Physician Quality Reporting Initiative (PQRI) and Electronic Prescribing Incentive Program

Updated: 6/17/2009

Overview

Two CMS (Centers for Medicare and Medicaid Services) quality improvement programs described in the 2009 Medicare Physician Fee Schedule final rule will provide the opportunity for incentives of up to 4% of total Medicare allowed charges for participation: the Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (e-prescribing) Incentive Program. PQRI, first established in 2006, offers incentives to Medicare providers who report on quality performance measures. The e-prescribing program offers incentives to clinicians who use a qualified e-prescribing system. Participation in both programs involves the reporting of designated administrative codes on billing claims. More information is available on the CMS website about other methods of reporting (registries and measures groups) which may be an option in certain circumstances.

The PQRI program will continue in 2009 with 153 measures, including 3 on major depressive disorder, and a new measure on screening for unhealthy alcohol use. Physicians who report on at least 3 measures applicable to their practice between January 1 and December 31, 2009, will receive a bonus of up to 2% of their total Medicare allowed charges for that period. To be eligible for the bonus, measures must be reported in at least 80% of encounters where a measure applies. The incentive is awarded for reporting on applicable measures, regardless of whether or not the measure was met.

The Electronic Prescribing Incentive Program is new in 2009. Clinicians who meet the requirements for being a successful e-prescriber will be eligible for an additional 2% bonus in 2009 and 2010, a 1% bonus in 2011 and 2012, and a 0.5% bonus in 2013. Clinicians who do not meet the requirements for being a successful e-prescriber will have their payments reduced by 1% in 2012, 1.5% in 2013, and 2% in 2014 and in each subsequent year. Being a successful e-prescriber means reporting the availability and use of a qualified e-prescribing system in at least 50% of covered encounters between January 1 and December 31, 2009. APA members currently using an electronic prescribing system are encouraged to share their impressions with other members at http://www.psych.org/softwarereview.

Detailed specifications for these programs are on the CMS PQRI Page and the CMS E-Prescribing Incentive Page. CMS has posted PQRI Help Desk contact information here. Check this page (psych.org/pqri) periodically for updates and more information on these programs.

Electronic Prescribing Incentive Program

Adoption/Use of Medication Electronic Prescribing Measure

Description: Documents whether the provider has adopted a qualified e-prescribing system and the extent of use in the ambulatory setting. A qualified electronic prescribing system must be capable of:

Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available
Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks
Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any)
Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan

Although the Electronic Prescribing Incentive Program Measure does not include the psychiatric pharmacologic management procedure code 90862, a psychiatrist using a qualified electronic prescribing system would still be eligible for the full bonus (2% of all Medicare Part B charges) if at least 10% of his/her total estimated Medicare Part B charges derive from procedure codes that are included in the measure (e.g. 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 99201, etc., see the measure specifications for the full list), and he/she reports an electronic prescribing code along with at least 50% of those procedure codes included in the measure. A prescription need not be generated during an encounter to report a valid electronic prescribing code (e.g., G8445 means the prescriber had a qualified e-prescribing system, but didn’t generate any prescriptions during the encounter).

The specifications of this measure are subject to change after December 31, 2009, and likely will include 90862 and other codes in future years. Since there is no penalty for reporting electronic prescribing codes even if the accompanying procedure code is not included in the program, one approach to this issue would be for a psychiatrist with a qualified electronic prescribing system to report the appropriate electronic prescription code for all patient encounters.

PQRI 2009 Measures

The following measures may be most pertinent to psychiatry, but others may apply to individual practices. The complete list of PQRI measures and specifications for 2009 can be found here.

Measure #9 (Includes changes to specifications for 2009)
Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD

Description: Percentage of patients aged 18 years and older diagnosed with new episode of major depressive disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase.

Measure #106 (Includes changes to specifications for 2009)
Major Depressive Disorder (MDD): Diagnostic Evaluation

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified during the measurement period

Measure #107 (Includes changes to specifications for 2009)
Major Depressive Disorder (MDD): Suicide Risk Assessment

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who had a suicide risk assessment completed at each visit during the measurement period

Measure #124 (Includes changes to specifications and criteria for 2009)
Health Information Technology (HIT) - Adoption/Use of Electronic Health Records (EHR)

Description: Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted and be using a certified/qualified EHR

Measure #173 (New Measure for 2009)
Preventive Care and Screening: Unhealthy Alcohol Use – Screening

Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months

Other Measures

Measures such as Medication Reconciliation (#46), Advance Care Plan (#47), Inquiry Regarding Tobacco Use (#114), and Advising Smokers to Quit (#115) may also apply for psychiatrists who routinely use certain general medical CPT evaluation and management codes (e.g. 99201). Certain measures, such as Screening for Clinical Depression (#134), and Elder Maltreatment Screen and Follow-up Plan (#181), may be pertinent to mental health but are only for non-MD/DO professionals.

Links

Links pertaining to 2009 PQRI Program:

    CMS PQRI Website

    CMS PQRI 2009 Measure Specifications (zip file)

    CMS PQRI 2009 Implementation Guide

    2009 PQRI Data Collection Worksheets (AMA)

    Implementation Advice for 2009 PQRI and E-Prescribing (CMS)

Links pertaining to Electronic Prescribing Incentive Program:

    CMS Electronic Prescribing Incentive Program Website