Physician Quality Reporting Initiative (PQRI)

QUESTION: Is the primary diagnosis the only diagnosis that is applicable to the quality measure being reported or will Physician Quality Reporting Initiative (PQRI) consider all diagnoses reported on a claim?

ANSWER: All diagnoses and quality-data line items are considered for Physician Quality Reporting Initiative (PQRI) reporting. There is no requirement to sequence diagnoses into primary and secondary categories for PQRI. Quality-data codes (QDCs) should be submitted for any measures that are applicable to each Medicare Physician Fee Schedule (PFS) claim, as determined by all the diagnosis (ICD-9-CM) and service (CPT Category I) codes submitted on the claim line items for payment. Each QDC should point to one of the diagnosis codes already present on the claim for the payable service. Without a diagnosis pointer on the QDC line item, the line item will be rejected and returned to the provider as unprocessable. The PQRI quality measure specifications identify the combinations of diagnosis and service codes making a claim eligible for each measure. The PQRI Quality Measure Specifications Manual is available in a download from the CMS PQRI Measures.

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