Physician Quality Reporting Initiative (PQRI

QUESTION: Is the primary diagnosis the only diagnosis that is applicable to the quality measure being reported or will Physician Quality Reporting Initiative (PQRI) consider all diagnoses reported on a claim?

ANSWER: All diagnoses and quality-data line items are considered for Physician Quality Reporting Initiative (PQRI) reporting. There is no requirement to sequence diagnoses into primary and secondary categories for PQRI. Quality-data codes (QDCs) should be submitted for any measures that are applicable to each Medicare Physician Fee Schedule (PFS) claim, as determined by all the diagnosis (ICD-9-CM) and service (CPT Category I) codes submitted on the claim line items for payment. Each QDC should point to one of the diagnosis codes already present on the claim for the payable service. Without a diagnosis pointer on the QDC line item, the line item will be rejected and returned to the provider as unprocessable. The PQRI quality measure specifications identify the combinations of diagnosis and service codes making a claim eligible for each measure. The PQRI Quality Measure Specifications Manual is available in a download from the CMS PQRI Measures.
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QUESTION: Please clarify how the various assessment and facilitation services required by the Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities will be reimbursed.

ANSWER: Special demonstration billing codes will be established to allow reimbursement for the annual cancer screening assessment for the intervention group, the entrance and exit cancer screening assessment for the control group, and the monthly capitated rates for cancer screening, diagnostic, and treatment facilitation services. The annual cancer screening assessment for the intervention group and the entrance and exit cancer screening assessment for the control group will be reimbursed as separate capitated costs derived from the overall budget specified by the awardee. The cancer screening, diagnosis, and treatment facilitation services delivered to project enrollees will be reimbursed under the capitation payment system.

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