Program Overview: 2009 Physician Quality Reporting Initiative (PQRI) and The 2009 Electronic Prescribing (E-Prescribing) Incentive Program
MLN Matters Number: MM6394
Related Change Request (CR) #: 6394
Related CR Release Date: March 20, 2009
Effective Date: January 1, 2009
Related CR Transmittal #: R459OTN
Implementation Date: June 22, 2009
Provider Types Affected
Physicians and other practitioners who qualify as eligible professionals to participate in the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) or the new 2009 E-Prescribing Incentive Program.
Provider Action Needed
This article is based on Change Request (CR) 6394, which gives high-level overviews of the 2009 PQRI implementation and the new 2009 E-Prescribing Incentive Program implementation. Make sure that your billing staffs are aware of the PQRI reporting changes and the E-Prescribing Incentive Program.
Background
The 2006 Tax Relief and Health Care Act (P.L. 109-432) (TRHCA) required CMS to establish a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007. CMS named this program the Physician Quality Reporting Initiative (PQRI).
For the 2009 PQRI, the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 (P.L. 110-173) (MMSEA) required the Secretary to select measures for 2009 through rulemaking and to establish alternative reporting criteria and alternative reporting periods for reporting measures groups and for registry-based reporting. In addition, the Medicare Improvements for Patients and Providers Act (P.L. 110-275) (MIPPA), which was enacted on July 15, 2008, includes many provisions that impact the 2009 PQRI. The 2009 PQRI requirements are outlined in the 2009 Medicare Physician Fee Schedule (MPFS) final rule with comment period that was published in the Federal Register on November 19, 2008, (visit http://edocket.access.gpo.gov/2008/pdf/E8-26213.pdf (PDF, 19.9 MB)) and are summarized below.
Section 132 of the MIPPA also authorizes a new and separate incentive program for eligible professionals who are successful electronic prescribers (e-prescribers) as defined by MIPPA. This new incentive is separate from and is in addition to the PQRI. The 2009 program requirements for the E-Prescribing Incentive Program are also outlined in the 2009 MPFS final rule with comment period and summarized below.
The purpose of this article is to give high-level overviews of the 2009 PQRI implementation and the new 2009 E-Prescribing Incentive Program implementation, as directed by the statute. Detailed information, educational materials, and supportive tools for the 2009 PQRI and the 2009 E-Prescribing Incentive Program will be posted as they become available on the CMS PQRI Web site at http://cms.hhs.gov/PQRI and the CMS E-Prescribing Incentive Program Web site at http://cms.hhs.gov/ERXIncentive. In addition, there are fact sheets available for the 2009 PQRI and E-Prescribing programs at www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf (PDF, 537 KB) and
The 2009 PQRI overview section below highlights changes from the 2008 PQRI with respect to: (1) eligible professionals, (2) form and manner of reporting, (3) reporting periods, (4) payment for reporting, (5) individual quality measures, (6) measures groups, (7) determination of satisfactory reporting, (8) validation, (9) appeals, and (10) confidential feedback reports.
The 2009 E-Prescribing Incentive Program overview section of this article addresses: (1) eligible professionals, (2) form and manner of reporting, (3) reporting periods, (4) payment for reporting, (5) determination of a successful e-prescriber, and (6) confidential feedback reports.
2009 PQRI Overview
1. Eligible Professionals
Beginning with the 2009 PQRI, the definition of 'eligible professional' has been expanded to include qualified audiologists, as required by the MIPPA. Therefore, for the 2009 PQRI, the following professionals are eligible to participate in PQRI:
1. Medicare physicians
- Doctor of Medicine
- Doctor of Osteopathy
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Doctor of Oral Surgery
- Doctor of Dental Medicine and
- Doctor of Chiropractic
2. Practitioners
- 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 and
- Audiologists (as of January 1, 2009)
3. Therapists
- Physical Therapist
- Occupational Therapist and
- Qualified Speech-Language Therapist
All Medicare-enrolled professionals in these categories are eligible to participate in the 2009 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims. However, some professionals are eligible to participate but are not able to participate for one or more reasons.
Professionals eligible to participate but not able to participate include:
- Professionals paid under or based upon the MPFS billing Medicare Carriers or Medicare Administrative Contractors (MACs) who do not bill directly. For example, Qualified Speech-Language Therapists do not currently bill Medicare directly. It is anticipated that Qualified Speech-Language Therapists will begin billing Medicare directly on July 1, 2009, at which point they would be able to participate.
- Professionals paid under the MPFS billing Medicare fiscal intermediaries (FIs) or MACs. The FI/MAC claims processing systems currently cannot accommodate billing at the individual physician or practitioner level:
- Critical access hospital (CAH), method II payment, where the physician or practitioner has reassigned his or her benefits to the CAH. In this situation, the CAH bills the FI/MAC for the professional services provided by the physician or practitioner.
- All institutional providers that bill for outpatient therapy provided by physical and occupational therapists and speech language pathologists (for example, hospital, skilled nursing facility Part B, home health agency, comprehensive outpatient rehabilitation facility, or outpatient rehabilitation facility). This does not apply to skilled nursing facilities under Part A.
Services payable under fee schedules or methodologies other than the MPFS are not included in PQRI (for example, services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals [including method I critical access hospitals], rural health clinics, ambulance providers, and ambulatory surgery center facilities).
2. Form and Manner of Reporting
For 2009, eligible professionals can continue to choose whether to report through claims-based submission or through a qualified PQRI registry. In addition, eligible professionals can continue to choose to report on individual quality measures or on measures groups.
- For claims-based submission, there is no need to enroll or register to begin claims-based reporting for the 2009 PQRI. Participating eligible professionals whose Medicare patients fit the specifications of the 2009 PQRI quality measures and/or measures groups will simply report the appropriate current procedural terminology (CPT) Category II codes or G-codes (where CPT Category II codes are not yet available) on their claims. CPT Category II codes and G-codes are Healthcare Common Procedure Coding System (HCPCS) codes for reporting quality data. Claims-based reporting may be via: (1) the paper-based CMS 1500 Claim form or (2) the equivalent electronic transaction claim, the 837-P.
The applicable CPT Category II code or G-code quality data must be reported on the same claim as the patient diagnosis and service to which the quality-data code applies. Additional guidance about how to implement 2009 PQRI claims-based reporting of measures to facilitate satisfactory reporting of quality data codes by eligible professionals for the 2009 PQRI is available in the 2009 PQRI Implementation Guide, which is available as a downloadable document in the Measures/Codes section of the CMS PQRI Web site at www.cms.hhs.gov/PQRI.
- For registry-based reporting, eligible professionals should submit information to a qualified PQRI clinical data registry and authorize or instruct the registry to submit quality measures results and numerator and denominator data on quality measures to CMS on their behalf.
For 2009, CMS will conduct another self-nomination process for registries so additional registries can potentially be approved for submitting quality measures data for the 2009 PQRI. Registries qualified to submit data on behalf of their eligible professionals in 2008 are not required to self-nominate again for 2009 unless they are unsuccessful at submitting 2008 data by March 31, 2009. The list of qualified registries for the 2009 PQRI will be available on the CMS PQRI Web site at www.cms.hhs.gov/PQRI in the summer of 2009.
3. Reporting Periods
There are no changes to the PQRI reporting period or the alternative reporting periods for measures group reporting or for registry-based reporting for 2009. In other words, the 2009 PQRI reporting period continues to be the entire calendar year. There also continues to be two alternative reporting periods for measures group reporting and for registry-based reporting (i.e., the entire calendar year and a six-month reporting period beginning July 1, 2009).
4. Payment for Reporting
Participating eligible professionals who satisfactorily report as prescribed by the 2009 MPFS final rule with comment period (and as summarized below in the Determination of Satisfactory Reporting section) may earn a 2.0% incentive payment. Because claims processing times may vary, participating eligible professionals should submit claims from the end of 2009 promptly, so that those claims will reach the Medicare’s National Claims History (NCH) file by February 28, 2010. PQRI incentive payments will be paid as a lump sum in mid-2010.
The PQRI incentive payment will apply to allowed charges for all covered professional services, under the MPFS not just those charges associated with reported quality measures. The term “allowed charges” refers to total charges, including the beneficiary deductible and copayment, not just the 80% paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. Other Part B services and items that may be billed by eligible professionals but are not paid under or based upon the MPFS do not apply to the PQRI incentive payment.
For 2009, the analysis of satisfactory reporting will continue to be performed at the individual eligible professional level using individual-level National Provider Identifier (NPI) data. CMS, however, will continue to use the Taxpayer Identification Number (TIN) as the billing unit, so any PQRI incentive payments earned will be paid to the TIN holder of record. PQRI incentive payments will be paid to the holder of the TIN, aggregating individual incentive payments for groups that bill under one TIN. For eligible professionals who submit claims under multiple TINs, CMS will continue to group claims by TIN for payment purposes. As a result, a provider with multiple TINs who qualifies for the PQRI incentive payment under more than one TIN will receive a separate PQRI incentive payment associated with each TIN.
In situations where eligible professionals who are employees or contractors have assigned their payments to their employers or facilities, Section 1848(m)(1)(A)(ii) of the Act specifies that any PQRI incentive payment earned will be paid to the employers or facilities.
5. Individual Quality Measures
The 2009 PQRI includes a total of 153 quality measures. This total includes 52 new measures. In addition, whereas all of the 2008 PQRI quality measures were reportable either through claims-based submission or registry-based reporting, 18 of the 153 PQRI quality measures for 2009 are reportable only through registries. A complete list of the 2009 PQRI individual quality measures can be found in the 2009 PQRI Quality Measures List, which is available as a downloadable document in the Measures/Codes section of the CMS PQRI Web site at www.cms.hhs.gov/PQRI.
6. Measures Groups
7. Determination of Satisfactory Reporting
In order to qualify to earn an incentive payment, eligible professionals must meet the criteria for satisfactorily reporting data on PQRI quality measures. For the 2009 PQRI, there are a total of nine reporting options, or ways in which an eligible professional can attempt to satisfactorily report. Although there are multiple reporting options for satisfactory reporting, an eligible professional only needs to satisfactorily report less than one option to qualify for the 2.0 % incentive payment for the applicable reporting period. An eligible professional who qualifies for more than one reporting period will receive the incentive payment for the longest reporting period for which the professional qualifies. Only one incentive payment may be obtained regardless of how many reporting options the eligible professional chooses.
As stated in the Payment for Reporting section, the analysis of whether an eligible professional has satisfactorily reported will continue to be performed at the individual eligible professional level using the individual-level NPI. The eligible professional’s individual NPI must be listed along with the HCPCS codes for services, procedures, and quality data on the claim. Thus, to participate in the 2009 PQRI, eligible professionals must have their individual-level NPIs and must consistently use their individual NPIs to correctly identify their services, procedures, and quality-data codes for an accurate determination of satisfactory reporting.
Eligible professionals select the quality measures and/or measures groups that are applicable to their practices. If an eligible professional submits data for a quality measure or a measures group, then that measure or measures group is presumed to be applicable for the purposes of determining satisfactory reporting. For eligible professionals choosing to report on individual quality measures, CMS recommends that eligible professionals report on every quality measure that is applicable to their patient populations to increase the likelihood that they will reach the 80% satisfactorily reporting requirement for the requisite number of measures.
As detailed information, education, and tools to support satisfactory claims-based reporting of individual quality measures and/or measures groups become available, they will be posted on the CMS PQRI Web site at www.cms.hhs.gov/PQRI.
8. Validation
Section 1848(m)(5)(D)(ii) of the Social Security Act (the Act) permits CMS to validate, using sampling or other means, whether quality measures applicable to the services furnished by a participating eligible professional have been reported.
Under the claims-based reporting method of individual measure(s), the determination of satisfactory reporting, as defined by statute, will itself serve as a general validation because the analysis will assess whether quality-data codes are appropriately submitted by an eligible professional in a sufficient proportion of the instances when a reporting opportunity exists. In addition, for those eligible professionals who satisfactorily submit quality-data codes for fewer than three (3) PQRI measures, a two-step measure-applicability validation (MAV) process will determine whether they should have submitted quality-data codes for additional measures. If CMS finds that eligible professionals who have reported fewer than three quality measures have not reported additional measures that are also applicable to the services they furnished during the reporting period, then CMS cannot pay those eligible professionals the incentive payment. More information on the MAV process for the 2009 PQRI is available in the Analysis and Payment section of the CMS PQRI Web site at www.cms.hhs.gov/PQRI.
9. Appeals
For the 2009 PQRI, the statute specifically states that there will be no administrative or judicial review of the determination of: (1) quality measures applicable to services furnished by eligible professionals, (2) satisfactory reporting, or (3) the incentive payment. However, CMS will establish a process for eligible professionals to inquire about these matters.
10. Confidential Feedback Reports
CMS will provide confidential feedback reports on 2009 PQRI reporting to participating eligible professionals at or near the time that the lump sum incentive payments are made in 2010. Access to confidential feedback reports may require eligible professionals to complete an identity-verification process to obtain a login identification and password for a secure interface. However, this process is not required to participate in the 2009 PQRI or to receive an incentive payment.
In addition, Section 1848(m)(5)(G) of the Act requires CMS to post on the CMS Web site, in an easily understandable format, a list of the names of the eligible professionals who satisfactorily submitted data on quality measures under PQRI. The names of eligible professionals who satisfactorily submitted data on quality measures for the 2009 PQRI will be posted at www.medicare.gov after the lump sum incentive payments are made in 2010.
E-Prescribing Incentive Program Overview
1. Eligible Professionals
For the 2009 E-Prescribing Incentive Program, “eligible professional” includes the same list of professionals as previously shown as eligible for the PQRI program.
However, in order to participate in this incentive program, a professional in one of categories of eligible professionals must be authorized by his or her respective state laws to prescribe medication and prescribing medications must fall within the individual eligible professional’s scope of practice.
All Medicare-enrolled professionals in these categories are eligible to participate in the 2009 E-Prescribing Incentive Program, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.
However, some professionals are eligible to participate but are not able to participate for one or more reasons and the reasons are the same as those which preclude professionals from participating in PQRI as mentioned earlier in this article.
Professionals not eligible to participate in the E-Prescribing Incentive Program and not able to qualify to earn an incentive payment are those that are not defined as eligible professionals in the Medicare Improvements for Patients and Providers Act of 2008.
Services payable under fee schedules or methodologies other than the MPFS are not included in E-Prescribing Incentive Program (for example, services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals [including method I critical access hospitals], rural health clinics, ambulance providers, and ambulatory surgery center facilities).
2. Form and Manner of Reporting
For 2009, participation in the E-Prescribing Incentive Program is limited to the submission of quality data codes for the e-prescribing measure through Medicare’s claims processing system, as described in the 2009 MPFS final rule with comment period. There is no need to enroll or register to begin claims-based reporting for the 2009 E-Prescribing Incentive Program.
Participating eligible professionals who bill for the services or procedures included in the denominator of the 2009 e-prescribing measure will report the corresponding appropriate numerator G-code on their claim. Claims-based reporting may be via: (1) the paper-based CMS 1500 Claim form or (2) the equivalent electronic transaction claim, the 837-P. The specifications for the 2009 e-prescribing measure are available on the CMS E-Prescribing Incentive Program Web site at www.cms.hhs.gov/ERXIncentive.
The applicable CPT Category II code or G-code quality data must be reported on the same claim as the billable service or procedure to which the quality-data code applies. The 2009 e-prescribing measure does not require a diagnosis code to help determine the denominator.
3. Reporting Periods
For 2009, the reporting period for the E-Prescribing Incentive Program is the entire calendar year, or January 1, 2009, – December 31, 2009.
4. Payment for Reporting
For 2009, eligible professionals, who are determined to be “successful e-prescribers” (as discussed below), may earn an incentive payment equal to 2.0 percent of the total estimated allowed charges for all such MPFS covered professional services: (1) furnished by the eligible professional during the reporting period of January 1 through December 31, 2009, (2) received into the CMS NCH file by February 28, 2010, and (3) paid under or based upon the MPFS. Because claims processing times may vary, participating eligible professionals should submit claims service dates late in 2009 promptly, so that those claims will reach Medicare’s NCH file by February 28, 2010. CMS anticipates that the e-prescribing incentive payments will be paid as a lump sum in mid-2010. There is no beneficiary co-payment or notice to the beneficiary regarding the e-prescribing incentive payments.
According to the statute, however, there is a limitation with regard to the application of the incentive. For 2009, the incentive does not apply to eligible professionals, for the reporting period, if the Medicare allowed charges for all covered professional services for the codes to which the e-prescribing measure applies are less than 10% of the total of the allowed charges under Medicare Part B for all such covered professional services furnished by the eligible professional. Under the E-Prescribing Incentive Program, covered professional services are those paid under or based upon the MPFS.
The e-prescribing incentive payment will apply to allowed charges for all covered professional services, not just those charges associated with the e-prescribing measure. The term “allowed charges” refers to total charges, including the beneficiary deductible and copayment, not just the 80% paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. Note that the amounts billed above the MPFS amounts for assigned and non-assigned claims will not apply to the incentive. The statute defines e-prescribing covered services as those paid under or based upon the MPFS only, which includes technical components of diagnostic services and anesthesia services, as anesthesia services are considered fee schedule services though based on a unique methodology.
For 2009, the analysis of determining successful e-prescribers will be performed at the individual eligible professional level using individual-level NPI data. CMS, however, will use the TIN as the billing unit, so any e-prescribing incentive payments earned will be paid to the TIN holder of record. E-prescribing incentive payments will be paid to the holder of the TIN, aggregating individual incentive payments for groups that bill under one TIN. For eligible professionals who submit claims under multiple TINs, CMS will group claims by TIN for payment purposes. As a result, a provider with multiple TINs who qualifies for the e-prescribing incentive payment under more than one TIN will receive a separate e-prescribing incentive payment associated with each TIN. In situations where eligible professionals who are employees or contractors have assigned their payments to their employers or facilities, section 1848(m)(2)(A) of the Act specifies that any e-prescribing incentive payment earned will be paid to the employers or facilities.
5. Determination of a Successful E-Prescriber
For purposes of qualifying for the e-prescribing incentive payment for 2009, an eligible professional will be considered a successful e-prescriber if he/she reported the applicable e-prescribing quality measure in at least 50 percent of the cases in which such measure is reportable by the eligible professional during the reporting period.
6. Confidential Feedback Reports
CMS will provide confidential feedback reports to participating eligible professionals at or near the time that the lump sum incentive payments are made in 2010. As with PQRI, access to confidential feedback reports may require eligible professionals to complete an identity-verification process to obtain a login identification and password for a secure interface. However, this process is not required to participate in the 2009 E-Prescribing Incentive Program or to receive an incentive payment.
In addition, section 1848(m)(5)(G) of the Act requires CMS to post on the CMS Web site, in an easily understandable format, a list of the names of the eligible professionals who are successful e-prescribers. The names of eligible professionals who are determined to be successful e-prescribers for the 2009 E-Prescribing Incentive Program will be posted at www.medicare.gov after the lump sum incentive payments are made in 2010.
Additional Information
If you have questions, please contact the Palmetto GBA Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.