Physicians not currently participating in the Physician Quality Reporting System (PQRS) must take action by Oct. 15 (today) to avoid a 1.5% penalty from Medicare in 2015, according to a recent story from MedPage Today.
The Centers for Medicare and Medicaid Services (CMS) is responsible for implanting the PQRS and calculating a physician’s PQRS quality measures on 2013 claims. As explained by CMS, “PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).”
“The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).”
Beginning in 2015, the program also applies a payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.
Thus, the “PQRS program demands require physicians to meet specialty-specific documentation and reporting requirements for CMS,” MedPage writes. “For example, radiology practices are scrutinized on their reporting of such measures as prevention of catheter-related bloodstream infections, the inappropriate use of the “probably benign” assessment category in mammography screening, and stenosis measurement in carotid imaging studies.”
The American Medical Association (AMA) and others requested CMS simplify the PQRS reporting requirements to help physicians avoid penalties in 2015. “CMS listened and eased requirements.”
Physicians can either report three individual measures or one measures group to CMS — with a deadline of Feb. 28 for doing so — or they can sign up for an exemption via an “administrative claims-based reporting mechanism” offered by CMS, according to the article.
It’s that second option that has a deadline of Oct. 15; physicians can sign up for this exemption on the CMS Enterprise Portal, according to the California Medical Association.
“Providers who choose this exemption will be evaluated from claims data on 19 quality measures for all applicable Medicare Part B fee-for-service beneficiaries in 2013 to whom the measure applies.”
“A study published earlier this year found fewer than one in five physicians met the PQRS reporting requirements in 2010 before the changes were made,” MedPage writes.
According to CMS, there are multiple ways in which providers can report their quality information, including:
- To CMS on their Medicare Part B claims
- To a qualified Physician Quality Reporting registry
- To CMS via a qualified electronic health record (EHR) product
- To a qualified Physician Quality Reporting EHR data submission vendor
Physicians who meet PQRS reporting time frames currently receive a 0.5% Medicare bonus payment. In 2015, those bonuses will be replaced by a 1.5% penalty for those who don’t meet the time frames, which jumps to 2% in 2016.
The American Academy of Family Physicians (AAFP) calculates the 2015 penalty equates to a $4,275 hit to a three-physician practice with a $1.425 million annual revenue and a 20% Medicare payer mix.
Formerly known as the Physicians Quality Reporting Initiative, PQRS was made mandatory by the Affordable Care Act in 2010 and is yet another sign that organized medicine is moving away from fee-for-service payment models to more outcome-driven arrangements.
PQRS Quick Links
For step-by step instructions on how to implement PQRS, view the How to Get Started page. In addition, learn more about PQRS and how to participate by visiting the following pages:
• For information on how to select measures, review the Measures Codes page
• For information on the methods of reporting review the following pages:
o Registry Reporting page
o EHR Incentive Program Reporting page
o Group Practice Reporting Option page
• For information on incentive payments, review the Analysis and Payment page
• For information on adjustments, review the Payment Adjustment Information page
Help Desk
If you have questions or need assistance with PQRS reporting please contact the QualityNet Help Desk. The help desk is available Monday – Friday; 7:00 AM–7:00 PM CST:
Phone: 1-866-288-8912 TTY: 1-877-715-6222 Email: Qnetsupport@sdps.org
No Sign Up or Pre-Registration.
Individual EPs do not need to sign-up or pre-register in order to participate in PQRS. However, to qualify for a PQRS incentive payment an EP must meet the criteria for satisfactory reporting specified by CMS for a particular reporting period. A revised List of Eligible Professionals who may participate in PQRS is available by clicking on this link.
Note: The PQRS program requirements and measure specifications for the current program year may be different from the PQRS program requirements and measure specifications for a prior year. EPs are responsible for ensuring that they are using the PQRS documents for the correct program year.
2013 PQRS
To participate in the 2013 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measures groups:
(1) to CMS on their Medicare Part B claims
(2) to a qualified PQRS registry
(3) to CMS via a qualified electronic health record (EHR) product
(4) to a qualified PQRS data submission vendor.
Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms above for services furnished during a 2013 reporting period will qualify to earn a PQRS incentive payment equal to 0.5% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period.
A group practice may also potentially qualify to earn PQRS incentive payments equal to 0.5% of the group practice’s total estimated Medicare Part B PFS allowed charges for covered professional services furnished during a 2013 PQRS reporting period based on the group practice meeting the criteria for satisfactory reporting specified by CMS.
For an overview of changes for the 2013 PQRS, review the Physician Quality Reporting System: Updates for 2013 fact sheet.
How To Get Started – 5 Steps from CMS
STEP 1:
Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of eligible medical care professionals considered eligible to participate in PQRS is available. Read this list carefully, as not all entities are considered “eligible professionals“ because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS).
STEP 2:
Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An eligible professional may choose from the following methods to submit data to CMS: claims-based, registry-based, qualified Electronic Health Record (EHR), or the Group Practice Reporting Option (GPRO).
In order to satisfactorily report, it is important to review each method’s specific reporting criteria. For additional guidance, refer to the 2013 Physician Quality Reporting System Participation Decision Tree.
- Reporting via registry or qualified EHR requires eligible professionals to utilize vendors. Registry information, including reporting criteria and vendors, is available on the Registry Reporting page.
- EHR reporting information, including reporting criteria and qualified vendors, is available on the Electronic Health Record Reporting page.
- GPRO information may be reviewed on the Group Practice Reporting Option page.
STEP 3:
If the chosen method to report is claims-based or registry-based, determine which measure reporting option (individual measures or measures group) best fits your practice. Review the specific criteria for the chosen reporting option in order to satisfactorily report.
Eligible professionals who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. Refer to MAV information available on the Analysis and Payment page.
All PQRS measures and their available reporting methods can be reviewed in the 2013 Physician Quality Reporting System (PQRS) Measures List. The list is available in the 2013 PQRS Measure List Implementation Guide zip file.
STEP 4:
Individual Measures or Measures Group
Eligible professionals may choose at least three individual measures or one measures group as an option to report on measures to CMS. Review the following supporting documentation for specific criteria to satisfactorily report on these two options.
If already participating in PQRS, there is no requirement to select new/different measures for the 2013 PQRS. NOTE: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, eligible professionals will need to review them for any revisions or measure retirement for the current program year.
Notice that each measure or measure group has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period by each individual eligible professional (NPI). The reporting frequency (i.e., report each visit, once during the reporting period, each episode, etc.) is found in the instructions section of each measure specification or in the Measure Group Overview section. Ensure that all members of the team understand and capture this information in the patients’ medical record to facilitate reporting.
Individual Measures
The following documents can be found in the 2013 PQRS Individual Claims Registry Measure Specification Supporting Document zip file:
- 2013 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Individual Claims and Registry Reporting for instructions on how to report claims-based or registry-based individual measures. Just print the pages for the measure specifications you are reporting as the document is very lengthy. The document is available below and in the “Downloads”section of the link titled “Measures Codes”.
- 2013 Physician Quality Reporting System (PQRS) Implementation Guide which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Form CMS-1500 format. The guide is available below and in the “Downloads” section of the link titled “Measures Codes”.
Measures Groups
The following documents can be found in the 2013 PQRS Measure Group Specification, Release Notes, Getting Started with 2013 PQRS Measures Groups, 2013 Quality-Data Code Categories, and 2013 PQRS Measures Groups Single Source Code Master zip file:
- 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual and Release Notes, available below and in the “Downloads” section of the link titled “Measures Codes”, for claims-based or registry-based reporting of measures groups. Just print the pages for the measure specifications, including the measure group denominator coding, you are reporting. Note that the specifications for a measures group are different from those for individual measures because they identify a common denominator across the measures group. Be sure you use the correct specifications.
- Getting Started with 2013 Physician Quality Reporting System (PQRS) Measures Groups is the implementation guide for reporting measures groups. It is available below and in the “Downloads”section of the link titled “Measures Codes”.
As you read the specifications and reporting instructions, you will notice that each of the measures has a Quality-Data Code (QDC) (a Current Procedural Terminology [CPT] II code or G-code) associated with it. Note that several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Only allowable CPT II modifiers may be used with a CPT II code. Eligible professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.
To qualify for the incentive, the correct numerator QDC must be reported on at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. A claim is considered “eligible” in PQRS when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes on the claim match the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification.
Refer to the 2013 Physician Quality Reporting System (PQRS) Quality-Data Code Categories for a complete list of how each code will be used to calculate performance rates.
STEP 5:
Review information on the PQRS Payment Adjustment. To avoid being subject to a future PQRS payment adjustment, the numerator QDC must be reported at least once during the 12-month reporting period, or the eligible professional must satisfactorily report at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. Refer to the Payment Adjustment Information titled link for complete information on how to avoid future PQRS payment adjustments.
Need Assistance?
Contact the QualityNet Help Desk for help with:
- General CMS PQRS & eRx information
- PQRS Portal password issues
- PQRS/eRx feedback report availability and access
- PQRS-IACS registration questions
- PQRS-IACS login issues
Monday – Friday; 7:00 a.m.–7:00 p.m. CST
Phone: 1-866-288-8912
TTY: 1-877-715-6222
Email: qnetsupport@sdps.org
Frequently Asked Questions (FAQs)
Visit our Physician Quality Reporting System FAQ page and enter keywords in the search box to find answers on “How do I get started” or any other area of the program you may have questions about.
To view all of the 2013 PQRS Program Requirements, review the 2013 Medicare PFS Final Rule.