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How to decipher PQRI protocol, how to handle same-day consultations


Various areas of coding, including PQRI measures, ophthalmology consults, are addressed

Key Points

Q: Our multi-location primary care practice has been attempting to submit our Physician Quality Reporting Initiative (PQRI) data with each encounter. We have devised a PQRI sheet and attach a copy to each encounter form to make it easier for our physicians to mark the measures appropriate to visits. Also, we have educated our providers and support staff about group measures specific to our specialty. Nonetheless, an internal audit elicited that we probably are missing data for 40% to 50% of our encounters. The codes are either missed at submission or are not picked up by the carrier. Can we resubmit the claims with the appropriate PQRI information? If so, what is the time limit for submitting 2009 data?

An example of a group measure is diabetes mellitus. Some of the measures applying to diabetes are an HgA1c level checked at regular intervals, with results falling into specific value ranges; monitored and controlled blood pressure; and having a dilated eye examination every year to check for diabetic retinopathy. Those measures all are connected to the diagnosis of diabetes, but some of them may be reported individually by specialty providers such as endocrinologists or ophthalmologists.

With claims-based reporting, the window of opportunity to submit the PQRI measure ends when the claim is submitted. No opportunity exists to resubmit the claim with the correct PQRI information attached unless the carrier has failed to pick up the measure or its "claims scrubber" eliminated the entry because of a "0" charge and you can document that it was submitted correctly.

A registry may be able to scan your data if you are using electronic medical records and have the opportunity to "correct" a claim for missing PQRI information before the system sends the file to CMS electronically for the year.

The number of registries has more than doubled in the past year, from 32 to 74. Not all registries are equal, however. Some report both individual and group measures, whereas others report only one or the other. All charge a fee.

The Centers for Medicare and Medicaid Services (CMS) requires that registries be qualified and has posted a list of qualified registries for the 2009 PQRI at

Some PQRI measures reported for 2010 will require submission through a registry, so now may be a good time to evaluate that process.


Q: Our ophthalmology group has several subspecialists. We are having problems getting reimbursed for multiple consultations on the same day. For instance, a glaucoma specialist may evaluate a patient for suspected glaucoma (a consult request from an optometrist) and during that evaluation may see a suspected retinal tear. Our retina specialist's claim for a consultation will be rejected if he sees the patient on the same day as did the glaucoma specialist. Any suggestions?

A: CMS does not recognize certain subspecialties. The agency considers retinologists to be ophthalmologists and, therefore, will not recognize multiple consultations on the same day. After January 1, CMS does not plan to recognize consultations either in an inpatient or outpatient setting.

Medical Economics Consultant Virginia Martin, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Have a coding or managed care question for our experts? Send it to

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Jennifer N. Lee, MD, FAAFP
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