PQRI Bonus Payment
The number of measures that need to be reported by a participating physician in the 2009 Physician Quality Reporting Initiative (PQRI) program to earn an incentive bonus remains the same as in 2007 and 2008. If three measures are applicable to an individual physician’s practice (cases), the Category II quality data codes for those three measures should be submitted to Medicare on at least 80 percent of all cases that are relevant to those measures. If only one or two measures are applicable to the services provided by an individual, the individual is still able to participate and should report Category II codes for the one or two measures that are applicable.
At the end of the 2009 reporting period, the Centers for Medicare and Medicaid Services (CMS) will validate satisfactory reporting for each participant based on their National Provider Identifier number. If a participant successfully submits Category II codes for only one or two PQRI measures for the reporting period and achieves a reporting rate of at least 80 percent on each measure submitted, and does not submit any Category II codes for any other PQRI measure, the participating individual’s claims will be subject to the measure-applicability validation (MAV) process.
In the MAV process, the first step is a “clinical relation test,” which is used to determine whether the individual could have submitted additional measures. Most, but not all, of the 153 PQRI measures are grouped into “clinical clusters.” During the clinical relation test, claims submitted by an individual reporting one or two measures will be analyzed to validate whether other measures in the same clinical cluster could have been reported. For 2009, a Diagnostic Imaging cluster includes measures 10, 11, 145, 146, and 147 . After analysis, if no additional reportable measures were in the same cluster as the one or two reported, then the participant is considered eligible for the bonus. If an additional measure(s) is included in the same cluster, then the “minimum threshold test” will be performed.
In the minimum threshold test, claims for which an additional measure (from the same cluster) could have been reported are counted. If 15 or more claims are submitted, the participant is considered accountable for reporting the additional measure(s) and will not receive a bonus. If fewer than 15 claims are submitted for which an additional measure(s) could be reported, the participant is not accountable for reporting and will receive a bonus for successfully reporting the one or two measures.
Consider the following examples:
Example 1: You successfully reached the 80 percent reporting rate for measures 10 and 11 in the diagnostic imaging cluster; therefore, your claims will be analyzed to see whether you could have reported on measures 145, 146, or 147, which are also listed in the diagnostic imaging cluster. If there were no claims with the associated International Classification of Diseases, Ninth Revision (ICD-9)/Current Procedural Terminology® (CPT®) combinations for those measures, you will receive a bonus. If you submitted claims that had ICD-9/CPT® codes associated with measures 145, 146, or 147 on 15 or more claims, you will not receive a bonus, because you should have reported these claims with the appropriate PQRI Category II code. If there were fewer than 15 claims with the associated ICD-9/CPT® codes for measures 145, 146, or 147, you will receive a bonus.
Additionally, perhaps you could have submitted the Category II quality codes for perioperative measure 20, but you did not. You still may be eligible to receive a bonus based on the above analysis, because the MAV clinical relation test does not look across clusters, and measure 20 is in the perioperative clinical cluster ― not the diagnostic imaging cluster.
Example 2: You successfully reached the 80 percent reporting rate for measures 145 (diagnostic imaging cluster) and 20 (perioperative cluster); therefore, your claims will be subject to the MAV process. Because you submitted measures in two clinical clusters (diagnostic imaging and perioperative), your claims will be analyzed to see whether you could have reported one additional measure from either of those clusters for a total of three measures. The perioperative cluster has five measures, each with the same denominator, so it is likely you could have reported 21, 22, and 23 with the same frequency as 20; therefore, you would not receive a bonus.
Important note: If you report Category II codes for three measures, even if you report the code on only one claim, you will need to report 80 percent of cases for those three measures or you will not receive a bonus. If a Category II code is submitted just once, then you are saying to Medicare that you are reporting on that measure. In another scenario, if you report Category II codes on four measures and successfully report on three measures, but not the fourth, you will still receive the bonus.
If you report only one measure and you do so diligently and accurately and meet the 80 percent successful submission rate, and pass the MAV process, you will receive a bonus of 2 percent of total allowable charges submitted under the Medicare Physician Fee Schedule, that is, all charges, not just the charges submitted on claims with Category II codes.
The above information has been verified with a CMS representative in the PQRI program office. More information on the MAV can be found on the CMS Web site in the Downloads section at http://www.cms.hhs.gov/PQRI/25_AnalysisAndPayment.asp#TopOfPage. Questions can be sent to p4pquestions@acr.org or submitted in the FAQs on the CMS Web site.
Judy Burleson
Director, Metrics
