The document provides an overview of the 2008 Physician Quality Reporting Initiative (PQRI) program run by the Centers for Medicare & Medicaid Services. It discusses that PQRI aims to shift Medicare payments to value-based purchasing by incentivizing reporting of quality measures. Eligible professionals can earn a 1.5% bonus payment by successfully reporting on PQRI measures. The document outlines 119 quality measures eligible for reporting, explains principles of the measures, and provides coding examples. It also discusses additional reporting options like registry-based and EHR-based reporting for PQRI in 2008.

1. Centers for Medicare & Medicaid Services
2008 Physician Quality
Reporting Initiative (PQRI)
December 19, 2007
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2. Overview
• PQRI Introduction: Information about PQRI
• PQRI Tools: Implementing PQRI
• PQRI Principles: Understanding the
Measures
• PQRI Coding: Examples of Measures
• PQRI 2008: Additional Considerations
• PQRI Readiness: Ensuring Success
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3. PQRI Introduction:
Value-Based Purchasing
• Value-based purchasing is a key
mechanism for transforming Medicare from
a passive payer to an active purchaser.
– Current Medicare Physician Fee Schedule is
based on quantity and resources consumed,
NOT quality or value of services.
• Value = Quality / Cost
– Incentives can encourage higher quality and
avoidance of unnecessary costs to enhance the
value of care.
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4. PQRI Introduction:
The Statute
• Tax Relief and Healthcare Act (TRHCA)
Section 101 Implementation
– Eligible Professionals
– Quality Measures
– Form and Manner of Reporting
– Determination of Successful Reporting
– Bonus Payment
– Validation
– Appeals
– Confidential Feedback Reports
– 2008 Considerations
– Outreach and Education
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5. PQRI Introduction:
Focus on Quality
• PQRI reporting will focus attention on
quality of care.
– Foundation is evidence-based measures
developed by professionals
– Measurement enables improvements in care
– Reporting is the first step toward pay for
performance
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6. PRQI Introduction:
Building a Platform
Visit Documented in Encounter Form Coding & Billing
the Medical Record
NCH
Analysis Contractor National Claims Carrier/MAC
History File
Confidential Bonus Payment
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Report Procurement Sensitive
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7. PQRI Introduction:
Successful Reporting
• Determination of Successful Reporting
– Reporting thresholds
• If there are no more than 3 measures that apply, each
measure must be reported for at least 80% of the cases in
which a measure was reportable
• If 4 or more measures apply, at least 3 measures must be
reported for at least 80% of the cases in which the
measure was reportable
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Procurement Sensitive
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8. PQRI Introduction:
The Bonus
• Bonus Payment
– Participating eligible professionals who successfully report
may earn a 1.5% bonus, subject to cap
• 1.5% bonus calculation based on total allowed charges
during the reporting period for professional services billed
under the Physician Fee Schedule
• Claims must reach the National Claims History (NCH) file
by February 29, 2008
– Bonus payments will be made in a lump sum in mid-2008
– Bonus payments will be made to the holder of record of the
Taxpayer Identification Number (TIN)
– No beneficiary coinsurance
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Procurement Sensitive
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9. PQRI Introduction:
The Cap Calculation
• Bonus Payment
– Cap may apply when relatively few instances of
quality measures are reported
– Cap calculation =
1. (Individual’s instances of reporting quality data) X
2. (300%) X
3. (National average per measure payment amount)
National average per measure payment amount =
(National charges associated with quality measures) /
(National instances of reporting)
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Procurement Sensitive
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10. Physician Quality Reporting
Initiative (PQRI)
• Validation
– TRHCA requires CMS to use sampling or other
means to validate whether quality measures
applicable to the services have been reported
– Validation plan posted on website
• Appeals
– Determinations are excluded from formal
administrative or judicial review
– CMS will establish an informal inquiry process
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Procurement Sensitive
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11. PQRI Introduction:
Feedback Reports
• Confidential Feedback Reports
– enable quality improvement at the
practice level
– include reporting and performance
rates by NPI for each TIN.
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12. PQRI 2008:
Additional Reporting Options
• Registry-based reporting
– Use of a data system that collects PQRI measure data and
quality data codes for electronic submission to a CMS-
designated clinical data warehouse using a CMS-specified
record layout based on PQRI measure specifications
• Electronic health record (EHR)-based reporting
– Specifications recently posted on the CMS website for the
electronic reporting of 5 measures
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13. Coding for Quality:
PQRI Tools
Implementing
PQRI
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14. PQRI Tools:
Where to Begin
• Gather information and educational
materials from the PQRI web page:
www.cms.hhs.gov/pqri on the CMS
website.
• Gather information from other sources,
such as your professional association,
specialty society or the American Medical
Association.
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15. PQRI Tools:
The PQRI Website
• www.cms.hhs.gov/pqri
– Overview
– CMS Sponsored Calls
– Statute/Regulations/Program Instructions
– Eligible Professionals
– Measures/Codes
– Reporting
– Analysis and Payment
– Educational Resources
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16. PQRI Tools: MLN 5640: Coding and
Reporting Principles
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Procurement Sensitive
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17. PQRI Tools:
The Measure List
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Procurement Sensitive
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18. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
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Procurement Sensitive
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19. PQRI Tools:
Check the Release Notes
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Procurement Sensitive
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20. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
• Selecting measures and preparing to report
• PQRI coding and reporting principles for the
claims based submission of quality data codes
• Sample clinical scenarios for each measure, listed
by clinical condition/topic, describes successful
reporting (and performance where applicable)
• PQRI Glossary
• 2007 PQRI Code Master
• Sample implementation flow chart
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21. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
Examples of Clinical Conditions/Topics
• Clinical Conditions • Clinical Topics
– Asthma – Advance Care Planning
– Cancer ( Breast, Colon, – Screening for Fall Risk
CLL, etc) – Imaging
– Chest Pain – Medication
– COPD Reconciliation
– CAD – Perioperative Care
– Depression
– Diabetes
– GERD
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22. PQRI Tools: Measure-specific Data
Collection Worksheets
• Measure Specific
– Measure Description
– Worksheet
– Coding Specifications
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23. Coding for Quality:
PQRI Principles
Understanding the Measures
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24. PQRI 2008-
Statutory Requirements
Statutory Requirements for 2008 Measures
• Adopted or endorsed by a consensus organization, such
as the AQA Alliance or National Quality Forum (NQF)
• Include measures that have been submitted by a
physician specialty
• Used a consensus-based process for development
• Include structural measures, such as the use of
electronic health records or electronic prescribing
technology
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25. Understanding the Measures:
Commonalities
• 119 unique measures associated with
clinical conditions that are routinely
represented on Medicare Fee-for-Service
(FFS) claims
– ICD-9-CM diagnosis codes
– HCPCS codes
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26. PQRI 2008:
119 Measures
• Seven Categories of Measures
– National Quality Forum-endorsed 2007 PQRI Quality Measures
– AMA Physician Consortium for Performance Improvement developed
measures
– Measures for non-physician eligible professionals developed by
Quality Insights of Pennsylvania
– Structural measures related to EHRs and e-prescribing developed by
Quality Insights
– Measures from the AQA Alliance starter set
– Other NQF-endorsed measures not included in 2007 PQRI
– Measures under development by the American Podiatric Medical
Association
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27. Understanding the Measures:
Scope
• The measures address various aspects of
quality care
– Prevention
– Chronic Care Management
– Acute Episode of Care Management
– Procedural Related Care
– Resource Utilization
– Care Coordination
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28. Understanding the Measures:
Construct
Clinical action required for reporting and
performance
________________________________
Eligible cases for a measure (the eligible
patient population associated with the
numerator)
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29. Understanding the Measures:
Construct
CPT II Code
or
Temporary G Code
________________________________
ICD-9-CM
and
CPT Category I Codes
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30. Understanding the Measures:
Quality Data Codes
Quality-Data Codes translate clinical actions
so they can be captured in the
administrative claims process
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31. Understanding the Measures:
Quality Data Codes
• Quality-Data Codes can relay that:
– The measure requirement was met
or
– The measure requirement was not met due to
documented allowable performance exclusions
(i.e., using performance exclusion modifiers)
or
– The measure requirement was not met and the
reason is not documented in the medical record
(i.e., using the 8P reporting modifier)
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32. Understanding the Measures:
The Performance Modifiers
• Performance Measure Exclusion Modifiers indicate that an
action specified in the measure was not provided due to
medical, patient or systems reason(s) documented in the
medical record:
– 1P- Performance Measure Exclusion Modifier due to Medical Reasons
– 2P- Performance Measure Exclusion Modifier used due to Patient
Reason
– 3P- Performance Measure Exclusion Modifier used due to System
Reason
• One or more exclusions may be applicable for a given
measure. Certain measures have no applicable exclusion
modifiers. Refer to the measure specifications to determine
the appropriate exclusion modifiers.
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33. Understanding the Measures:
The Reporting Modifier
• Performance Measure Reporting Modifier
facilitates reporting a case when the patient
is eligible but the action described in a
measure is not performed and the reason
is not specified or documented
– 8P- Performance Measure Reporting
Modifier- action not performed, reason
not otherwise specified
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34. Understanding the Measures:
Performance Time Frame
• Some measures have a Performance
Timeframe related to the clinical action
that may be distinct form the reporting
frequency.
– Perform within 12 months
– Most Recent
• Clinical test result needs to be obtained,
reviewed, reported one time. It need not
have been performed during the reporting
period.
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35. Understanding the Measures:
Reporting Frequency
• Each measure has a Reporting Frequency
requirement for each eligible patient seen
during the reporting period
– Report one-time only
– Report once for each procedure performed
– Report for each acute episode
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36. Coding for Quality:
PQRI Coding
Examples
Of
Measures
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37. Coding for Quality:
Example - Procedure Related Care
Measure # 20 – Timing of
Antibiotic Prophylaxis –
Ordering Physician
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Procurement Sensitive
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Procurement Sensitive
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Current Procedural Terminology © 2006 American Medical
Procurement Sensitive
Association. All Rights Reserved. 39

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Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All
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Rights Reserved.

41. Current Procedural Terminology © 2006 American
Medical Association. All Rights Reserved.
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Procurement Sensitive
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42. Coding for Quality:
PQRI 2008
Additional
Considerations
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43. PQRI 2008:
Registries and EHR-based Data Submission
• CMS plans to test two options for registry-
based data submission
• Self-nomination letters must be received by
6pm EST on January 4, 2008
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44. PQRI 2008:
Registries and EHR-based Data Submission
• CMS plan to test the feasibility of offering
eligible professionals the option of
submitting clinical quality data extracted
from EHRs directly to a data warehouse.
• Self-nomination letters are due by 6pm
EST on January 4, 2008
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45. Coding for Quality:
PQRI Readiness
Ensuring
Success
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46. PQRI Reporting:
Ensuring Success
• Start reporting early to increase the probability of
achieving the 80 percent rate of reporting during
the reporting period.
• Report on as many measures as possible to
increase the likelihood of achieving successful
reporting.
• Report on as many eligible patients as you can to
decrease the probability of being subject to the
bonus cap.
• Ensure that quality codes are reported on the
same claim as the diagnosis or CPT-I codes.
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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

47. PQRI Reporting:
Ensuring Success
• Educational Resources
– CMS PQRI website contains all publicly available
information at: www.cms.hhs.gov/PQRI
• Frequently Asked Questions
• PQRI Fact Sheet
• Medicare Carrier/Medicare Administrative Contractor (MAC)
inquiry management
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