May 2007 Client Newsletter

Medicare’s Physician Quality Reporting Initiative (PQRI) Program

Detailed program instructions, educational materials, and supportive tools are posted as they become available on the CMS PQRI Web site at: http://cms.hhs.gov/PQRI . Here are a few key aspects of the program that begins July 1, 2007 and ends December 31, 2007.

Eligible Professionals

1. Medicare physician, as defined in Social Security Act (SSA) section 1861(r):
• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Chiropractor

2. Other practitioners described in SSA section 1842 (b)(18)(C):
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist
• Certified Nurse Midwife
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional

3. Therapists:
• Physical Therapist
• Occupational Therapist
• Qualified Speech Language Pathologist

All Medicare enrolled professionals in these categories are eligible to participate in the 2007 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.

Payment for Reporting

Participating eligible professionals who successfully report as prescribed by TRHCA Section 101 may earn a 1.5% percent bonus, subject to the cap. The potential 1.5 percent bonus will be based on allowed charges for covered professional services:
Furnished during the reporting period of July 1 through December 31, 2007,
Received into the CMS National Claims History (NCH) file by February 29, 2008, and
Paid under the Medicare Physician Fee Schedule.

The bonus will apply to allowed charges for all covered professional services, not just those charges associated with reported quality measures. The term “allowed charges” refers to total charges, including the beneficiary deductible and co-payment, not just the 80 percent paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. So if you were paid $50,000 by Medicare during the 6 month period you could earn up to $750 extra.

Feel free to call Rich with any questions.

If you plan to participate in this incentive program please notify CPB ASAP so we can begin to load the Quality codes into your data set. We will also need to discuss how you will report these codes on your charge forms.