Assumption: Readers understand what PQRS is, how it relates to medical coding and reimbursement as well as an understanding of the current measures that are reportable for CMS. If you, the reader do not understand some or all of these assumptions, please contact us or do some additional research before proceeding with our PQRS how to guide.

Here is a million mile overview of our procedures surrounding PQRS and medical coding.
Disclaimer: We built a purpose driven emergency medicine, medical coding software application suite. Since inception, we have unboarded specialties including Hospitalist Medicine and Anesthesia Medicine and use the following procedures for ALL of our practices in the workflow. Your practice may have different procedures that may not align with how we handle PQRS, at the point of coding. Please review the following guide to determine if this is a practical solution for your physician practice, medical coding company and or medical billing company.

Our PQRS validations require integration of patient demographics (ADT) to support age, sex and insurance based validations.
PQRS validation occurs at the point of coding; all 2015/2016 measures for quality reporting are available but are not necessary.
Some 2015/2016 PQRS measures may include:

Measure #54: Electrocardiogram Performed for Non-Traumatic Chest Pain
% of patients >40 with an ED discharge diagnosis of non-traumatic chest pain who had an ECG performed.

Measure #254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
% of pregnant women aged 14-50 who presented to the Emergency Department with a chief complaint of abdominal pain OR Vaginal bleeding who receive a trans abdominal or trans vaginal ultrasound to determine pregnancy location.

Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnancy Woman at Risk of Fetal Blood Exposure
% of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh Immunoglobulin (Rhogam) in the emergency department

Measure #317: PREVENTIVE CARE AND SCREENING FOR BLOOD PRESSURE
for all Medicare patients over the age of 18

Medical coding and PQRS: In most instances, we only queue patient accounts to medical coders if we have a complete medical record and patient demographics (ADT), allowing medical coders to key data such as POS, admit, providers, ICD-10, CPT, PQRS all in one, pre-billing. PQRS prompts are algorithm driven validations that allow for medical coders to assure quality driven medical coding.

Let’s look at measure #254– Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

Description: % of pregnant women aged 14-50 who presented to the Emergency Department with a chief complaint of abdominal pain OR Vaginal bleeding who receive a Transabdominal or Transvaginal ultrasound to determine pregnancy location
Involved CPT E/M Service Codes
ICD-10 Codes
(denominators)
CPT II Code
CPT II Code Descriptor
99201 – 99205
99212 – 99215
99241 – 99245
99281 – 99285
99291
O26.891, O26.899, O26.90., O26.91

AND

R10.0
R10.10
R10.13
R10.2
R10.30
R10.13
R10.32
R10.33
R10.813
R10.814
R10.815
R10.816
R10.817
R10.819
R10.823
R10.824
R10.825
R10.826
R10.827
R10.829
R10.84
R10.9
OR
O20.0
O20.8
O20.9
O44.10
O44.11
O45.001
O45.009
O45.011
O45.019
O45.021
O45.029
O45.091
O45.099
O45.8X1
O45.8X9
O45.90
O45.91
O46.001
O46.009
O46.011
O46.019
O46.021
O46.029
O46.091
O46.8X1
O46.8X9
O46.90
O46.91
O46.099
G8806

G8807

G8808
PERFORMANCE MET:
Performance of trans-abdominal or trans-vaginal ultrasound

OTHER PERFORMANCE EXCLUSION:
Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (eg: pt has visited the ED multiple times within 72 hours, patient has a documented Intrauterine Pregnancy (IUP)

PERFORMANCE NOT MET:
Performance of trans-abdominal or trans-vaginal ultrasound NOT ordered, reason not given (e.g., patient had visited the ED multiple times with no documentation of a trans abdominal or trans vaginal ultrasound within ED or from referring eligible professional)

For display purposes, I am choosing to omit medical record data, patient demographic (ADT) data and have limited the displayed selection to PQRS codes that are keyed by medical coders.

Below is a 19 y/o female, with a chief complaint of abdominal pain OR Vaginal bleeding who receive a Transabdominal or Transvaginal ultrasound to determine pregnancy location.

As seen above, we limit the opportunity of not capturing PQRS data pre-billing through our table driven algorithms. We aim to eliminate risk and maximize our clients time and reimbursements through our home grown process laid out above.

We believe that as part of the coding process technology should help enforce regulations like PQRS.

When coding occurs there is a natural lateral to incorporate workflow checks for PQRS and various other validations like:

Was the provider on schedule at this day/time?
Is any data missing that will cause a denial?
Are there issues with the provider documentation?
Are the problems with the documentation that will prevent coding?

Let us know if you have any questions, we would be happy to discuss this in detail.

Ben Bohlen is the operations/client lead at LightSpeed Technology Group, makers of VeriDOCS coding and revenue cycle workflow system. LightSpeed works with coding, billing and physician groups throughout the US and abroad. Handling emergency, hospital, anesthesia medicine, and other specialties. He is driven to provide clients with meaningful and relevant results.

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