The Physician Quality Reporting Initiative (PQRI) was formally launched under a provision of the Tax Relief and Health Care Act of 2006. In 2011, the program name was changed to Physician Quality Reporting System (PQRS).

The PQRS program provides a financial incentive to eligible professionals for voluntarily reporting data on specific quality measures applied to the Medicare population.  Medicare Part C–Medicare Advantage beneficiaries are not included in this program.  Under PQRS, incentives will be paid simply for satisfactorily reporting on designated quality measures. However, it is anticipated that PQRS eventually will be transitioned to a formal pay for performance model. CMS uses the word "report" to mean a claim form where the medical services reported (CPT codes and ICD-9 codes) indicate an opportunity for PQRS measure reporting. The 13 individual measures that pertain to emergency medicine are available for submission by a claim form or a qualified registry.  PQRS measures are available to indicate that the measure was performed, or not performed based on an acceptable exemption or exclusion.  If a specific PQRS code is not submitted, the opportunity to receive the financial incentive is forfeited. 

The eligible quality measures under PQRS are listed on the CMS website and are not specialty-specific, i.e., a provider does not have to be a cardiologist to report on giving aspirin to a patient with acute myocardial infarction (AMI).  In addition, CMS will allow more than one participating provider to report on quality codes on the same patient.

The 2013 PQRS System Measures List identifies over 300 quality measures.  There are no new measures that apply to Emergency Medicine for 2013.  Note that gaps in measure numbering reflect retired PQRS measures that were not included in the updated list.

PQRS measures can originate from multiple sources. The majority of PQRS measures have been developed by the AMA PCPI (Physician Consortium for Performance Improvement). Additional information regarding the scope and work of PCPI is available at:  http://www.ama-assn.org/ama/pub/category/2946.html.  ACEP is represented as a standing member of the PCPI and actively participates. Additionally, several ACEP members served on an Emergency Medicine Work Group that revised and finalized those PCPI measures that were directly relevant to our specialty. The next step before PQRS inclusion requires vetting by the National Quality Forum and ACEP participates in this process as well.

As required by applicable statutes, the list for each year is developed through formal notice-and-comment rulemaking in the previous year.  According to federal statute, the measures shall: (1) have been adopted or endorsed by a consensus organization, such as the Ambulatory Quality Association (AQA) Alliance or National Quality Forum (NQF); (2) include measures that have been submitted by a physician specialty; (3) are identified by CMS as having used a consensus-based process for development; and (4) include structural measures, such as the use of electronic health records and electronic prescribing technology. 

Incentive payments are available through 2014.  Beginning in 2015, physicians who do not satisfactorily report PQRS measures will be subject to negative payment adjustments.  Incentive payments and negative payment adjustments are based upon the physician's total allowable Medicare charges for a given year.  Physicians who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2013- December 31, 2013, will earn an incentive payment of 0.5% of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished during that applicable reporting period.  This includes all deductibles and co-pays. Additionally, where Medicare is the secondary insurance, PQRS bonuses are based on overall charges, and not limited just to the portion paid by Medicare.  There is no current requirement to participate in the PQRS.  However, CMS finalized in its 2012 Medicare Physician Fee Schedule that 2015 program penalties will be based on 2013 performance.  Therefore, those physicians who elect not to participate or are found unsuccessful during the 2013 program year, may receive a 1.5% payment penalty in 2015 and 2% therafter.  Information on the PQRS program may be found at:  www.cms.hhs.gov/PQRS

In addition, starting in 2012 ABEM certified physicians became eligible for the ABEM PQRS MOC (Maintenance of Certification) Additional Incentive Payment Program.  Physicians have the potential to earn an additional 0.5% of total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS).  To be eligible for the additional incentive payment, you must successfully submit Medicare claims and PQRS measures via the usual process.  You must also meet additional ABEM MOC requirements such as:     

•Pass a LLSA test

•Complete and report a practice improvement (PI) activity

•Complete and report a communications/professionalism (CP) activity

The following ABEM link lists complete requirements for the PQRS MOC program:

www.abem.org/PUBLIC/portal/alias_Rainbow/lang_en-US/tablD_4347/DesktopDefault.aspx

 The program applies to physicians as well as Physician Assistants and Nurse Practitioners who report on eligible services provided to Medicare beneficiaries. Credit for quality measures will be assigned to the reporting provider, based on his or her individual National Provider Identifier (NPI); however, payment of the bonus will be based on the Taxpayer Identification Number (TIN) of the reporting entity.

No, registration is not necessary to participate in PQRS. If the physician or physician extender chooses to participate, the required PQRS codes will need to be reported on the CMS 1500 physician claim form used for billing professional services to Medicare. Individual physician reporting will be tracked by the provider's NPI.

The AMA Physician Consortium for Performance Improvement (PCPI) Committee, with active participation by ACEP members, is responsible for identifying measures that apply to Emergency Medicine. For 2013, there are 13 measures potentially linked to emergency medicine by CPT E/M codes 99281 through 99285 and/or critical care services (CPT codes 99291), as well as specific ICD-9 diagnosis codes.

These include:

Measure #28 Aspirin at Arrival for Acute Myocardial Infarction (AMI)
Description:  Percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay

Measure #31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage (only critical care code 99291 applies)
Description:  Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day two. Though the specifications further state: “It is anticipated that clinicians who care for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital setting will submit this measure.”, making these measures less applicable to Emergency Physicians in the acute care setting.

Measure #54 Electrocardiogram Performed for Non-Traumatic Chest Pain 
Description:  Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed

Measure #55 Electrocardiogram Performed for Syncope 
Description:  Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed

 
Measure #56 Vital Signs for Community-Acquired Bacterial Pneumonia 
Description: Percentage of patients aged 18 years and older with a diagnosis of community –acquired bacterial pneumonia with vital signs documented and reviewed

Measure #59 Empiric Antibiotic for Community-Acquired Bacterial Pneumonia 
Description:  Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed

Measure #76 Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol
Description: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for who CVC was inserted with all elements of maximal sterile barrier technique (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis followed).

Measure #91: Acute Otitis Externa (AOE): Topical Therapy

Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

Measure #93: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

Measure #252: Anticoagulation for Acute Pulmonary Embolus Patients
 
Anticoagulation ordered for patients who have been discharged from the emergency department (ED) with a diagnosis of acute pulmonary embolus.  This measure is to be reported each time a patient has been discharged from the emergency department (i.e., transferred to another unit within the facility, transferred to another facility, or discharged to home) with a discharge diagnosis of acute pulmonary embolus during the reporting period.

Measure #254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.

Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED).  This measure is to be reported each time a pregnant patient presents to the emergency department with complaints including blunt abdominal trauma, vaginal bleeding, ectopic pregnancy, and threatened or spontaneous abortion.  Patients who present to the emergency department with these complaints should have documentation in the medical record of receiving an order for Rh-Immunoglobulin (Rhogam).

PQRS Measures relevant to Emergency Medicine tht have been Deleted for 2013 include:

Measure #57  Assessment of Oxygen Saturation of Community-Acquired Bacterial Pneumonia

Description:  Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Measure #58  Assessment of Mental Status for Community-Acquired Bacterial Pneumonia

Description:  Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Measure #92:  Acute Otitis Externa (AOE): Pain Assessment

Percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.

Measure #253:  Pregnancy Test for Female Abdominal Pain Patients

Percentage of female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain for whom a pregnancy test is ordered.  This measure is to be reported each time a female patient aged 14 to 50 presents to the emergency department witha chief complaint of abdominal pain.  The patient should have documentation in the medical record of having a pregnancy test (urine or serum) ordered in the emergency department. 

In order to be eligible for the PQRS bonus, for registry submissions the threshold is 80% for at least 3 measures.  For claims submissions, the threshold is 50% for at least 3 measures.  As such, emergency physicians should report on at least three measures.  For professionals who achieve a reporting rate at or above threshold for each of fewer than three PQRS measures, a measure-applicability validation process will determine whether they should have submitted quality-data codes for additional measures and then eligibility for final payment will be determined. See the "2013 Measure-Applicability Validation Process for Claims-Based Participation" for details on CMS’ website: https://www.cms.gov/PQRS//25_AnalysisAndPayment.asp

In addition, ABEM certified physicians may be eligible for the ABEM PQRS MOC Additional Incentive Payment Program as described in FAQ# 5.

There are two reporting periods available for eligible professionals: a) 12-month reporting period from January 1 through December 31 OR b) a 6-month reporting period from July 1 through December 31. The 6-month reporting period only applies to registry submission of measures groups, which don't typically apply to the ED.  ED providers usually submit individual measures and the reporting period is 12 months for both claims and registry.

It is important to contact your coding and billing professionals and assure that your group is prepared to report PQRS measures.  Physicians will report on these measures through a defined set of newly developed CPT II codes and modifiers (1P, 2P, 3P and 8P) or five digit HCPCS codes (called "G-Codes") that are to be submitted on the usual CMS 1500 physician claim form in field 24D. As of January 1, 2012, the PQRS codes for measure #55 (12-lead EKG performed for Syncope) changed.  G8704, G8705, G8706 and G8707 have replaced 3120F-1P, 3120F-2P and 3120F-8P.  Quality codes under CPT Category II may be reported concurrently with other service codes on either paper-based CMS 1500 claims or electronic 837-P claims, and should be reported with a charge amount of $0.00 or $0.01.

Suppose you treat a patient with AMI in the ED.  If you order aspirin for the patient – and you document it on the medical record – your biller should give you credit for Quality Measure #28 (Aspirin at Arrival for Acute Myocardial Infarction). But if for some reason you don’t order aspirin, e.g., because of an aspirin allergy or patient refusal, and you likewise document it, you would also get credit for reporting on Quality Measure #28. And if you do this for 50% of the AMI patients you treat and duplicate this 50% performance level for at least two other quality measures, you become eligible for a bonus payment under PQRS.

Scenario 1: Aspirin received or taken within 24 hours before emergency department arrival or during emergency department stay

PQRS assigned code: 4084F

OR

Scenario 2: Aspirin not Received or Taken 24 hours Before Emergency Department Arrival or during Emergency Department Stay

PQRS assigned code:  4084F, with one of the following modifiers:

•      1P: Documentation of medical reason(s) for not receiving or taking aspirin within 24 hours before emergency department arrival or during emergency department stay
•     2P: Documentation of patient reason(s) for not receiving of taking aspirin within 24 hours before emergency department arrival or during emergency department stay
•    8P: Aspirin was not received within 24 hours before emergency department arrival or during the emergency department stay, reason not otherwise specified.

[Of note, the 3P modifier is not eligible to append to the aspirin for AMI measure. 3P is available for other measures to describe system reasons that justify why a measure may not have been satisfied.]   

CMS has defined a numerator and a denominator that permit the calculation of the percentage of patient visits that achieve appropriate reporting of quality measures.

There are 4 elements that must be extracted from the record to determine if the encounter qualifies for a PQRS measure: insurance status, patient age, ICD-9 code(s) and CPT code(s).  The following is the step-by-step process that your biller would use to document Quality Measure #28 on the CMS 1500 billing form. First, the biller would determine the insurance status and age of the patient.  Then check for documentation on the medical record that supports one of the ICD-9 Acute MI diagnostic codes for the measure for example:  

Then, the biller would check for documentation that supports the correct CPT service code (99281-99285 or 99291). Assuming the above criteria were met, the biller would then report on your PQRS quality measure based on your documentation. Conversely, if the patient’s diagnosis was chest pain or acute coronary syndrome, the encounter would not meet the measure specifications for measure #28  and the PQRS code would not apply.

A threshold of 50%, i.e. reporting the appropriate quality measure codes for 50% of qualifying cases that are eligible for the quality measure, is required for each of three measures to be able to receive the 0.5% PQRS bonus for 2013.

If the patient encounter qualifies for a PQRS measure, but the measure is not received, CPT Category II code modifiers 1P, 2P, or 3P are available to describe medical, patient, or system reasons, respectively, to communicate the reason the measure was not received.  

Where an exclusion does not apply, the CPT Category II modifier 8P may be used to indicate that the process of care was not provided for a reason not otherwise specified.

• 1P Performance measure exclusion modifier due to medical reasons includes:
  • Not indicated (absence of organ/limb, already received/performed, other)
  • Contraindicated (patient allergy history, potential adverse drug interaction, other)
  • Other medical reasons
• 2P Performance measure exclusion modifier due to patient reasons includes:
  • Patient declined
  • Economic, social, or religious reasons
  • Other patient reasons
• 3P Performance measure exclusion modifier due to system reasons includes:
  • 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
• 8P Performance measure reporting modifier - action not performed, reason not otherwise specified.  The 8P reporting modifier facilitates reporting an eligible case on a given measure when the clinical action does not apply to a specific encounter.  Eligible professionals can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance.  Eligible professionals should use the 8P reporting modifier sensibly for applicable measures they have selected to report.  The 8P modifier may not be used freely in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice's quality improvement goals.

Each practitioner will be identified and scored individually using his/her National Provider Identifier (NPI) number. Each NPI with greater than 50% reporting on three or more measures will be awarded a PQRS bonus. The aggregate funds of the individual providers will be paid to the Tax Identification Number (TIN) or Employer Identification Number (EIN) of the reporting entity.

Documentation should reflect the measure was provided or the reason the measure was not provided. Contact your coding and billing professionals to determine an efficient system for communicating the quality measure report from physician to coder. This could include the use of a separate and easily identified reporting note, stamp or template.

CMS has established a website for PQRS information at: www.cms.hhs.gov/PQRS.