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Under PQRI, covered professional services are those paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services which get paid under or based on the PFS, those services are eligible for PQRI. Eligible and Able to Participate The following professionals are eligible to participate in PQRI: - Medicare physicians
- Doctor of Medicine
- Doctor of Osteopathy
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Doctor of Oral Surgery
- Doctor of Dental Medicine
- Doctor of Chiropractic
2. Practitioners - Physician Assistant
- Nurse Practitioner
- Clinical Nurse Specialist
- Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
- Certified Nurse Midwife
- Clinical Social Worker
- Clinical Psychologist
- Registered Dietician
- Nutrition Professional
- Audiologists (as of 1/1/2009)
3. Therapists - Physical Therapist
- Occupational Therapist
- Qualified Speech-Language Therapist
Eligible But Not Able to Participate The following professionals are eligible to participate but are not able to participate for one or more reasons: 1. Providers paid under the PFS billing Medicare Carriers or Medicare Administrative Contractors (MACs): • Qualified Speech-Language Therapist – Currently do not bill Medicare directly. It is anticipated that Qualified Speech-Language Therapists will begin billing Medicare directly on July 1, 2009 at which point they would be able to participate. 2. Providers paid under the Medicare PFS billing Medicare fiscal intermediaries/MACs. The FI/MAC claims processing systems currently cannot accommodate billing at the individual physician or practitioner level: • Critical access hospital (CAH), method II payment, where the physician or practitioner has reassigned his or her benefits to the CAH. In this situation, the CAH bills the regular FI for the professional services provided by the physician or practitioner. • All institutional providers that bill for outpatient therapy provided by physical and occupational therapists and speech language pathologists (for example, hospital, skilled nursing facility Part B, home health agency, comprehensive outpatient rehabilitation facility, or outpatient rehabilitation facility). This does not apply to skilled nursing facilities under Part A. Providers not defined as eligible professionals in the Tax Relief Health Care Act of 2006 or the Medicare Improvements for Patients and Providers Act of 2008 are not eligible to participate in PQRI and do not qualify for an incentive. Services payable under fee schedules or methodologies other than the PFS are not included in PQRI (for example, services provided in federally qualified health centers, independent laboratories, hospitals [including critical access], rural health clinics, ambulance providers, and ambulatory surgery center facilities). In addition, suppliers of durable medical equipment (DME) are not eligible for PQRI since DME is not paid under the PFS. Eligible professionals participating in the PQRI should familiarize themselves and their office staff with the PQRI measures that appear to apply to their patients for the relevant program year. To access the measures list and related materials, click on the "Measures/Codes" page in the left-hand column on this page.
Page Last Modified: 12/05/2008 12:38:43 PM
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