The ABCs of PQRI

The Physician Quality Reporting Initiative is not yet required by the government and offers only modest bonuses. Should you implement it now?

The ABCs of PQRI

The Physician Quality Reporting Initiative is not yet required by the government and offers only modest bonuses. Should you implement it now?


The Physician Quality Reporting Initiative (PQRI) arose out of legislation signed by President George W. Bush on Dec. 20, 2006. This new law, the Tax Relief and Health Care Act of 2006, led to the Centers for Medicare and Medicaid Services (CMS) adopting PQRI. Further legislation — here, the Patients and Providers Act of 2008 — offered a modest 2% bonus for physicians who implemented the PQRI that CMS laid out on Dec. 16, 2008.

Looming on the horizon is the possibility that CMS will make PQRI mandatory. This should provide some incentive for retinal physicians to adopt it sooner rather than later, particularly because the monetary incentive alone is not going to urge many doctors to adopt it. But what specific role does PQRI have in retinal practices?


Emily L. Graham, RHIA, associate director of regulatory affairs for the American Society for Cataract and Refractive Surgeons (note: no retinal organization in the United States has yet adopted guidelines for PQRI implementation), described PQRI for Retinal Physician.

"The Physician Quality Reporting Initiative is a pay-for-reporting program that gives physicians the opportunity to submit quality data to CMS in order to earn a bonus incentive payment," she said. "In the initial 2007 PQRI program, quality data could only be submitted to CMS via claims-based submission; however, in 2008 CMS added the option of submitting quality data through registries. Both claims-based reporting and registry reporting are available in the 2009 program."

As with any Medicare patient, under PQRI, doctors will continue to file CMS-1500 forms, but with the addition of PQRI, the CPT and ICD-9 codes will have added to them a "measure." Because CMS is responsible for healthcare issues outside of ophthalmology, there are nearly 200 measures, but there are only eight measures that pertain to ophthalmology and just five that pertain to retina.

Measure 14: Age-Related Macular Degeneration (AMD): Dilated Macular Examination; Measure 18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy: Measure 19: Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care; Measure 117: Diabetes mellitus: Dilated Eye Exam in Diabetic Patient; and Measure 140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplements are the five measures with which retinal physicians will be dealing. There are not yet measures to deal with retinal vein occlusions, uveitis, retinoblastoma, or any number of other conditions that have an impact on the posterior segment.


As noted above, the monetary benefits of implementing PQRI in a retinal practice are modest. Paul E. Tornambe, MD, a retinal specialist with Retina Consultants, San Diego, in Poway, CA, tells Retinal Physician that the reimbursement at his own practice ranged between $3,000 and $4,000 per year. So why has Dr. Tornambe implemented PQRI?

"It's just basically good care," Dr. Tornambe says, noting that, with an EMR system already in place in his practice, implementing PQRI was relatively painless. "Before PQRI," he continues, "we dictated a letter and we forwarded it to the referring doctors. Thanks to EMR, I haven't done transcription in a decade. All my reports are printed before the patient reaches the front desk."

He continues, "With a diabetic patient, it's a good practice to keep both the referring eye doctor informed, along with the patient's medical doctor. I think we've been doing PQRI before it became a mandate. Now, to comply with PQRI requirements, we have a face sheet that we circle to inform the front office it was done. This is in addition to the electronic documentation we make in the referral letter and chart note. For AMD, it is our practice to send or fax a report of each visit to the referring MD also, and mention our advice to take the AREDS vitamins and fish oil in the report. There are some drugs that can interact with AREDS and omega 3 fatty acids. This way, we're keeping everyone in the loop."

David S. Boyer, MD, a partner in the Retinal-Vitreous Associates Medical Group in Los Angeles, where he specializes in the treatment of vitreous and macular diseases, was more succinct but as pro-PQRI as Dr. Tornambe. "The questions for PQRI are already always done by a retinal physician on virtually every visit," he said. "All it takes is a small change in the computer software and the billing sheet. I don't know of any cons."


Obviously, not all retinal physicians agree with Drs. Boyer and Tornambe if PQRI has not yet been implemented in all retinal practices. Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona in Phoenix and founding member of Spectra Eye Institute in Sun City, AZ, laid out some of the cons of implementing PQRI.

"Other than monetary considerations, which are minor," Dr. Dugel said, "in my opinion, the main advantage to adding PQRI before it becomes a requirement would be establishing a system that will allow us to report the PQRI codes on every qualifying patient and, more importantly, creating a profile for each physician. The latter is critical, as our profile history may well have a profound impact on our reimbursement structure in the future."

According to Dr. Dugel, while his practice has implemented PQRI before it becomes mandatory to do so, a sheer cost-benefit analysis does not bear out doing it before it is required.

"It has created additional work for staff, ie, additional documentation in medical records, additional data entry for billing, modification of charge ticket, upgrading to existing software, and time spent setting up access to CMS Web site in order to access PQRI reports," Dr. Dugel said.

"We'll have to upgrade to the next version of NextGen software in order to utilize the claim edits they have created for PQRI," Dr. Dugel said. "These edits will alert our biller when charges are posted with a PQRI diagnosis if no PQRI code has been entered. This is a great edit to decrease the number of codes missed. However, it will also create additional work for billing, as with each edit created, the medical record will have to be researched before the PQRI code can be entered. Until we upgrade, we have to rely upon the physicians to remember to mark the codes on the fee tickets. And not every physician is consistently marking the tickets. If you look at the short-term benefits from a pure profit analysis, it is not worth the effort.

"However, we must look at the long-term benefit. I believe it is essential to create a physician PQRI profile as soon as possible, as this may serve as a basis for our reimbursement in the future. Additionally, this pre-requirement period is the time to iron out the wrinkles in our system and build an efficient reporting infrastructure. In the future, the efficiency of our reporting infrastructure, I am convinced, will have a direct correlation with our reimbursement profile. I would, therefore, advise my colleagues to not look at the short-term hassles, although they are real, but focus on the long term benefits and urge them to implement PQRI immediately."

Of course, CMS has been publishing materials to make the implementation process easier for physicians. Several "how-to" guides and pointers for streamlining an EMR system to accommodate PQRI are offered at CMS's Web site for PQRI, which is online here: Furthermore, offering more specific information for ophthalmologists is the American Academy of Ophthalmology (AAO), which has posted its own guidelines online here: The AAO Web site offers its own setup guide, as well as the most recent changes to CPT codes required to do PQRI reporting properly.


According to Ms. Graham of ASCRS, "each individual physician who intends to participate in PQRI should review the available measures and decide which measures apply to his or her practice and patient mix. If more than four apply, the individual physician must choose at least three to report. If less than three apply, the physician should report on those that apply. In ophthalmology, most physicians would need to report on at least three measures to qualify." Since there are five measures that are specific to retinal practice, it would seem the former advice would apply here.

Ms. Graham also addressed the incentive that CMS is currently offering to physicians who implement PQRI now. "To qualify for the bonus," she said, "providers must report quality data codes on at least 80% of the eligible reporting opportunities for each of three measures chosen. Some practices intentionally report on more measures than necessary to increase their odds of qualifying for the bonus."


While there is not yet any set date for making PQRI a requirement, nearly everyone in the medical field agrees that it will become required at some point in the near future. If, as predicted, healthcare reform becomes a hallmark of the Obama administration, this is likely to happen sooner rather than later. The drawbacks that Dr. Dugel points to are real, but at the same time, they are drawbacks that could soon become unavoidable. Particularly for those doctors who have not yet switched over to EMR, combining that process with implementing PQRI can be a way of killing two regulatory birds with one stone.

Emily Graham of ASCRS offers practical advice on PQRI implementation. "To be successful," she says, "it is important that billing/coding/front office staff, who are often responsible for entering charges and filing claims, include the appropriate quality data codes or can identify when a quality data code is missing, so claims are not sent without the quality data codes."

Ms. Graham continues, "ASCRS has also developed a Web site and multiple tools to help ophthalmologists participate, should they decide to do so. The society has developed a PQRI Data Collection tool [at] and laminated ‘pocket cards’ that have all eight ophthalmology measures and the associated codes. These cards fit nicely into a lab coat and have been extremely popular with ASCRS members."

But a more patient-based message comes through from Dr. Tornambe, and this is really where the initiative can be most beneficial. "PQRI is nothing but preferred practice pattern backed by science," Dr. Tornambe says. "It's something everyone should adopt." Yes, it is a process that still has kinks that need working out, but in the long term, it seems PQRI will be a positive step for retinal physicians and, most importantly, their patients. As Dr. Dugel emphasizes, creating a physician profile now may prove to be a shrewd investment for the future. RP