News

Coding Modifiers May Be Needed In Pay-for-Performance Reports


 

Physicians who 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) that began 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 lets physicians earn a bonus payment of up to 1.5% of total 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, 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 when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

▸ Modifier −1P is shows the service was not indicated or is contraindicated.

▸ Modifier −2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

▸ Modifier −3P is used to indicate 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 a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document are available online at www.cms.hhs.gov/pqri

Recommended Reading

Policy & Practice
MDedge Rheumatology
CMS Poised to Launch Pay-for-Reporting Program : The small bonus payment for physicians who report on selected quality measures goes into effect July 1.
MDedge Rheumatology
Regional Networks to Form the Basis of New Quality Push
MDedge Rheumatology
Physicians Throw Money at Language Barrier
MDedge Rheumatology
Patient Demographics May Affect Physician Quality Scores
MDedge Rheumatology
DME Suppliers May Face Big Changes in 2008
MDedge Rheumatology
Physicians Reservedly Applaud New Unfunded Trauma Law
MDedge Rheumatology
Policy & Practice
MDedge Rheumatology
Software Tracks Patients' Calls Easily, Cheaply
MDedge Rheumatology
Retail Giant Wal-Mart Tackles Health Care Reform
MDedge Rheumatology