Quality Data Codes

"We have to use all these G codes, and we don't get any RVUs (relative value units) for them." 

This was a complaint I heard from a primary-care doctor employed by a community hospital. What codes did she mean? There are many HCPCS codes that start with a letter that do carry RVUs and are reimbursed by Medicare and private payers. This physician was referring to quality data codes (QDCs), some of which (not all) start with the letter G, that she added on to a visit when selecting her charges in the electronic health record. What are these QDCs and why submit them if there are no RVUs attached to them?

QCDs are add-on codes submitted on claim forms for Medicare fee-for-service patients that report either use of a qualified e-prescribing program or participation in the Physician Quality Reporting System (PQRS). They are add-on codes that do not affect payment on an individual claim, but may make the professional eligible for a bonus or incentive payment. Some are HCPCS codes (such as G8553) developed by CMS and some are Category II CPT codes that are alpha-numeric (1032F). As the family physician noted, the codes themselves have no RVUs and carry no payment for that claim. However, using the codes correctly may result in a bonus payment from Medicare and not reporting them successfully - as defined by CMS - will result in a penalty of decreased payment on the claim as early as Jan. 1, 2012 for e-prescribing, and Jan. 1, 2015 for PQRS.

The quality data codes can change yearly. Each code needs to be used to report on a specific PQRS measure, or e-prescribing. The measures themselves are changed from year-to-year, and are reported in the Physician Final Rule that is released in early November. Besides setting fees, the final rule describes policy changes and defines the individual and group measures for the PQRS program for the coming year. Each measure has three-to-five unique QDCs. Because both the measures and the accompanying data codes can change from year-to-year, it is imperative for practices participating in PQRS to review these in December of each year. The measures and codes for 2012 are posted on CMS's website. The American Medical Association develops worksheets to help practices successfully report these measures. These can be found here.

Why should a physician take the extra time and effort to review PQRS measures and learn about these quality data codes? For two reasons: The first is that incentive payments tied to successful reporting are available right now, with the threat of decreased payments for not participating in PQRS. The second reason is that CMS is planning to publish the names of the eligible professionals who participate in these programs on a public website. Together, these two factors will encourage many groups to master the use of QDCs.

Betsy Nicoletti is the founder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com.