PQRS Sample CMS 1500 Claim Submission: Diabetes & CAD Reporting Example

Please Note: This post serves as a historical reference. The Physician Quality Reporting System (PQRS) was replaced by the Merit-based Incentive Payment System (MIPS) under MACRA in 2017. Furthermore, the diagnostic codes used in this example are ICD-9, which were replaced by ICD-10 codes in 2015. While this content provides a valuable illustration of CMS 1500 claim form submission mechanics for quality measures, current reporting requires adherence to MIPS and ICD-10 guidelines. For more current information on MIPS, please refer to our guide to MIPS.

This detailed example demonstrates how to accurately complete a CMS 1500 form for PQRS measure reporting, specifically for patients with diabetes and coronary artery disease (CAD). Below, you’ll find a visual sample of a CMS 1500 claim illustrating the proper placement of Quality Data Codes (QDCs) and corresponding diagnostic codes, addressing common billing scenarios and providing a clear “pqr example”.

Consider a patient seen for an office visit (CPT code 99213). The provider is reporting several quality measures related to diabetes, coronary artery disease (CAD), and urinary incontinence. Let’s break down the reporting requirements for each measure:

Detailed Breakdown of Diabetes Measures

Measure #2 (LDL-C: Low-Density Lipoprotein Cholesterol)

This measure involves reporting QDC 3048F alongside a diabetes line-item diagnosis. In this historical context, we replace the ICD-9 DX 250.00 with its ICD-10 equivalent, E11.9 (Type 2 diabetes mellitus without complications). The medical necessity for LDL-C testing in patients with diabetes and CAD is well-established. As outlined in the CMS National Coverage Determination (NCD) for Lipid Testing (NCD-102-v2), lipid panels are indicated for the “assessment of patients with atherosclerotic cardiovascular disease” and for “secondary dyslipidemia, including diabetes mellitus.” Monitoring frequency is also critical; for stable patients, annual testing is often sufficient, but for those initiating new lipid-lowering therapy, monitoring may be required up to six times in the first year to assess treatment effectiveness.

Measure #3 (BP in Diabetes: Blood Pressure Management)

This measure requires reporting QDCs 3074F and 3078F, again linked to a diabetes line-item diagnosis. The ICD-10 equivalent for DX 250.00, E11.9 (Type 2 diabetes mellitus without complications), would be used. Effective blood pressure management is a cornerstone of comprehensive diabetes care, significantly reducing the risk of cardiovascular and renal complications. While the CMS NCD for Glycated Hemoglobin/Glycated Protein (NCD-100-v1) primarily focuses on HbA1c testing, it underscores the broader principle of active management and control necessary for optimal diabetes outcomes, which inherently includes blood pressure control.

Reporting Coronary Artery Disease (CAD) Measures

Measure #6 (CAD: Coronary Artery Disease)

For this measure, QDC 4011F is reported with a CAD line-item diagnosis. The ICD-9 DX 414.00 is updated to its ICD-10 counterpart, I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris). The rationale for reporting this measure ties directly into effective CAD management. The Lipid Testing NCD (NCD-102-v2) emphasizes the role of lipid testing in “evaluating atherosclerotic cardiovascular disease” and the “diagnostic evaluation of diseases associated with altered lipid metabolism.” Maintaining appropriate lipid levels, particularly LDL-C, is fundamental in preventing progression and managing existing CAD, making this measure vital for tracking quality of care.

Understanding Urinary Incontinence Assessment

Measure #48 (Assessment – Urinary Incontinence)

This measure is reported with QDC 1090F. For PQRS, this measure does not require a specific diagnosis code directly associated with it, but billers should ensure the measure points to an appropriate diagnosis code relevant to the overall patient encounter in Item 21. This ensures the claim provides a complete clinical picture.

Practical Billing Advice for CMS 1500 Form Submission

Diagnosis Linking: All diagnoses listed in Item 21 on the CMS 1500 claim form will be considered for PQRS analysis. For measures requiring two or more diagnoses, the claim will be analyzed as submitted in Item 21, so careful attention to linking is crucial.

NPI Placement for Individual Providers: When a group is billing for services, Item 24J of the CMS 1500 form must accurately contain the National Provider Identifier (NPI) of the individual provider who rendered the service. This ensures proper attribution and processing of claims.

Handling Multiple Line Items and Software Limitations: Billing software can sometimes limit the number of line items on a single claim. If you encounter such limitations and need to split PQRS reporting across multiple claims for the same date-of-service, beneficiary, and provider (TIN/NPI), a practical solution is to add a nominal line-item charge of one penny to one of the QDC line items on the subsequent claim. PQRS analysis systems are designed to join these claims based on the common beneficiary, date-of-service, and TIN/NPI, treating them as a single comprehensive submission. This best practice helps avoid claim rejections and ensures all quality data is captured for analysis.