WellCentive PQRI 2010
Frequently Asked Questions

1. What is PQRI

The Physician Quality Reporting Initiative (PQRI) is a voluntary pay-for-reporting program in Medicare. It offers a financial incentive to physicians and other eligible professionals (EP’s) who successfully report quality measures related to services provided under the Medicare Physician Fee Schedule between January 1 and December 31, 2010.

2. Who is eligible to participate in the PQRI?

Eligible Providers include physicians and other professionals (e.g., physician assistants, nurse practitioners, chiropractors, physical therapists, ophthalmologists) who provide services paid under the Medicare Physician Fee Schedule.

3. What are the incentives for participation in the PQRI?

A PQRI participant who reports successfully will be eligible for a bonus payment of up to 2.0 percent of the total Medicare Physician Fee Schedule allowed charges for services provided during the reporting period. In addition, participants who utilize e-rx will receive an additional 2% for a total bonus payment of up to 4.0%. WellCentive provides confidential feedback reports on the data reported.

4. How were these measures developed?

Through the AMA’s Physician Consortium for Practice Improvement (PCPI), specialty societies served as a lead organizations in the development of evidence based measures. These measures were subsequently approved and endorsed by the AQA alliance and the National Quality Forum (NQF) for inclusion in the 2010 PQRI.

5. What should I consider before deciding whether or not to participate in the PQRI?

Participation is voluntary in 2010; however, there is a good chance that Congress may make participation mandatory in the future. The PQRI is a first step toward linking Medicare health professionals’ payments to quality, which is expected to evolve over time into a value-based purchasing or pay-for-performance program. Review the measure groups and individual quality measures to see which are applicable to your practice. Measure groups include a patient sample of 30 patients of any payer type with some Medicare included in the sample. Start to think about the changes you would need to make to report this data.

6. What objectives did Congress have for the PQRI program?

The PQRI is a first step toward linking Medicare health professionals’ payments to quality, which is consistent with Medicare’s ongoing transformation from passive payer to active purchaser of high-value health care.

7. What is the difference between 2009 PQRI reporting and 2010 PQRI reporting?

The 2009 PQRI consisted of 153 quality measures and 7 measures groups. Physicians reporting during the calendar year 2009 could earn up to 2 percent of total allowed charges. For 2010 PQRI consists of 173 individual measures and 13 measure groups. Also e-rx was included for 2010 for an additional 2% incentive bonus bringing the potential bonus to 4% in 2010.

8. What is the difference between registry reporting and claims reporting?

Registry-based reporting is different from claims-based reporting in that the data is aggregated and transmitted to CMS only once after the end of the calendar year. If a practice has been doing claims-based reporting they will be in the habit of reporting frequently throughout the year. This is not necessary with the registry.

9. If I have been reporting data using G codes and the 80% rule, can I submit data for payment using WellCentive PQRI?

Yes. Physicians are allowed to report measures by BOTH claims and registries. CMS will base their evaluation on the method that yields the best results for the physician.

10. Are Eligible Professionals (EP) required to pre-register or sign up with CMS?

EPs do not need to sign-up or pre-register in order to participate in the 2010 PQRI. Submission of quality data codes for the 2010 PQRI quality measures to CMS through claims or a qualified registry will indicate your intent to participate in the 2010 PQRI.

11. Can I use the registry that is part of my EMR?

You must submit your quality data codes through a qualified CMS registry. A list of qualified registries for the 2010 PQRI can be found on the CMS PQRI “Reporting” section page at http://www.ccms.hhs.gov/PQRI on the CMS website.

12. What is the last day I can submit my data to WellCentive?

You can submit your data to WellCentive as late and January 31st, 2011. However, data must reflect the calendar year of participation (January 1, 2010 – December 31, 2010).

13. Can WellCentive accept claims and/or clinical data from our database, so we do not have to manually enter the data to WellCentive PQRI?

Yes, WellCentive can interface any data you store electronically into the WellCentive PQRI system.

14. Do all patients have to be traditional Medicare patients Fee-For-Service?

When submitting using the measure group, only two patients must be Medicare Fee-For-Service patients. Submitting individual measures must meet the 80% of eligible Medicare patients rule.

15. If a patient sees a physician on a certain DOS and then follows up with a blood test on a later DOS, should /can the results of that blood test be used for the DOS on which the patient saw the physician? This applies to measures 1 & 2.

Yes the blood test can be used for reporting of the measure.

16. How early will the registries be able to submit a file?

The portal is currently set to open in first quarter 2011 for data submissions.

17. How are payments calculated?

Eligible Professionals that are considered incentive eligible will receive a 2% incentive based off of their total allowed Medicare Physician Fee Schedule Part B Charges for the reporting period.

18. If we are submitting for multiple providers and its being submitted for 12 months would it still be 1/01/09-12/31/09 (in reference to encounter dates)?

Multiple TIN/NPIs can be submitted within a file as long as it is for the same submission method. The encounter date tags are now at a provider level, so the encounter to and from dates will be specific for each NPI/TIN.

19. Can all Eligible Professionals (EP’s) Submit Data and Get Paid?

a. Yes. For example, NPs are eligible professionals and can participate in PQRI using their own NPI/TIN or, if working under an M.D., can perform and report the quality action if billed under the M.D. providing back-up and billing for their services.

20. Can you use 1P, 2P, 3P exclusion modifiers for all measures or only if it listed in the measure specification?

Only if it’s listed in the measure specification.

21. If you are reporting on the individual measures, is one limited to only Part B patients?

Yes.

22. Is there a difference between performance not done and performance not applicable? What would count as performance exclusion?

Performance not done would be considered performance not met, and a reporting exclusion whereas performance not applicable would be considered a performance exclusion.

23. What do I do if there is no response to a question? For example, the patient’s LDL value is not known.

Use exclusion code 8P or unspecified. The patient will be considered eligible for reporting purposes and excluded from performance reporting.

24. How will I know when I have completed my requirement?

You will be provided a “receipt” directly from CMS. WellCentive PQRI utilizes a user interface to alert you if information is missing, allowing you to complete the data. WellCentive performs one last integrity check before submitting to CMS on your behalf.