Submit PQRS Codes to CMS Directly – Not to EmblemHealth

Date Issued: 11/5/2014

EmblemHealth does not reimburse for measurement codes used with the Physician Quality Reporting System (PQRS). Therefore, physicians should not report or bill PQRS codes in claims submitted to EmblemHealth. Instead, PQRS codes – along with the relevant CPT and ICD-9 codes for the service(s) rendered – must be submitted directly to CMS. Payment is also not due from the member.

How Are PQRS Codes Used?
PQRS codes are used by CMS to measure the quality of care provided to Medicare Part B patients in the physician’s office. CMS offers an incentive payment to practitioners for the satisfactory reporting of these codes to CMS. CMS will provide the bonus payment for the quality measures as one lump sum, which is in turn distributed by EmblemHealth.

CMS has created over 300 quality measures. Eligible professionals who satisfactorily report quality data under three quality measures on at least 80 percent of the Medicare Part B patients they see will be paid a bonus of 1.5 percent of their total estimated allowed charges.

PQRS Information Is Available from CMS
CMS has created a number of files to assist with the appropriate coding and documentation of the PQRS quality measures. You may access these files from the CMS website. Please note: To download these documents from the zipped files, you will need to accept an end-user agreement.

Documents pertaining to the 2014 PQRS quality measures are included in the zipped file entitled 2014 Physician Quality Reporting System (PQRS) Implementation Guide:

  • 2014 Physician Quality Reporting System (PQRS) Implementation Guide – Details how to implement claims-based reporting of measures to facilitate satisfactory reporting of quality-data codes by eligible professionals.
  • 2014 Physician Quality Reporting System (PQRS) Measures List – Identifies and describes the measures used in PQRS, including all available reporting methods/options.

Documents pertaining to the 2014 PQRS individual measures can be found in 2014 PQRS Individual Claims Registry Measure Specification Supporting Documents:

  • 2014 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures – Includes codes and reporting instructions for the 2014 PQRS measures for claims and/or registry-based reporting.
  • 2014 Physician Quality Reporting System (PQRS) Measure Specification Manual Release Notes – Outlines 2014 updates to the 2013 PQRS Measures Specifications Manual in the form of release notes.
  • 2014 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines for each claims and registry measure the QDC that should be reported for a corresponding quality action performed. This document identifies how each code will be used when CMS calculates performance rates. The QDC categories table also clarifies those measures that require two or more QDCs for satisfactory reporting. Insufficiently reporting the QDCs (as specified in the 2014 PQRS measure specifications) will invalidate the report.
  • 2014 Physician Quality Reporting System (PQRS) Single Source Code Master – A numerical listing of all codes (denominator and numerator) included in the 2014 PQRS individual claims and registry measures for incorporation into billing software.

Documents pertaining to the 2014 PQRS measures groups are included in the zipped file titled 2014 PQRS Measure Groups Specifications, Release Notes, Getting Started with 2014 PQRS Measures Groups, 2014 Quality-Data Code Categories, and 2014 PQRS Measures Groups Single Source Code Master:

  • 2014 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual – Measures groups specifications that are different from those of the individual measures that form the group. Instruction for measures group reporting is provided in a separate manual. The 2014 measures groups specifications include codes and reporting instructions on the 25 PQRS measures groups for claims or registry-based reporting.
  • 2014 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual Release Notes – Outlines 2014 updates made to the 2013 PQRS Measures Groups Specifications Manual in the form of release notes.
  • 2014 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups – Shows how to select measures groups for reporting and how to read and understand a measure group specification for satisfactory reporting.
  • 2014 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines every QDC that should be reported for a corresponding quality action performed, as noted in the measures specification. It clarifies those measures that require two or more QDCs for satisfactory reporting. Insufficiently reporting the QDCs (as specified in the 2014 PQRS) will invalidate the report. This document also defines the differences between the QDCs for individual and measure group specifications.
  • 2014 Physician Quality Reporting System (PQRS) Measures Groups Single Source Code Master – Includes a numerical listing of all codes included in 2014 PQRS Measures Groups for incorporation into billing software.