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There is no question that Medicare and Medicaid Services (CMS) is slowly evolving out of fee-for-service and into a system of recording quality data, otherwise known as Physician Quality Reporting System (PQRS).

The understanding and adopting of PQRS has been a slow process despite the 2% bonuses from Medicare. And why? It’s a tremendous burden on the medical practice. A few weeks ago I attended an ICD-10-CM conference. When PQRS was addressed, many providers commented that they would rather see a few extra patients to offset CMS’s bonus money than burden their entire staff with getting the PQRS criteria right. Eligible Professionals (EP) felt they reported their diagnosis codes appropriately and implementing PQRS would be a waste of time. Unfortunately, this trend is not going away. In fact, private payers will soon be following in CMS’s footsteps, so perhaps providers should rethink how they report their data. We are in business to make money, not lose it and this is a trend that is here to stay.

Medical Billing and Coding Course Online – The Challenge of PQRS

So what exactly is PQRS? It is a system that formulated back in 2006 under the Tax Relief and Health Care Act. Initially it was referred to as PQRI, Physician Quality Reporting Incentive with an initial incentive of 1.5%. I remember purchasing a 1000 page manual in an attempt to understand what was being presented. I quickly put the text on the shelf – but not for long! The Medicare Improvement for Patients and Providers Act established in 2008 changed all that by making it a permanent program and changed the PQRI to PQRS with increased bonus money.

PQRS is comprised of a series of measures which consist of a denominator and numerator. Denominators identify who qualifies as an eligible patient for reporting a specific measure such as age, sex, CPT codes, ICD-9-CM codes, etc. Numerators describe the specific action that was performed. This is actually the “quality measure” on an eligible patient. An example would be a diabetic foot exam.

This is considered a clinical action required by the measure for performance and reporting purposes.
There are different methods to report quality measures such as individual claims, group reporting, reporting through registries, or through your EMR. There are 288 measures in 2014 for PQRS.

Each specialty is different so I suggest going to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS and follow the criteria specific to your specialty.

Setting up a tracking system will benefit you in the long run. For example, using diabetes, you should list all patients with diabetes and chart the measures as you report them. If you are still using charts, put a sticker on the charts of your diabetic patients and check off measures as you report them. Most EMR systems have notification systems that remind you when the patient is eligible for the measures selected and tracks when the patient has had all eligible measures submitted for the year.

PQRS is not an easy concept to grasp. I suggest visiting https://questions.cms.gov/ for Frequently Asked Questions (FAQs) which will guide you in the right direction. Also, visit your specialty’s Medical Association website. Information will be geared towards your practice’s specific needs.

Medical Billing and Coding Course Online – The Challenge of PQRS

 Learn More about Medical Billing and Coding Course Online – The Challenge of PQRS

Basic Medicare Information Medical Coding
AAPC – Three New Educational Resources for 2011 PQRS

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2016-11-20T23:37:51+00:00

About the Author:

JoAnne Sheehan
JoAnne Sheehan has been successfully providing medical billing, coding and practice management services in the New England area for over thirty-three years. She has witnessed the evolution of healthcare and the increased complexities of medical billing and coding regulations, creating a need for education in this field. JoAnne has been featured in numerous medical publications and has acted as a medical billing expert in highly profiled Medicare and Medicaid fraud cases in Boston and has trained others on both a local and national level in medical billing and coding. She is a certified medical coding instructor, practice management consultant, and an AAPC approved ICD-10-CM instructor. Her hands-on experience is an asset for the CCO students she coaches. She is President and Founder of Lomar Associates, Inc., a practice management company established in 1981.

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