PQRI: Start Reporting Quality Measures on Your Medicare Claims

Thomas Valuck, MD, JD

Dr Valuck is Director of the Centers for Medicare & Medicaid Services? new Special Program Office for Value-Based Purchasing. He is also a pediatrician and an attorney specializing in regulatory health law.

On July 1, 2007, Medicare took an important first step toward supporting the high-quality, result-oriented care you strive to provide every day. That was the date that Medicare launched the Physician Quality Reporting Initiative (PQRI).?

?Created by the Tax Relief and Health Care Act in December 2006, PQRI provides a bonus payment of up to 1.5% of the total allowed charges for Medicare physician fee schedule services to physicians who successfully report on a set of 74 specific PQRI measures between July 1 and December 31, 2007.?

?PQRI is a major advance toward Medicare's new commitment to value-driven healthcare.

?In August 2006, the president issued an executive order on healthcare quality and transparency.?It laid out 4 cornerstones that are basic to quality healthcare:?

• Transparent quality information
• Transparent price information
• Interoperable health information technology
• Incentives for healthcare delivery driven by value to the patient, not volume of services.?

The use of incentives to improve healthcare value—which includes PQRI —is a seismic shift for the Centers for Medicare & Medicaid Services (CMS) from passively paying for healthcare services to actively purchasing high-quality, efficient care. These 4 goals are not just statements of intent, they are changes that are long overdue, and we're working hard to achieve them.?

Historically, as healthcare costs began to rise sharply in the 1980s, Medicare moved to a prospective payment system for hospitals, but its fee-for-service payment for ambulatory services continued to be based on resource consumption and quantity of care.?

As a result, Medicare payments don't support physicians' efforts to provide the best care to their patients, and they don't help patients seek care that will help them stay well and manage chronic illness.

Instead, the rules of the Medicare payment system too often reward unnecessary treatment, duplicate services, and care that addresses the complications of disease but fails to prevent them. With PQRI, we aim to turn these disincentives around.

Medicare has made considerable progress toward value-driven healthcare. CMS has been working with a broad array of stakeholders—health professionals, institutional providers, purchasers, payers, consumers, and others—who are developing measures of healthcare quality. We're also working with these stakeholders to develop useful and fair measures of health professional resource use.

PQRI incorporates these consensus-based quality measures. You report the quality measures by using the code on the claim system.?

You can find 2007 PQRI measures, as well as detailed measure specifications and tools that will help you to report your quality measures on the claim by:

• Going to www.cms.hhs.gov/PQRI/
• Clicking on the "Measures/Codes" link, and selecting the downloads
• Identifying the types of care you provide your Medicare patients, as well as the settings of care for your work.?
• Printing the specifications for those measures you want to report.

PQRI: Points to Remember

• Even if you're a specialist with just 1 or 2 PQRI measures, you can still participate and get the payment?
• PQRI is a voluntary program; physicians, therapists, and other clinicians can participate
• You do not need to register
• You must be enrolled in Medicare, but you don't need to be a Medicare participating provider who accepts assignment to submit PQRI quality data
• PQRI's bonus payment is for reporting, not for performance; a simple, but necessarily precise, method for claims-based reporting is detailed on the PQRI website
• You need to select quality measures that apply to your practice, and report the corresponding appropriate quality codes (usually CPT category II codes, but temporary G-codes can be used when CPT II codes are not available)
• You must submit your claims by the end of February 2008 to receive the potential 1.5% bonus for 2007. ?

PQRI is just a first step toward performance-based payment. Feedback reports—which we expect to include reporting and performance rates—will be confidential in the first year of PQRI.?We will not report 2007 quality data to the public.?We will make reports available to participating clinicians who request them at or near the time of the bonus payments in mid-2008.?

There are many reasons for you to participate in PQRI—professionalism, to receive feedback for performance improvement, investment in the future of the practice, and, of course, the potential 1.5% bonus for 2007, to name a few.?But value-driven healthcare is the future of Medicare reimbursement, and as we gain experience with this new way of paying for services, Medicare's investment in it will grow over time.?

Your Feedback to CMS Can Help You

Medicare needs your help. We need you to tell us, based on your experience with the first year of quality reporting, what works and what needs to be refined. We need your real-world experience to create a payment system that's an accurate reflection of healthcare today.

The more we can support physicians and patients in pursuing the best care at the lowest cost, the less pressure there will be for tightening payment rates. But we need your participation to make sure we do this right.?

Done right, everyone wins—patients as well as the physicians who care for them. ?

PQRI at a Glance

• There is no public reporting associated with the 2007 PQRI program
• Successful reporting is calculated based on the level of the eligible professional, using the NPI
• A 1.5% calculation is based on total allowed charges submitted by an eligible professional during the reporting period for severices billed under the physician fee schedule
• The bonus will be paid in mid-2008 to the holder of the tax ID number
• For information on the 2008 PQRI program visit, www.cms.hhs.gov/PQRI/35_2008PQRIInformation.asp#TopOfPage