MLN Matters® Number: MM6514
Related Change Request (CR) #: 6514
Related CR Release Date: July 2, 2009
Effective Date: June 1, 2009
Related CR Transmittal #: R513OTN
Implementation Date: September 2, 2009
Provider Types Affected
Physicians and practitioners (referred to as eligible professionals (EPs)) who wish to participate in the Medicare Physician Quality Reporting Initiative (PQRI) and/or the E-Prescribing Incentive programs in 2009.
What You Need to Know
CR 6514, from which this article is taken, provides a high-level overview of the coding and reporting principles for the claims-based reporting of quality measures data for the 2009 PQRI, and for the claims-based reporting of the e-prescribing measure for the 2009 E-Prescribing Incentive Program. Because the information in CR 6514 is quite detailed and important for these two programs, this article will mirror virtually all of that detail.
Background
The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007. The Centers for Medicare & Medicaid Services (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 (MMSEA) required the Secretary of Health and Human Services (HHS) to select measures for 2009 through rulemaking, and to establish alternative reporting criteria and alternative reporting periods for reporting on a group of measures, or measures groups, and for registry-based reporting. In addition, the Medicare Improvements for Patients and Providers Act (MIPPA), which was enacted on July 15, 2008, includes many provisions that impact the 2009 PQRI. Thus, for 2009, PQRI submission of quality data may be performed via claims or via a qualified registry; and multiple reporting options are available for each method of submission, including the option of reporting on individual quality measures or on measures groups.
Section 132 of the MIPPA also authorizes a new and separate incentive program for EPs who are successful electronic prescribers (e-prescribers) as defined by MIPPA. This new incentive 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.
To be considered a successful e-prescriber for 2009, an EP must report an e-prescribing measure on at least 50 percent of reportable cases and at least 10percent of an EP’s total allowed Medicare Part B charges must come from the services delineated in the measure’s denominator. For 2009, the e-prescribing measure may be reported via claims only.
CR 6514, from which this article is taken, provides a high-level overview of the coding and reporting principles for the claims-based reporting of quality measures data for the 2009 PQRI, and for the claims-based reporting of the e-prescribing measure for the 2009 E-Prescribing Incentive Program.
Coding and Reporting Principles for the Claims-based Reporting of PQRI Measures
To implement 2009 PQRI claims-based reporting of measures or measures groups, eligible professionals (EPs), using your individual national provider identifier (NPI) and submitting billable services on Part B claims for allowable Medicare Physician Fee Schedule (MPFS) charges, may report the quality action for selected PQRI quality measure(s) or measures groups, which are comprised of four or more PQRI quality measures. In general, the PQRI quality measures consist of a unique denominator (eligible case) and numerator (quality action) that permit the calculation of the percentage of a defined patient population: 1) who receive a particular process of care or achieve a particular outcome, or 2) for whom care was delivered using a particular structural element. It is important that you review and understand each measure specification, which provides definitions and specific instructions for reporting a measure.
Note: 1) You should review the following documents if you choose to report individual PQRI quality measures:
- ‘2009 PQRI Measure Specifications Manual for Claims and Registry’
- ‘2009 PQRI Implementation Guide,’ which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Centers for Medicare & Medicaid Services (CMS) 1500 format
2) You should review the following documents if you choose to report PQRI measures groups:
- ‘2009 PQRI Measures Groups Specifications Manual’. Note that the specifications for a measures group are different from those for individual measures because measures groups require a common denominator. Be sure you use the correct specifications.
- ‘Getting Started with 2009 PQRI Reporting of Measures Groups’ – this is the implementation guide for reporting measures groups
- ‘2009 PQRI Tip Sheet: PQRI Made Simple – Reporting the Preventive Care Measures Group’ – this tip sheet provides a useful worksheet to keep track of each patient reported when using the 30-consecutive patient sample method for a measures group
As mentioned above PQRI measures consist of two major components: 1) A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure’s numerator); and 2) A numerator that describes the quality action required by the measure for reporting and performance. Each component is defined by specific codes described in each measure specification along with reporting instructions and use of modifiers.
Current Procedural Terminology (CPT) Category I Modifiers
The PQRI measure specifications include specific instructions regarding inclusion of CPT Category I modifiers. Unless otherwise specified, CPT Category I codes may be reported with or without CPT modifiers. You should refer to each individual measure specification for detailed instructions to identify CPT Category I modifiers that qualify or do not qualify a claim for denominator inclusion.
Please note that PQRI-eligible CPT Category I procedure codes, billed by surgeons performing surgery on the same patient, submitted with CPT modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population for applicable PQRI measure(s). Both surgeons participating in PQRI will be fully accountable for the quality action(s) described in the PQRI measure(s).
However, surgical procedures billed by an assistant surgeon(s) will be excluded from the denominator population so their performance rates will not be negatively impacted for PQRI. PQRI analyses will exclude otherwise PQRI-eligible CPT Category I codes, when submitted with assistant surgeon CPT modifiers 80, 81, or 82. The primary surgeon, not the assistant surgeon, is responsible for performing and reporting the quality action(s) in applicable PQRI measures.
Quality-Data Codes (QDCs)
QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT Category II codes and/or G-codes that describe the quality action required by a measure’s numerator. Quality actions can apply to more than one condition, and therefore can also apply to more than one measure. Where necessary, to avoid shared CPT Category II codes, G-codes are used to distinguish quality actions across measures. Some measures require more than one quality action and therefore have more than one CPT Category II code, G-code, or a combination associated with them. You should review numerator reporting instructions carefully.
CPT Category II Codes
CPT Category II or CPT II codes, developed through the CPT Editorial Panel for use in performance measurement, serve to encode the quality action(s) described in a measure’s numerator. CPT II codes consist of five alphanumeric characters in a string ending with the letter ‘F.’ CPT 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.
Use of CPT II Modifiers
CPT II modifiers are unique to CPT II codes and may be used to report PQRI measures by appending the appropriate modifier to a CPT II code as specified for a given measure. The modifiers for a code are mutually exclusive and their use is guided by the measure’s coding instructions, which are included in the numerator coding section of the measure specifications. Use of the modifiers is unique to CPT II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. Descriptions of each modifier are provided below to help identify circumstances when the use of an exclusion modifier may be appropriate. Note that in a pay-for-reporting model, accurate reporting on all selected applicable measures counts the same, whether reporting that the quality action was performed or not.
CPT II code modifiers fall into two categories, exclusion modifiers and the 8P reporting CPT modifier:
1) Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some measures do not allow performance exclusions. Reasons for appending a performance measure exclusion modifier fall into one of three categories:
- 1P exclusion CPT modifier due to medical reasons
Examples include: not indicated (absence of organ/limb, already received/performed, other); contraindicated (patient allergic history, potential adverse drug interaction, other); other medical reasons.
- 2P exclusion CPT modifier due to patient reasons
Examples include: patient declined; economic, social, or religious reasons; other patient reasons.
- 3P exclusion CPT modifier due to system reasons
Examples include: resources to perform the services not available (e.g., equipment, supplies); insurance coverage or payer-related limitations; other reasons attributable to health care delivery system.
2) The 8P reporting CPT modifier is available for use only with CPT II codes to facilitate reporting a denominator eligible case when an action described in a measure is not performed and the reason is not specified. Instructions for appending this reporting modifier to CPT Category II codes are included in applicable measures. Use of the 8P reporting CPT modifier indicates that the patient is eligible for the measure; however, there is no indication in the record that the action described in the measure was performed, nor was there any documented reason attributable to the exclusion modifiers.
- 8P reporting CPT modifier - action not performed, reason not otherwise specified
The 8P reporting CPT modifier facilitates reporting an eligible case on a given measure when the quality action does not apply to a specific encounter. EPs can use the 8P CPT modifier to receive credit for satisfactory reporting but will not receive credit for performance.
For example, a clinician who has selected and submitted QDCs during the reporting period for 2009 PQRI Measure #6, Oral Antiplatelet Therapy, sees a patient during an encounter and the claim for services for that encounter contains ICD-9-CM and CPT codes that will draw the patient into the measures’ denominator during analysis. The 8P CPT modifier serves to include the patient in the numerator when reporting rates are calculated for PQRI.
Claims-Based Reporting Principles for PQRI
The following principles apply to the reporting of QDCs for PQRI measures:
- The CPT Category II code(s) and/or G-code(s), which supply the numerator, must be reported:
- On the same claim as the denominator billing code(s)
- For the same beneficiary
- For the same date of service (DOS)
- By the same EP (individual NPI) who performed the covered service as the payment codes, usually ICD-9-CM, CPT Category I or HCPCS codes, which supply the denominator
- All diagnoses reported on the base claim, regardless of the order listed, will be included in PQRI analysis, as some PQRI measures require reporting more than one diagnosis on a claim. To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, both primary and all secondary diagnoses are considered in PQRI analysis.
- Up to four diagnoses can be reported in the header on the CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim. However, only one diagnosis can be linked to each line item, whether billing on paper or electronically.
- If your billing software limits the number of line items available on a claim, you may add a nominal amount such as a penny, to one of the line items on that second claim for a total charge of one penny. PQRI analysis will subsequently join both claims based on the same beneficiary for the same date-of-service, for the same TIN/NPI and analyze as one claim. You should work with your billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses or QDCs are not dropped.
- QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed
- The submitted charge field cannot be blank
- The line item charge should be $0.00
- If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted - the beneficiary is not liable for this nominal amount
- Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00.)
- Whether a $0.00 charge or a nominal amount is submitted to the carrier/contractor, the PQRI QDC line is denied and tracked
- QDC line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. EPs will receive a Remittance Advice (RA) associated with the claim which will contain the PQRI QDC line-item and will include a standard remark code (N365) and a message that confirms that the QDC(s) passed into the National Claims History (NCH) file. N365 reads: ‘This procedure code is not payable. It is for reporting/information purposes only.’ The N365 remark code does NOT indicate whether the QDC is accurate for that claim or for the measure the EP is attempting to report.
- Multiple EPs’ QDCs can be reported on the same claim using their individual NPI. Therefore, when a group is billing, you should follow their normal billing practice of placing the NPI of the individual EP who rendered the service on each line item on the claim including the QDC line(s).
- Some measures require the submission of more than one QDC in order to properly report the measure. Report each QDC as a separate line item, referencing one diagnosis and including the rendering provider NPI.
- Solo practitioners should follow your normal billing practice of placing your individual NPI in the billing provider field, (#33a on the CMS-1500 form or the electronic equivalent)
- EPs may submit multiple codes for more than one measure on a single claim
- Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim
- If a denied claim is subsequently corrected through the appeals process to the Palmetto GBA, with accurate codes that also correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be included on the resubmitted claim as instructed in the measure specifications
- Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs
You may submit QDCs to Palmetto GBA either through electronic or paper based submission.
When using electronic submission, which is accomplished using the ASC X 12N Health Care Claim Transaction (Version 4010A1), you should submit CPT Category II and/or temporary G-codes in the SV101-2 ‘Product/Service ID’ Data Element on the SV1 ‘Professional Service’ Segment of the 2400 ‘Service Line’ Loop.
You must also identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 ‘Professional Service’ Segment. Further, you should submit diagnosis codes at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI08 as needed with a single reference number in the diagnosis pointer. In general for group billing, you should report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data element NM109 (with NM108=XX).
For paper-based submissions, use the CMS-1500 claim form (version 08-05). Enter the relevant ICD-9-CM diagnosis codes in Field 21 and enter Service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers in Field 24D with a single reference number in the diagnosis pointer Field 24E that corresponds with the diagnosis number in Field 21.
For group billing, you should enter the National Provider Identifier (NPI) of the rendering in Field 24J, and the Tax Identification Number (TIN) of the employer is entered in Field 25.
Group and Solo NPI Submission
When a group bills, the group’s NPI is submitted at the claim level, therefore, the individual rendering physician’s NPI must be placed on each line item, including all allowed charges and quality-data line items.
Solo practitioners must include your individual NPI on the claim line as is the normal billing process for submitting Medicare claims. For PQRI, the QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.
Timeliness of Quality Data Submission
You should be aware that claims processed by Palmetto GBA must reach the national Medicare claims system data warehouse (National Claims History file) by February 28, 2010 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not be included in the analysis.
Analysis of PQRI Data: Reporting Frequency and Performance Timeframes
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically. Some measures, due to their complexity, are reportable as registry only or measures group only.
Each measure specification includes a reporting frequency for each denominator-eligible patient seen during the reporting period. The reporting frequency described in the instructions applies to each individual EP participating in PQRI. PQRI uses the reporting frequency to analyze each measure for determination of satisfactory reporting:
- Patient-Process: Report a minimum of once per reporting period per individual EP (NPI)
- Patient-Intermediate: Report a minimum of once per reporting period per individual EP (NPI)
- Patient-Periodic: Report once per timeframe specified in the measure for each individual EP (NPI) during the reporting period
- Episode: Report once for each occurrence of a particular illness/condition by each individual EP (NPI) during the reporting period
- Procedure: Report each time a procedure is performed by the individual EP (NPI) during the reporting period
- Visit: Report each time the patient is seen by the individual EP (NPI) during the reporting period
A measure’s performance timeframe is defined in the measure’s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the quality action described in the numerator may be accomplished.
Coding and Reporting Principles for Claims-based Reporting of the E-Prescribing Measure
Similar to the PQRI, the e-prescribing measure consists of a unique denominator (eligible case) and numerator (quality action) that permit the calculation of the percentage of a defined patient population for whom care was delivered using a particular structural element. Also, similar to PQRI, claims-based reporting of the e-prescribing measure requires EPs, using their individual national provider identifier (NPI) and submitting billable services on Part B claims for allowable PFS charges, to report the quality action for the e-prescribing measure. You should review and understand the e-prescribing measure specification, which provides definitions and specific instructions for reporting the measure.
Note: you should review the following documents if you choose to participate in the E-Prescribing Incentive Program:
- ‘E-Prescribing Measure Specifications’
- ‘Claims-based Reporting Principles for E-Prescribing’ – this provides guidance about how to report the e-prescribing measure on claims
- ‘Sample E-Prescribing Claim’ – this provides a detailed sample of an individual NPI reporting the e-prescribing measure on a CMS-1500 claim
The following principles apply for claims-based reporting of the e-prescribing measure:
1. You should report one of the three e-prescribing codes listed below as the claim numerator:
- HCPCS code G8443 - ‘All prescriptions created during the encounter were generated using a qualified e-prescribing system’
- HCPCS code G8445 - ‘No prescriptions were generated during the encounter’
- HCPCS code G8446 - ‘Provider does have access to a qualified e-prescribing system and some or all of the prescriptions generated during the encounter were printed or phoned in as required by the State or Federal Law or regulations, patient request or pharmacy system being unable to receive electronic transmission; or because they were for narcotics or other controlled substances’
2. You must report the e-prescribing code (which supplies the numerator):
- On the same claim as the denominator billing code
- For the same beneficiary
- For the same date of service (DOS)
- By the same EP (individual NPI) who performed the covered service
3. You must submit the e-prescribing code with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed.
- The submitted charge field cannot be blank
- The line item charge should be $0.00
- If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted - the beneficiary is not liable for this nominal amount
- Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00.)
- Whether a $0.00 charge or a nominal amount is submitted to the carrier/MAC, the e-prescribing code line is denied and tracked
- E-prescribing line items will be denied for payment, but are passed through the claims processing system to Medicare’s National Claims History database (NCH), used for e-prescribing claims analysis. EPs will receive a Remittance Advice (RA) which includes a standard remark code (N365). N365 reads: ‘This procedure code is not payable. It is for reporting/information purposes only.’ The N365 remark code does NOT indicate whether the e-prescribing code is accurate for that claim or for the measure the EP is attempting to report. N365 only indicates that the e-prescribing code passed into NCH.
4. When a group bills, the group NPI is submitted at the claim level, therefore, the individual rendering/performing physician’s NPI must be placed on each line item, including all allowed charges and quality-data line items. Solo practitioners should follow your normal billing practice of placing your individual NPI in the billing provider field, (#33a on the CMS-1500 form or the electronic equivalent).
5. Claims may NOT be resubmitted for the sole purpose of adding or correcting an e-prescribing code.
Submission through Carriers/MACs
You may submit E-prescribing codes to carriers/MACs either through electronic submission using the ASC X 12N Health Care Claim Transaction (Version 4010A1), or paper-based submission using the CMS-1500 claim form.
When using electronic submission you should submit the E-prescribing codes in the SV101-2 ‘Product/Service ID’ Data Element on the SV1 ‘Professional Service’ Segment of the 2400 ‘Service Line’ Loop. You will need to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 ‘Professional Service’ Segment.
You should submit diagnosis codes at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI08 as needed with a single reference number in the diagnosis pointer.
In general for group billing, report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data elements NM108 and NM109.
For Paper-based submissions, use the CMS-1500 claim form (version 08-05) and enter relevant ICD-9-CM diagnosis codes in Field 21. Enter service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers in Field 24D with a single reference number in the diagnosis pointer Field 24E that corresponds with the diagnosis number in Field 21.
For group billing, the NPI of the rendering/performing provider is entered in Field 24J and the TIN of the employer is entered in Field 25.
Timeliness of Quality Data Submission
As mentioned above, claims processed by the Carrier/MAC must reach the Medicare NCH file by February 28, 2010 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not be included in the analysis.
Additional Information
If you have any questions, please contact our 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.