Independent Labs Excluded from Participating in PQRI
PSA's recent email, regarding CMS’s question/answer comments that physicians employed by independent laboratories will not be included in the PQRI program, has attracted much attention from the industry and appears to have spawned new and widespread interest in the industry aimed at pressuring CMS to provide a remedy.
PSA received numerous calls from clients and industry contacts regarding this issue and therefore held a conference call on Thursday, August 7 to provide further details. Listed below is a brief summary of some of the key points discussed during the call.
Not a CMS Policy Issue
This was not the result of a policy decision to exclude independent labs from participating in PQRI. However, it appears that CMS simply did not recognize until after the fact that the way the carrier's systems treated claims from independent labs did not allow them to collect the data needed for PQRI reporting.
Claims Adjudication System
CMS has indicated that its claims adjudication systems do not capture data needed for PQRI reporting for providers that are enrolled as independent labs (provider type 69). It has nothing to do with the place of service that is submitted on the claim, but how the provider is enrolled (independent lab or physician practice.)
New Pathology PQRI Measures
The pathology PQRI measures are expected to be expanded in 2009. Two additional measures have been approved for 2009 and other measures are currently being evaluated by the AMA. Approximately 60% of pathologists in the United States are employed by an independent laboratory. At some point reporting these quality measures will be required and therefore to capture quality lab data CMS is going to have to address this issue.
Continued Participation
PSA encourages independent labs to continue to report PQRI quality data through the end of the year with the hope that CAP and other industry advocates are successful in efforts to get CMS to make necessary systems changes or otherwise create some alternative mechanism for reporting PQRI data.
CMS Question and Answer
QUESTION: I am a pathologist employed by an independent laboratory and have been informed by the Medicare carrier that I cannot participate in PQRI for place of service 81. Is this correct?
ANSWER: Yes. Independent Laboratories (ILs) are a supplier specialty (69), not a physician specialty. The rendering provider field (24J) on the CMS-1500 claim is not valid for IL claims in the billing methodology for ILs. Because the statute authorizing PQRI requires analysis of reporting and allowed charges at the level of the individual professional, pathology services billed under IL rules are not able to be considered in PQRI analyses.
PSA will continue to keep affiliated practices updated on any new developments.