Frequently Asked Questions

1. What is the Physician Quality Reporting Initiative (PQRI)?

Answer:The Physician Quality Reporting Initiative (PQRI) is a voluntary physician quality reporting program administered by CMS that provides a financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the Medicare Physician Fee Schedule. The establishment of this federal program was mandated by the Tax Relief and Health Care Act of 2006 (TRHCA) and was made permanent by the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA). 

2. What is the main focus of the Physician Quality Reporting Initiative (PQRI)?

Answer: PQRI is a first step toward linking Medicare health professionals’ payments to quality, which is consistent with Medicare’s ongoing transformation from a passive payer to active purchaser of high-value health care. Physicians and other eligible professionals, who choose to participate in the PQRI in 2009, will gain experience in capturing and submitting data on the quality of care they submit through the claims process.

3. Is participation in the PQRI mandatory?

Answer: No. Participation in the PQRI is voluntary.

4. Why should I participate in the Physician Quality Reporting Initiative (PQRI)?

Answer: Physicians and other eligible professionals will have the opportunity to use participation in the PQRI program to improve the care of the patients they serve through the evidence-based measures that are based upon clinical guidelines. Participating in PQRI is also a way to prepare for future pay-for-performance programs. Additionally, the 2.0% bonus incentive is new money being made available to reward participating professionals.

5. What if I choose not to participate?

Answer:  Although participation is voluntary this year, CMS has given indication that future quality initiatives and electronic health record reporting may be required, and will likely be based on a pay-for-performance structure. Other payers are likely to follow suit. Reporting in 2009 will give you a head start to assimilate documentation requirements and/or workflow changes needed to report successfully in the future.

6. What are the financial benefits of participation in the Physician Quality Reporting Initiative (PQRI)?

Answer: A PQRI participant who reports successfully will be eligible for a lump-sum bonus payment of up to 2.0% of the Medicare Physician Fee Schedule allowed charges for services provided during the reporting period. For example, a physician who has $15,000 in total Medicare allowed charges per month will realize a potential bonus of $3,600 (2.0% of $180,000 charges for the full year).

7. What is considered successful reporting under the Physician Quality Reporting Initiative (PQRI)?

Answer: If there are four or more quality measures applicable to the services provided by the eligible professional, then at least three measures, selected by the professional, must be reported for at least 80% of the cases in which each measure was reportable. If there are no more than three quality measures applicable to the services provided by an eligible professional, then each measure must be reported for at least 80% of the cases in which the measure was reportable. Eligible professionals are encouraged to report on as many quality measures as are applicable to the services provided. Reporting on as many applicable measures as is practical will increase the opportunities to reach the 80% successful reporting level.

8. How do I report?

Answer:  There are two ways to report for PQRI in 2009: reporting through an approved registry one time at the end of a reporting period, or reporting throughout the period by appending appropriate G codes on individual claims. To make participation easier for eligible professionals, PQRI offers two reporting periods for registry reporting in 2009: January 1 through December 31, and July 1through December 31.
    If they are using Allscripts CQS, all eligible professionals need to do is document appropriate information in their PM and EHR systems, and Allscripts CQS will take care of the rest. CQS extracts applicable PQRI data from these systems, stores it in a data warehouse, and reports it to CMS at the end of the reporting period, (as TeamPraxis is a CMS-approved registry).

9. What changes will I see on my Medicare Explanation of Benefits?

Answer: When participating in PQRI via claims based reporting, extra lines with a charge of $0.00 will appear on the Explanation of Benefits with a remark code indicating that the line is for quality reporting purposes only on all PQRI qualified claims. These lines can be ignored and should not affect payment posting.

10. Is PQRI participation for Primary Care Physicians (PCPs) only?

Answer: No, there are PQRI measures that are relevant to many specialties. 

11. How will TeamPraxis assist me with PQRI reporting?

Answer: TeamPraxis will assist with selecting measures, identifying eligible patients, and reporting data to CMS via registry reporting. Filling out forms and worksheets for CMS will not be necessary to participate. Allscripts CQS will extract the information directly from the electronic health record (EHR) and practice management (PM) systems. The Physician Dashboard will provide each provider with up-to-date reporting and performance status, which CMS will not provide during the reporting period. Using the Allscripts CQS, successful reporting can be achieved with minimal effort or change in workflow.

12. Will PQRI clinical performance measure results be publicly reported?

Answer: The 2009 PQRI will not publicly report PQRI quality information at the individual-professional, group practice, or Taxpayer Identification Number (TIN) level. Some information about participation, reporting, and performance rates, aggregated at state, regional, or national average levels, may be made available to the public.

13. If only one physician in a group practice successfully reports PQRI quality data codes on claims, how will the bonus be calculated and paid?

Answer: CMS will use the Taxpayer Identification Number (TIN) as the billing unit for the 2009 PQRI, any bonuses earned by individual physicians will be paid to the TIN holder on record. Though the analysis of satisfactory reporting will be performed at the individual eligible professional level using individual-level NPI data, bonuses will paid to the holder of the TIN, aggregating individual bonuses for groups that bill under one TIN.

14. Will CMS permit more than one physician or other eligible professional to submit quality data for the same Physician Quality Reporting Initiative (PQRI) measures on the same patient(s)?

Answer: Yes. Eligible professionals choose measures that are specific to the patients they treat and the services they furnish. It is possible that more than one professional will submit quality-data codes for the same measure(s) for the same beneficiary. In the 2009 PQRI, CMS will not attribute a beneficiary to only one eligible professional.

15. Does CMS have a PQRI site?

Answer: Yes, it is http://www.cms.hhs.gov/pqri/