information on the PQRI available at www.cms.hhs.gov/pqri.
Final ACR Recommendation
To maximize your bonus under the PQRI, maximize the number of valid claims with appropriate quality measures that you submit to your carrier.