QRUR: What is it, and why should you care?

I have heard thatQuality and Resource Use Reports (QRURs) for 2015 have been released and that some practices are facing payment penalties for next year. What is a QRUR? How do I find out if I am going to be penalized?

Your question has a longer answer than this article allows. We will provide only a high-level response here. For more information, you can contact Physician Reimbursement Services directly and/or go to the following section of the Medicare website: bit.ly/VMinformation. (Note: This is a landing page, with an overview of the program with links to more detailed data.)

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The QRUR for 2015 was released in late September for all tax ID numbers (TIN) that had at least one eligible provider bill Medicare under the TIN in 2015.

The QRUR shows how providers performed in 2015 on quality and cost measures used to calculate the 2017 value-based modifier (VM). For providers subject to the 2017 VM, the QRUR shows how the VM will apply to physician payments under the Medicare fee-for-service payments for physicians who bill under the TIN in 2017. The data were collected by Medicare from your reporting on the Physician Quality Reporting System (PQRS) and from all of the bills submitted by the provider for all services provided from Jan. 1, 2015 through Dec. 31, 2015. The report targets two separate areas:

• Cost: This is derived from claims-based outcome measures and utilization data based on all services provided to a provider’s attributed patients.

• Quality data: This is based on PQRS data submitted by the provider and on claims submitted by the provider to a lesser degree.

To learn more about how to obtain your QRUR, go to bit.ly/QRURresource.

If a solo physician did not successfully participate in PQRS, that provider will be subject to a PQRS negative payment adjustment as well as a negative VM adjustment. Groups of more than two eligible providers billing Medicare under the same TIN that did not have at least 50% of providers successfully reporting PQRS will be subject to both a PQRS and VM negative adjustment.

If you successfully reported PQRS and belong to a group of nine providers or fewer, you will not be subject to a negative downward VM adjustment for 2017, however, there is a possibility that the group will receive a positive adjustment. For groups of 10 or more eligible providers that were successful in reporting PQRS, the QRUR will indicate whether Medicare is planning to subject the provider as a whole to a negative, positive, or neutral VM adjustment.

We strongly recommend that you obtain your practice QRUR regardless of your practice size and learn more about the report. Even though Medicare is changing to the Merit-Based Incentive Payment System next year, the QRUR measurement will have a part. Another piece to an increasingly complex puzzle.

Next: Questions on cystourethroscopy with fulguration of large bladder tumor and mitomycin instillation, and billing for prostate biopsies

A hospital patient had surgery that consisted of cystourethroscopy with fulguration of large bladder tumor and mitomycin instillation while still in the operating room. Can these two procedures (51720 and 52240) be billed together with a –59 modifier since there is an NCCI edit?

Yes, the two codes are bundled, but can be unbundled with a modifier, according to current NCCI edits. Instilling the mitomycin is for treatment of the disease process and not a component of the primary procedure. Therefore, you are justified in using the –59 modifier. However, if your carrier is paying for the “–X” modifiers, we would suggest using the –XU modifier.

I am a radiology coder working at an outpatient free-standing facility. For prostate biopsies, how can we bill just a facility fee for allowing urologists to use our equipment to perform biopsies? I have done some research and have not found the answer. I really enjoy your articles.

Thanks for your comment.

As a facility, services provided are paid under a package for Medicare and therefore subject to different guidelines. Code 55700 is reported for outpatient facility fees and ambulatory surgery center fees and includes the technical costs related to 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]). In short, Medicare considers these services as paid for under the package, and they are not allowed to be reported separately.

Also see: CMS releases pay, Quality Payment Program rules

Code 76872 (Ultrasound, transrectal) is a diagnostic service that can be reported by the facility, with a –TC modifier, if the service is performed and documented by the urologist. The urologist should charge this same procedure with a –26 modifier. The diagnostic code is considered a radiology or diagnostic service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS non-facility PE RVUs. (Medicare Final ASC Payment Indicators Addenda BB and DD1) We should caution you that the diagnostic service represented by this code requires that the urologist (MD providing the service) clearly documents that the service was provided, and an interpretive note should be included in the provider’s medical record that is separate from the biopsy and guidance procedure notes,  if they charge for the professional interpretation.

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MACRA: How changes in final rule affect urology
 

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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