PQRS Reporting for Mental Health

PQRS For Mental Health Made Easy

If you are anything like me you are sick to death of hearing about PQRS, but have you done anything about it yet?  It may be driving you crazy, but if you just take the time to learn what you have to know and then implement a plan it would go away.  Well it won’t actually go away, but it will become less obnoxious.

Just a quick recap for those who still don’t know what PQRS is:  PQRS or Physician Quality Reporting System is a system used by physicians to report performance measures to Medicare.  Prior to 2015 PQRS was simply an incentive program (known as PQRI).  But in 2015 it will become a penalty program.  Physicians who do not report performance measures using PQRS will be faced with a 1.5% penalty in 2015 and a 2% penalty in 2016.  Even though the penalty program doesn’t start until 2015 the penalty is based on reporting done in 2014 so in order to avoid the penalty providers must be reporting performance measures now.

The PQRS program is for Fee-For-Service Medicare patients.  It does not include patients who are enrolled in Medicare Advantage Plans, or Part C Medicare.  So let’s break this down and make it as simple as we can.  (Don’t forget, it is a government program.  They don’t usually make anything easy.)

Let’s break the whole process down into 3 steps:

1.    Identify the measure you will use to report
2.    Link the chosen measure to the appropriate reporting code
3.    Report them to Medicare

That doesn’t sound so bad.  So let’s get started!

1.     Identify the measure you will use  –  CMS has over 300 reporting measures but (thankfully) most are not relevant for mental health.  There are really only 10 measures that relate to mental health and they are:
1.    106  Adult Major Depressive Disorder: Comprehensive Diagnostic Evaluation
2.    107  Adult Major Depressive Disorder: Suicide Risk Assessment
3.    128  Body Mass Index Screening and Follow-Up
4.    130  Documentation of Current Medications in Medical Record
5.    131  Pain Assessment and Follow-up
6.    134  Screening for Clinical Depression and Follow-up Plan
7.    181  Elder Maltreatment Screen and Follow-up Plan
8.    226  Tobacco Use: Screening and Cessation Intervention
9.    247  Substance Abuse Disorders (counseling regarding options)
10.    248  Substance Abuse Disorders (Screening for depression)

•     Remember, the performance measure must be reported using the appropriate g-code or CPT-II code, but the actual results do not get reported.

2.    Link the chosen measure to the appropriate reporting code – Find the appropriate G-Code or CPT II code to report the measure.  Make sure the procedure code that is being billed is appropriate for the measure being reported.

Click here to see a table showing the measures, the CPT codes and the reporting codes (info from CMS)
(*  Please note that this information is always changing.  Please check the CMS website to make sure that you are using the most up to date codes.)

So now that we have covered the steps of PQRS, let’s go through a couple of examples:

Psychologist Dr Jones sees a patient for the first time and diagnoses the patient as having Major Depressive Disorder.  He performs an assessment of the severity of the Major Depressive Disorder during the initial visit.  The claim for the initial visit could be coded as follows:
1.    09/04/2014        90791        $225.00
2.    09/04/2014        G8930        $    0.00

LCSW Mary Smith sees a patient that she has been seeing fairly regularly for the past 12 months.  The patient missed the past couple of scheduled appointments and Mary sees some changes in the patient so she decides to screen the patient for clinical depression.  After completing the screening she determines that the patient is not clinically depressed.  The patient was seen for a 45 minute session and may be coded as follows:
1.    09/04/2014        90834        $125.00
2.    09/04/2014        G8510        $    0.00



  1. Report the measures to Medicare – Measures can be reported to Medicare in one of four different ways:
  2. Claims based reporting – codes are included on the claim for the services
  3. Registry based reporting – measures are reported to large Medicare approved organizations that report the data to Medicare
  4. EHR based reporting – measures are reported through the EHR system
  5. Group practice reporting – measures are reported through a group practice

The most common reporting method is claims based reporting. Claims based reporting is done by adding a G-Code or a CPT II code to the claim. Once the appropriate code is selected it is billed on the same claim as the services. The code must be entered with either a $0.00 or a $0.01 charge. (Nothing is paid on the code. Some systems will not allow it to be entered with a $0.00 charge so a $0.01 charge must be used. It will depend upon the system being used to create the claim.)
So now that you understand how the coding is done you need to understand what patients need to be reported.  In order to avoid the penalty practitioners must report on at least 50% of eligible instances.  Keep in mind this is only in regards to patients with traditional part B Medicare.  Even though it is only required to report on 50% of eligible cases it is a good idea that practitioners routinely report on all Medicare part B patients even if they are simply reporting that no screening was done.  That will ensure that they avoid the penalty.    But simply reporting the codes is not enough.  Practitioners must also make sure that their documentation reflects the PQRS code reported.

Many people feel that PQRS just puts added paperwork on the practitioner and their staff.  It does take a little additional effort on behalf of the provider but some feel that it will act as a brief reminder to the provider to perform these essential tasks that they should be performing regularly.  The reality is that if you take the time to figure out what needs to be done it really doesn’t take that much extra effort to implement it.  However, there are some providers who are just willing to take the penalty or will choose to no longer treat Medicare patients.


12 Responses to “PQRS Reporting for Mental Health”

  1. KITTYMC@aol.com Says:

    Thank you so much for this! It is most helpful!

  2. Deborah Says:

    Thank for keeping us all up to date. Very helpful and much appreciated!!!

  3. Wendy Says:

    I have been searching for something that explained this simply & you nailed it. Thank you!

  4. Maggie Says:

    Do you have any information on internal medicine providers that is this easy to understand?

  5. Charissa Says:

    Wow! Been trying to get my head around PQRS, this is the only explanation that made sense 🙂 I wish I saw this article earlier!! So, is it too late to start now? If I understand their information correctly, Feb. 2015 is the cutoff date for 2014 reporting, is that correct? Please enlighten us more! Thanks for your help!

    • solutionsmedicalbilling Says:

      No it is not too late to start now but I’m afraid you may see penalties for 2015 if you don’t get started soon.
      Penalties will increase from year to year so start ASAP!

  6. Norman Hoffman, PhD Says:

    Your information is quite refreshing; Is there a sample insurance billing form that you could provide to help us further? It would be most informative if I had a complete sample insurance form filled out.

  7. Leanne Says:

    OMG you made it sound so simple! Wish I had seen this earlier. Obviously I missed the cut off for 2016 but I want to get started now so I don’t miss 2017 deadlines. So you’re saying all I have to do is file my claims with the appropriate G-code (assuming the provider has documentation supporting that code) and that’s it???

  8. Dr. Marvin W. Jones Says:

    I appreciate this simple explanation of PQRS measures for mental health.

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