Physicians who choose to participate in Medicare's pay-for-reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.
Under the Physician Quality Reporting Initiative (PQRI) slated to begin July 1, reporting for certain measures will include adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.
The PQRI is a voluntary program that allows physicians to earn a bonus payment of up to 1.5% of allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures, and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.
When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT-II code if the service was not provided. These modifiers are not used with G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:
▸ Modifier −1P is used to show that the service was not indicated or is contraindicated for medical reasons.
▸ Modifier −2P means the service was not provided for patient reasons, such as the patient declining or religious objections.
▸ Modifier −3P indicates that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.
▸ Modifier −8P is used to indicate that the action was not performed and the reason has not been specified.
Specific instructions on when to use a modifier are in the 2007 PQRI Specifications Document, which is available online at www.cms.hhs.gov/pqri