Quick reference guide for PQRS measures, procedure codes and G-codes

Once an eligible patient and measure are identified, use this chart to select the appropriate procedure and G-code

By Government Relations staff

Formerly known as the Physician Quality Reporting Initiative (PQRI), the Physician Quality Reporting System is a voluntary reporting program that provides a financial incentive for certain health care professionals, including psychologists, who participate in Medicare to submit data on specified quality measures to the Centers for Medicare and Medicaid Services (CMS). In 2015, the reporting program will shift from an incentive program that offers bonuses for successful reporting to one in which penalties will be assessed for failure to participate.

Reporting in PQRS consists of selecting measures that match your Medicare population and identifying the types of services you provide to those patients. Medicare asks that you indicate whether or not the action described by the measures was taken through the use of a code (known as a “G” code) specific to each measure.

This chart provides a quick summary of Physician Quality Reporting System (PQRS) measures (in orange) and the procedure codes and G-codes available for each measure, based upon action taken. Prior to using this chart, providers will need to determine which measure is applicable by examining their Medicare patient population and identifying those who have a diagnosis covered by an eligible measure.

For more information on identifying eligible patients and measures, view the video on How to Report in the Physician Quality Reporting System. For additional materials and resources related to PQRS, visit the Quality Improvement Programs section at the APA Practice Organization’s Practice Central website.

Applicable procedure codes	Action taken	G-code (or F-code where applicable)
Measure #9: Major depressive disorder: antidepressant medication during acute phase for patients with MDD
90791, 90832, 90834, 90837,  90845, 90849, 90853	Acute treatment with antidepressant medication	G8126: Patient with new episode of MDD documented as being treated with antidepressant medication during the entire 12 week acute treatment phase
	Acute treatment with antidepressant medication not completed for documented reasons	G8128: Clinician documented that patient with a new episode of MDD was not an eligible candidate for antidepressant medication treatment or patient did not have a new episode of MDD
	Acute treatment with antidepressant medication not completed, reason not given	G8127: Patient with new episode of MDD not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase
#106: Major depressive disorder: diagnostic evaluation
90791, 90832, 90834, 90837,  90845	DSM-IV-TR criteria for Major Depressive Disorder documented (One CPT II code & one G-code [1040F & G8930] are required on the claim form to submit this numerator option)	CPT II 1040F: DSM-IV-TR criteria for major depressive disorder documented at the initial evaluation  and G8930: Assessment of depression severity at the initial evaluation
	DSM-IV-TR criteria for Major Depressive Disorder not documented, reason not otherwise specified (One CPT II code [1040-8P] or one G-code [G8931] are required on the claim form to submit this numerator option)	1040F with 8P: DSM-IV-TR criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified or  G8931: Assessment of depression severity not documented, reason not given
#107: Major depressive disorder: suicide risk assessment
90791, 90832, 90834, 90837,  90845	Suicide risk assessed	G8932: Suicide risk assessed at the initial evaluation
	Patient is not eligible for this measure because MDD is in remission	CPT II 3092F: Major depressive disorder, in remission
	Suicide risk not assessed, reason not given	G8933: Suicide risk not assessed at the initial evaluation, reason not given
#128: Preventive care and screening: Body mass index screening and follow-up
90791, 90832, 90834, 90837	BMI calculated as normal, no follow-up plan required	G8420: Calculated BMI within normal parameters and documented
	BMI calculated above normal parameters, follow-up documented	G8417: Calculated BMI above normal parameters and a follow-up plan was documented
	BMI calculated below normal parameters, follow-up documented	G8418: Calculated BMI below normal parameters and a follow-up plan was documented
	BMI not calculated, patient not eligible/not appropriate	G8422: Patient not eligible for BMI calculation
	BMI calculated, patient not eligible/not appropriate for follow-up plan	G8938: BMI is calculated, but patient not eligible for follow-up plan
	BMI not calculated, reason not given	G8421: BMI not calculated
	BMI calculated outside normal parameters, follow-up plan not documented, reason not given	G8419: Calculated BMI outside normal parameters, no follow-up plan documented
#130: Documentation and verification of current medications in the medical record
90791, 90832, 90834, 90837, 90839, 96116, 96150, 96152	Current medications documented	G8427: Eligible professional attests to documenting the patient’s current medications to the best of his/her knowledge and ability
	Current medications not documented, patient not eligible	G8430: Eligible professional attests the patient is not eligible for medication documentation
	Current medications with name, dosage, frequency, route not documented, reason not given	G8428: Current medications not documented by the eligible professional, reason not given
#131: Pain assessment prior to initiation of patient therapy and follow-up
90791, 96116, 96150	Pain assessment documented as positive	G8730: Pain assessment documented as positive utilizing a standardized tool and a follow-up plan is documented
	Pain assessment documented as negative, no follow-up plan required	G8731: Pain assessment documented as negative, no follow-up plan required
	Patient not eligible for pain assessment for documented reasons	G8442: Documentation that patient is not eligible for a pain assessment
	Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate	G8939: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate
	Pain assessment not documented, reason not given	G8732: No documentation of pain assessment, reason not given
	Pain assessment documented as positive, follow-up plan not documented, reason not given	G8509: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given
#134: Screening for clinical depression and follow-up plan
90791, 90832, 90834, 90837, 96150, 96151	Positive screen for clinical depression documented, follow-up plan documented	G8431: Positive screen for clinical depression with a documented follow-up plan
	Negative screen for clinical depression documented, follow-up plan not required	G8510: Negative screen for clinical depression, follow-up not required
	Screening for clinical depression not documented, patient not eligible/appropriate	G8433: Screening for clinical depression not documented, patient not eligible/appropriate
	Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate	G8940: Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate
	Screening for clinical depression not documented, reason not given	G8432: Clinical depression screening notdocumented, reason not given
#173: Preventive care and screening: Unhealthy alcohol use—screening
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient screened for unhealthy alcohol use using a systematic screening method	CPT II 3016F
	Unhealthy alcohol use screening not performed, for medical reasons	3016F with 1P: Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)
	Unhealthy alcohol use screening not performed, reason not otherwise specified	3016F with 8P: Unhealthy alcohol use screening not performed, reason not otherwise specified
#181: Elder maltreatment screen and follow-up plan
90791, 96116, 96150	Elder maltreatment screen documented as positive and follow-up plan documented	G8733: Documentation of a positive elder maltreatment screen and documented follow-up plan at the time of the positive screen
	Elder maltreatment screen documented as negative, follow-up plan not required	G8734: Elder maltreatment screen documented as negative, no follow-up required
	Elder maltreatment screen not documented, patient not eligible	G8535: No documentation of an elder maltreatment screen, patient not eligible
	Elder maltreatment screen documented, patient not eligible for follow-up	G8941: Elder Maltreatment Screen Documented, Patient not Eligible for Follow-Up
	Elder maltreatment screen not documented, reason not given	G8536: No documentation of an elder maltreatment screen, reason not given
	Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given	G8735: No documentation of an elder maltreatment screen, patient not eligible
#226: Preventive care and screening: Tobacco use assessment and tobacco cessation intervention
90791, 90832, 90834, 90837,  90845, 96150, 96151, 96152	Patient screened for tobacco use	CPT II 4004F: Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user
	Patient screened for tobacco use and identified as a non-user of tobacco	CPT II 1036F: Current tobacco non-user
	Tobacco screening not performed for medical reasons	4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
	Tobacco screening or tobacco cessation intervention not performed reason not otherwise specified	4004F with 8P: Tobacco screening or tobacco cessation intervention not performed, reasonnot otherwise specified
#247: Substance use disorders – counseling
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence	CPT II 4320F: Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence
	Patient not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified	4320F with 8P: Patient was not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified
#248: Substance use disorders Screening for depression
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient screened for depression	CPT II 1220F: Patient screened for depression
	Patient not screened for depression for medical reasons	1220F with 1P: Documentation of medical reason(s) for not screening for depression
	Patient not screened for depression, reason not otherwise specified	1220F with 8P: Patient was not screened for depression, reason not otherwise specified
#325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions – Note: Registry Reporting Only
90791, 90832, 90834, 90837,  90845	Clinician treating Major Depressive Disorder communicates to clinician treating comorbid condition	G8959:Clinician treating MDD communicates to clinician treating comorbid condition
	Clinician treating Major Depressive Disorder did not communicate to clinician treating comorbid condition, reason not given	G8960: Clinician treating MDD did not communicate to clinician treating comorbid condition, reason not given

http://www.apapracticecentral.org/update/2013/02-14/procedure-codes.aspx

20 Detroit-area Residents Charged in Medicare Fraud Strike Force Takedown for Approximately $34 Million in False Billing

Washington, DC—(ENEWSPF)—December 5, 2013. Twenty Detroit-area residents have been charged for their roles in physician home visit, home health care, chiropractic and psychotherapy schemes to submit more than $34 million in false billing to Medicare.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade, Special Agent in Charge Paul M. Abbate of the FBI’s Detroit Field Office and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Chicago Regional Office made the announcement.

“Medicare fraud hits every taxpayer and harms so many who are in need of critical health care,” said Acting Assistant Attorney General Raman.  “The defendants arrested yesterday and today include doctors, physical therapists and home health care agency owners who were entrusted by Medicare to provide their patients with necessary care and services.  Instead, they abused that trust for their own profit.  The Strike Force’s operation reflects our continuing and unflagging commitment to put an end to these harmful fraud schemes.”

“Doctors and clinic owners should take note that we are scrutinizing billing data to detect fraud and bring offenders to justice,” said U.S. Attorney McQuade.   “We are committed to recovering tax dollars intended for patient care.”

“These charges clearly send the message to criminals that committing fraud against government health care programs puts them squarely in the sights of the Medicare Fraud Strike Force,” said HHS-OIG Special Agent in Charge Pugh. “Taxpayers and patients should know that OIG with its Strike Force partners will continue to root out, expose, and hold accountable those who attack the Medicare program.”

“When medical doctors, physical therapists, and other health care providers conspire to defraud our government health care programs and undermine the public trust, they not only betray their profession, but also steal directly from the American people,” said FBI Special Agent in Charge Abbate. “The FBI and our law enforcement partners in the Medicare Fraud Strike Force will continue our efforts on behalf of the American taxpayer to prevent health care fraud and bring these criminal perpetrators to justice.”

Court documents unsealed this week in the Eastern District of Michigan charge defendants including physicians, owners and operators of companies, office employees and patient recruiters with submitting fraudulent claims for services that were never rendered and with paying kickbacks to obtain patients to be billed. Nineteen of the defendants were arrested or surrendered to authorities yesterday morning and this morning, and one defendant remains at large. In addition, law enforcement agents yesterday and today executed search warrants at nine locations and seizure warrants of 14 bank accounts related to the alleged fraud schemes.

The following charges were unsealed:

United States v. Goldfein, et al.

Two individuals, both medical doctors, were charged in an indictment with conspiring to commit health care fraud for their roles in a $5.4 million scheme to defraud Medicare by submitting fraudulent claims for physician home services that were not provided. The indictment alleges that the fraudulent claims were submitted by a physician clinic that provides both in-home and outpatient health care services. The clinic, with locations in Livonia, Mich., and Swartz Creek, Mich., is known as Tri City Medical Centers P.C.

The defendants charged in the indictment are Aaron Scott Goldfein, 49, of Bloomfield Hills, Mich., and William Clay Sokoll, 58, of Royal Oak, Mich.

United States v. Elhorr, et al.

Three individuals, one of whom is a medical doctor and one of whom is a nurse, were charged in a superseding indictment with conspiracy to commit health care fraud for their roles in an $11.5 million scheme to defraud Medicare by submitting fraudulent claims for physician home services that were not provided. The superseding indictment alleges that the fraudulent claims were submitted by a home visiting physician practice. The practice, located in Allen Park, Mich., was known as House Calls Physicians P.L.L.C.

The defendants charged in the superseding indictment are Ali Elhorr, 44, of Dearborn, Mich.; Lama Elhorr, 31, of Hollywood, Fla. (formerly of Dearborn, Mich.); and Kelly White, 44, of Dearborn, Mich.

United States v. Khan, et al.

Ten individuals were charged in an indictment with conspiracy to commit health care fraud or conspiracy to pay and receive illegal kickbacks for their roles in a $7 million scheme to defraud Medicare. The defendants include two medical doctors and three owners of home health care agencies, one of whom is also a physical therapist, as well as patient recruiters and office staff. The indictment alleges that the defendants caused the submission of fraudulent claims to Medicare for medically unnecessary home health care services and paid kickbacks in the form of cash payments and prescription narcotics to Medicare beneficiaries for the use of their Medicare beneficiary numbers. The indictment also alleges that physicians received kickbacks in the form of cash payments to certify Medicare beneficiaries for medically unnecessary home health care services. The fraudulent claims were submitted by two home health care agencies, Advance Home Health Care Services Inc. and Perfect Home Health Care Services LLP.

The defendants charged in the indictment are Walayat Khan, 65, of Ypsilanti, Mich.; Adelina Herrero, 72, of Ann Arbor, Mich.; Amer Ehsan, 44, of Canton, Mich.; Haroon Ur Rashid, 47, of West Bloomfield, Mich.; Mohammad Rafiq, 47, of West Bloomfield, Mich.; Salman Ali Sapru, 51, of Ypsilanti, Mich.; Farhan Khan, 25, of Ann Arbor, Mich.; James Zadorski, 48, of Detroit, Mich.; Cynthia Bell, 55, of Detroit, Mich.;   and John Sanders, 59, of Pontiac, Mich.

United States v. Hassan, et al.

Two individuals were charged in an indictment with conspiracy to commit health care fraud and conspiracy to pay and receive illegal kickbacks for their roles in a $4.5 million scheme to defraud Medicare. The indictment alleges that the defendants, the owner of a home health care agency who is also a physical therapist and a recruiter, caused the submission of fraudulent claims to Medicare for medically unnecessary home health care services and paid kickbacks in the form of cash payments to Medicare beneficiaries for the use of their Medicare beneficiary numbers. The indictment also alleges that physicians received kickbacks in the form of cash payments to certify Medicare beneficiaries for medically unnecessary home health care services. The fraudulent claims were submitted by Cherish Home Health Services LLC.

The defendants charged in the indictment are Zia Hassan, 47, of Saline, Mich., and Nathaniel Miller, 52, of Detroit, Mich.

United States v. Minhas

Naseem Minhas, 47, of West Bloomfield, Mich., was charged with conspiracy to commit health care fraud and conspiracy to pay and receive illegal kickbacks for his role in a $5.7 million scheme to defraud Medicare. The indictment alleges that the defendant, the beneficial owner of a home health care agency, caused the submission of fraudulent claims to Medicare for medically unnecessary home health care services and paid kickbacks in the form of cash payments to marketers to recruit Medicare beneficiaries and to certify Medicare beneficiaries for medically unnecessary home health care services. The indictment alleges that the fraudulent claims were submitted by Tricounty Home Care Services Inc.

United States v. Lovett, et al.

The owners of a Detroit-area billing company were charged in a criminal complaint for their roles in a health care fraud scheme involving claims for chiropractic and psychotherapy services. The complaint alleges that the operators of ABIX LLC obtained the Medicare numbers of licensed medical service providers in and around Detroit and used this information to bill Medicare for chiropractic and psychotherapy services that were not provided.

The defendants charged in the criminal complaint are Elaine Lovett, 58, of Wayne County, Mich., and Michelle Freeman, 54, of Livingston County, Mich.

An indictment or criminal complaint is merely an allegation, and the defendant is presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and the Department of Health and Human Services to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

These cases were investigated by the FBI and HHS-OIG and were brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of Michigan.   These cases are being prosecuted by Trial Attorney William G. Kanellis, Trial Attorney Matthew C. Thuesen, and Special Trial Attorney Katie R. Fink of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to:www.stopmedicarefraud.gov .

Source: justice.gov

Medicare Physician Fee Schedule Expands Telehealth Coverage

CMS' recently released finalized Medicare Physician Fee Schedule for 2014 includes expanded coverage for telehealth services and increased reimbursement payments for such services, MedPage Today reports (Pittman, MedPage Today, 11/27).

Background

In July, CMS proposed a policy change that would expand payments for telehealth services under the Medicare Physician Fee Schedule for 2014.

The agency said it was seeking evidence to "demonstrate the service furnished by telehealth to a Medicare beneficiary improves the diagnosis or treatment of an illness or injury" or boosts patient function (iHealthBeat, 7/9).

Details of Telehealth Rules

Under the finalized fee schedule, Medicare coverage for telehealth services will be expanded to rural areas as defined by the Office of Rural Health Policy.

The American Telemedicine Association says the new language will expand Medicare coverage of telehealth into the "fringes of metropolitan areas."

In addition, telehealth reimbursement rates for originating patient sites will increase from $24.43 to $24.63.

However, CMS said it does not have the authority to "waive the geographic telehealth requirements" for rural health clinics "that do not meet any of the requirements to serve as an originating site."

CMS officials said the agency is working with the Health Resources Services Administration to create a website to help providers determine their eligibility to serve as an originating site for telehealth services (Brino, Government Health IT, 12/3).

CMS will publish the final rule on Dec. 10 (Herman, Becker's Hospital Review, 12/2).

ATA's Response

In a release, ATA called the telehealth provisions in the fee schedule "good news."

ATA CEO Jonathan Linkous said, "The proposed new rules, while incremental, represent another step toward integrating the use of telecommunications technology into the delivery of health care" (ATA release, 11/30).

http://www.ihealthbeat.org/articles/2013/12/4/medicare-physician-fee-schedule-expands-telehealth-coverage