PQRS Measures: Claims Based Reporting Principles


After claims are submitted, you will receive a remittance advice N365 indicating that your quality measure medical codes and your quality data codes line items are denied. The Remittance Advice N365 tells you, “This procedure code is not payable. It is for reporting or information purposes only”. Now, also remember that this remittance advice, the N365 does not indicate that your coding accuracy or the accuracy of your QDC submission.

But what it means is that the claim has passed through local carrier, has been accepted by the local carrier for payment of the clinical services and has been forward to what we have called the National Claims History file for review and analysis of the QDC or quality data your quality measures submitted.

Let's look how these quality measures are reported. Let's look at quality measure number 48 urinary incontinence 1. This quality measure can only be reported once per reporting period. And this is for female age 65 or over. And your denominator in the fraction will include the office visit codes and the relevant E M codes.

Your numerator will be the 1090F presence or absence of urinary incontinence assessed. In other words, the urologist has asked the patient, “Do you have urinary incontinence?” Now you notice that you have specific modifiers for these category II quality measure codes to ensure correct use of modifiers. They're modifier 1P which says it is not assessed for medical reasons. Maybe the person is so ill that you're not going to get into that. Or modifier 8P not assessed for other reasons. Maybe the patient just doesn’t want to buy this to tell you about her incontinence.

Let’s look at a urinary incontinence, another quality measure reportable again reported once per year. It pertains to a female 65 years or older. And the denominating codes are the office visits and other E/M services. But also there's a diagnosis for stress incontinence, urinary incontinence and ureses. The codes for this, the category II code is 1091F, again, a five item alphanumeric code for urinary incontinence characterization whether it's how often they have it, how much volume is lost, the timing, the type of symptoms associated and how bothersome.

Let's look at quality measure, urinary incontinence III, quality measure number 50. We can report this once per reporting period. And here, we have a female again aged 65 or over. And our denominating codes are the E/M visits and office visit. And we also can use an ICD 9 codes for stress urinary incontinence, the various forms of incontinence and ureses. Again the category II code for urinary incontinence in which we are establishing or making a plan of care and this is documented, we use the category II code 0509S.

Let's look at the algorithm on four measure 50. The question is, “Is the patient female 65 years or old is seen for an E M code and an ICD diagnosis code?” And the answer is no which is not 65 or it's male patient. No PQRI code is supported. If the answer is yes, has an incontinence plan of care been reported for this patient since January 1st because you can only report this once a period. And yes, it has been reported so you don’t do it again.

But if it has not been reported, was urinary incontinence plan of care documented during this visit? And the answer yes, we're going to bill the 0509S. Now, if it wasn’t done, we can still get credit for the quality measure reporting by reporting the category II code 0509S 80 which indicates that this was not documented for other reason.

Let's look at how we're going to put these three medical codes, these three quality measures on one 1500 form. Here we have the patient that is seen in the office for a calculus of the kidney ICD 9 code 592.0 and she has a visit a 99213 which will be the denominator for which we charge.

And then you can see that now we have quality measures for urinary incontinence assessed. 1090F, classified 1091F and the documented plan of care 0509F. Again, notice in box 24F that there is a zero dollar charge. And in box 24K, the line item, that we have the NPI number of the providing urologist.

Now, we can get other quality PQRS measures for urologist. And let's look at another one. Let's look at perioperative care number 20. The timing of an Antibiotic Prophylaxis by the ordering physician. And the category II code is 4047F documentation of order for prophylactic antibiotic. And as you can see, again, we can use modifier 1P if it's not documented for medical reasons or 8P if it's not ordered or documented in reason not specified. And we have another category II code under this number 20 perioperative care, 4048F documented that antibiotics were administered one hour preop.

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