Managed Care Reimbursement

What Every Pathologist Needs to Know about Medicare's PQRI for 2008

In 2008, pathologists can earn extra reimbursement from Medicare by participating in the 2008 Physician Quality Reporting Initiative (PQRI).  However, many pathologists and their practice administrators remain unaware of this opportunity.

To give readers of Dark Daily a head start on this financial opportunity, we participated in an audio conference entitled "Medicare Physician Quality Reporting Initiative for Selected Pathology Measures."  The conference was conducted last week by Pathology Service Associates  (PSA).  Presenters John Outlaw, Chief Compliance Officer of PSA and Chappy Manning, Billing Support Services Coding Coordinator for PSA did a great "how to" session about PQRI and its coding requirements.

Although PQRI began in 2007 for most physicians, pathologists are just now getting the opportunity to participate.  The Centers for Medicare and Medicaid Services  (CMS) is making this a first step to get physicians involved in the reporting necessary to support pay-for-performance incentives. 

Pathology procedures eligible for additional reimbursement for 2008 are breast and colon cancer resections.  The bonus payment is equivalent to 1.5% of a practice's TOTAL Medicare allowed charges-NOT just breast and colon cancer resections!  There is a low volume cap for pathologists who perform a very small number of these procedures relative to other participating pathologists.  Those pathologists WILL still be reimbursed, but may not receive the full 1.5%.  It sounded "too good to be true" for many callers participating in the audio conference!

In order to be eligible, pathologists must report 80% of their applicable cases for the year.  Therefore, if you had 10 breast and colon cancer resections, you would need to report at least 8 cases.  PSA suggested that pathology practices decide as soon as possible whether to participate and aim to start this reporting on January 1, 2008.  PSA observed that pathology groups waiting until March to start reporting are likely to have already handled 20% of their applicable cases for the year, possibly preventing them from reporting the required 80% of cases.  It is expected that bonuses will be paid in 2009.  Congress still needs to approve PQRI in the 2008 funding bill for reimbursements to be administered, but all indications are that it will.

CMS does not require registration for the PQRI.  You simply report your cases, as usual.  If you work with coders outside of your practice or have outside entities like PSA handle your billing and coding, you should discuss the PQRI and its unique coding requirements with your billing service.  Since it's not too often that Medicare offers higher reimbursement to pathology groups and laboratories, PQRI is a program that is likely to see growing participation as more pathologists learn about it.