Eligible Professionals for PQRS
Under Physician Quality Reporting System (PQRS), covered profession al services are those paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services which get paid under or based on the PFS, those services are eligible for PQRS incentive payments and/or payment adjustments.
The following professionals are eligible to participate in PQRS:
1. Medicare physicians
Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic
2. Practitioners
Physician Assistant
Nurse P ractitioner*
Clinical Nurse Specialist*
CertifiedRegistered Nurse Anesthetist* (and Anesthesiologist Assistant)
CertifiedNurse Midwife*
Clinical Social Worker
Clinical Psychologist
Registered Dietician
NutritionProfessional
Audiologists
*Includes Advanced Practice Registered Nurse (APRN)
3. Therapists
PhysicalTherapist
Occupational Therapist
Qualified Speech-Language Therapist
Below for the PQRS measure or Modifiers used frequently
1P—Physician Quality Reporting System (PQRS), Performance Measure Exclusion due to Medical Reasons
The CMS Physician Quality Reporting System (PQRS) provides incentives to eligible health care providers who report quality measures. Beginning in 2015, the program also applies a negative payment adjustment to eligible providers who do not “satisfactorily” report certain quality data.
Submit this modifier with a quality data code (QDC) when the performance measure would normally apply, except in the case of the specific patient, the measure does not apply because of the patient”s medical condition (“medical reasons”). Examples:
- “Not indicated”
- Absence of organ or limb
- Already received/performed
- Contraindicated
- Patient allergic history
- Potential adverse drug interaction
Other helpful tips:
- Medicare does not reimburse the QDCs. Submit a $0 charge or a nominal amount, such as $0.01.
- The QDCs must be reported on the same claim as the applicable payable service(s).
2P—Physician Quality Reporting System (PQRS), Performance Measure Exclusion due to Patient Reason
The CMS Physician Quality Reporting System (PQRS) provides incentives to eligible health care providers who report quality measures. Beginning in 2015, the program also applies a negative payment adjustment to eligible providers who do not “satisfactorily” report certain quality data.
Submit this modifier with a quality data code (QDC) when the performance measure would normally apply, except in the case of the specific patient, the measure does not apply because of reasons given by the patient (“patient reason”). Examples:
- Patient declined due to economic, social, or religions reasons
Other helpful tips:
- Medicare does not reimburse the QDCs. Submit a $0 charge or a nominal amount, such as $0.01.
- The QDCs must be reported on the same claim as the applicable payable service(s).
3P—Physician Quality Reporting System (PQRS), Performance Measure Exclusion due to System Reason
The CMS Physician Quality Reporting System (PQRS) provides incentives to eligible health care providers who report quality measures. Beginning in 2015, the program also applies a negative payment adjustment to eligible providers who do not “satisfactorily” report certain quality data.
Submit this modifier with a quality data code (QDC) when the performance measure would normally apply, except in the case of the specific patient, the measure does not apply because of a reason related or attributable to the health care system. Examples:
- Resources to perform the service not available
- Insurance coverage/ payor-related limitations
Other helpful tips:
- Medicare does not reimburse the QDCs. Submit a $0 charge or a nominal amount, such as $0.01.
- The QDCs must be reported on the same claim as the applicable payable service(s).
8P—Physician Quality Reporting System (PQRS), Action Not Performed, Reason Not Otherwise Specified
The CMS Physician Quality Reporting System (PQRS) provides incentives to eligible health care providers who report quality measures. Beginning in 2015, the program also applies a negative payment adjustment to eligible providers who do not “satisfactorily” report certain quality data.
Submit this modifier with a quality data code (QDC) when the performance measure would normally apply, except in the case of the specific patient, the measure does not apply because of an exclusion that does not fall under the guidelines for CPT modifiers 1P, 2P, or 3P.
Other helpful tips:
- Medicare does not reimburse the QDCs. Submit a $0 charge or a nominal amount, such as $0.01.
- The QDCs must be reported on the same claim as the applicable payable service(s).
Reference:
- Main CMS PQRS web page
- http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf
