PQRS – Are you reporting the required codes to ‘dodge’ future Medicare payment adjustments/reductions?

PQRS – Are you reporting the required codes to ‘dodge’ future Medicare payment adjustments/reductions?

by abilling, July 1, 2013

Formally called PQRI, nothing much else has changed except the name.  This reporting program is designed to promote eligible providers to report on quality information and uses for incentive payments or soon payment adjustments or reductions.  PQRS is mandated by federal legislation with Centers for Medicare and Medicaid Services (CMS) implementing.  Up until now, we have seen a small incentive for participation; however, in 2015, the program begins to apply a payment adjustment, or reduction, to eligible providers who do not satisfactorily report data using the defined quality measures.


Currently, individual providers may choose to report PQRS measures in one of four methods;

  • Using Medicare Part B claims
  • Using a PQRS reporting registry
  • Using a qualified electronic heath record (EHR), or
  • Using a qualified PQRS data vendor.

Recently, ABI learned this is the seventh year of this program; and yet, many eligible professionals (EP) continue to not participate.  Earning the small .5% incentive payment for 2013 is relatively painless but not doing so now will ensure you will lose money down the road.  Failure to report in 2013 will cost you a 1.5% reduction in payments beginning in 2015.  Failure to report in 2014 will cost 2.0% in 2016.

The simplest and most widely used method to report the PQRS measures is via claims.  Using this method, eligible professionals simply include a 5-digit code on each claim they submit to Medicare.  To qualify, the EP must;

  • Report at least three PQRS measures, OR
  • If fewer than three measures apply, report 1 to 2 measures, AND
  • Report each measure on at least 50% of your Medicare Part B claims during the reporting year.

There are four measures applicable to surgical anesthesia;

  • Measure #30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
  • Measure #193 Perioperative Temperature Management
  • Measure #76 Prevention of Catheter-Related Bloodstream Infections: CVC Insertion Protocol
  • Measure #145 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy

Pain management providers and physicians who do not perform any surgical anesthesia cases can choose from a number of PQRS measures which are primarily reported with evaluation and management services; some of these include, but are not limited to;

  • Measure #130 Documentation of current medications in the medical record
  • Measure #131 Pain assessment and follow up using a standardized tool to measure pain level and follow up plan
  • Measure #128 Preventative Care and Screening; BMI screening
  • Measure #226 Preventative Care and Screening; Tobacco Use; Screening and Cessation Intervention

The following measure is for the use of fluoroscopy for pain management:

Measure #145 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy


It is easy to add these measures to all billings.  Simply modify the information you provide your billing office with something similar to the following.

PQRS Antibiotic Administration (Measure #30)   PQRS Perioperative Temperature Management (Measure #193)
Antibiotic Timely Delivered – 4048F   x Duration of general or neuraxial anesthesia less than 60 min – 4256F
Not Delivered – Medical Reasons – 4048F-1P   MAC Anesthesia or Peripheral Nerve Block less than 60 min – 4256F
Not Delivered – Unspecified Reasons – 4048F-8P    ** if either of the 2 boxes are checked – don’t go any further **
x Antibiotic Not Ordered – 4047F-8P   Active Warming Performed; 60 min or longer – 4250F & 4255F
PQRS CVC Insertion (Measure #76)   Active Warming Not Performed; 60 min or longer – 4250F-1P & 4255F
Sterile Technique Followed – 6030F   Active Warming Not Performed or Not Achieved, reason not otherwise specified; 60 min or longer – 4250F-8P & 4255F
Not Followed – Medical Reasons – 6030F-1P    
Not Followed – Unspecified Reasons – 6030F-8P   PQRS Radiology Exposure Fluoroscopy Time Reported (Measure #145)
    Radiation Exposure or Exposure Time Documented – 6045F
    Radiation Exposure or Exposure Time NOT Documented – Unspecified Reasons – 6045F-8P



If you would like help with a format to report these codes or would like to access a copy of the CMS 2013 PQRS Claims/Registry Measure Specification Manual, please contact Stephanie Kurtz at (316) 281-3710.



abinsights Contact Information

abinsights readers are invited to submit comments, questions, tips, and suggestions for articles on any subject related to billing, collections, coding, reimbursement, and compliance.  Send to:  Anesthesia Billing, Inc.,     P O Box 388, Newton, KS  67114-0388.  Phone 316-281-3700.  Fax 316-282-4322.

Our purpose is to help you meet inevitable challenges.  We hope to deliver practical knowledge and solutions drawn from top resources and business publications in every issue, knowledge you can use today.

Reasonable attempts have been made to be accurate.  However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ.  Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations.  For information specific to your practice, consult a qualified professional.

The information included in this publication is provided, among other things, to alert you to legal developments and should not be considered legal advice.  Specific questions about how this information affects your particular situation should be addressed to your attorney.

Editor:  Philip Blann (pblann@anesthesiabilling.com).

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