Physician Quality Reporting System (PQRS)
The Physician Quality Reporting System commonly known as PQRS is a reporting program that combines both payment adjustments and incentive payments to encourage eligible professionals (EPs) to report quality information.
The PQRS incentive payment is given to practices with EPs, who are identified via claims through their National Provider Identifier (NPI) and Tax Identification Number (TIN), or group practices via the GPRO program.
The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time.
By reporting on PQRS quality measures, individual EPs and group practices can also quantify how often they are meeting a particular quality metric. In 2015, the program began applying a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional
Physician Quality Reporting System (PQRS) Overview
The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals (EPs) to report on specific quality measures.
PQRS gives participating EPs the opportunity to assess the quality of care they are providing to their patients, helping to ensure that patients get the right care at the right time. By reporting PQRS quality measures, providers also can quantify how often they are meeting a particular quality metric. Using the feedback report provided by CMS, EPs can compare their performance on a given measure with their peers.
Choosing How to Participate
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]), or group practices participating in the group practice reporting option (GPRO) who 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).
To participate in the 2014 PQRS program, individual EPs may choose to report quality information through one of the following methods:
- Medicare Part B claims
- Qualified PQRS registry
- Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT)
- CEHRT via Data Submission Vendor
- Qualified clinical data registry (QCDR)
EPs should consider which PQRS reporting method best fits their practice when making this decision. Group practices participating through the Group Practice Reporting Option (GPRO) in the 2014 PQRS;Program year can participate through one of the following methods:
- Qualified PQRS registry
- Web interface (for groups of 25+ only)
- Direct EHR using CEHRT
- CEHRT via Data Submission Vendor
- CG CAHPS CMS-certified survey vendor (for groups of 25+ only)
Quality measures are developed by provider associations, quality groups, and CMS and are used to assign a quantity, based on a standard set by the developers, to the quality of care provided by the EP or group practice.
The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method.
When selecting measures for reporting, eligible professionals should consider factors such as:
- Clinical conditions commonly treated
- Types of care delivered frequently e.g., preventive, chronic, acute
- Settings where care is often delivered e.g., office, emergency department (ED), surgical suite
- Quality improvement goals for 2014
- Other quality reporting programs in use or being considered
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 the 2014 reporting period will qualify to earn an incentive payment. If they qualify, they will receive an incentive payment equal to 0.5% of their total estimated Medicare Part B PFS allowed charges for covered professional services furnished during that same reporting period. For more information about PQRS incentive payments visit the Analysis and Payment webpage.
EPs who do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2% payment adjustment to their Medicare PFS amount for services provided in 2016.
EPs who report PQRS quality measures data can request to receive National Provider Identifier (NPI)-level Physician Quality Reporting Feedback Reports.
The reports include information on reporting rates, clinical performance, and incentives earned by participating individual professionals, with summary information on reporting success and incentives earned at the practice level. The feedback reports can be accessed through the Web portal in the fall of the year following the reporting (e.g. 2013 feedback reports will be available in the fall of 2014).
Maintenance of Certification Program
In 2014, EPs have the opportunity to earn the PQRS incentive and an additional incentive of 0.5% by working with a Maintenance of Certification entity. Here is what is required:
- Satisfactorily submitting data, without regard to method, on quality measures under PQRS, for a 12-month reporting period either as an individual physician or as a member of a selected group practice
- More frequently than is required to qualify for or maintain board certification:
- Participate in a Maintenance of Certification Program and
- Successfully complete a qualified Maintenance of Certification Program practice
Value-Based Payment Modifier Program
The Value-Based Payment Modifier (VM) Program will provide comparative performance information tophysicians as part of Medicare’s efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.
In 2016, groups with 10 or more EPs who submit claims to Medicare under a single tax identification number will be subject to the value modifier, based on their performance in 2014. These groups will need to register and choose one of the PQRS GPRO quality reporting methods.
If a group does not choose to report quality measures as a group, and at least 50% of the EPs within the group report PQRS measures individually, CMS will calculate a group quality score based on their reporting. Failing to report will result in a negative 2% value modifier adjustment to 2016 payment under the PFS. The VM adjustment is in addition to the PQRS payment adjustment.
Under PQRS, an eligible professional (EP) is defined as one of the following types of professionals:
- Doctor of Medicine
- Doctor of Osteopathy
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Doctor of Oral Surgery
- Doctor of Dental Medicine
- Doctor of Chiropractic
- 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 *Includes Advanced Practice Registered Nurse (APRN)
- Physical Therapist
- Occupational Therapist
- Qualified Speech-Language Therapist
Eligible and Able to Participate
Under PQRS, covered professional and institutional services are those paid under or based on Medicare Physician Fee Schedule (MPFS). Only those EPs who render denominator eligible, Part B MPFS professional and/or institutional services are considered able to 2016 PQRS List of Eligible Professionals (V0.1 11/12/2015) Page 2 of 2 participate in PQRS and will be analyzed for future PQRS negative payment adjustments. If you need assistance determining whether or not you render services under Part B MPFS via the CMS-1500 or 1450 claim form, or the electronic equivalent, contact your Medicare Administrative Contractor (MAC).
PQRS EPs who are able to participate, and their office staff, should familiarize themselves with the PQRS reporting requirements and the measures that are applicable to their practice. The PQRS reporting requirements and measures are updated on an annual basis; therefore, EPs are strongly encouraged to review program materials on an annual basis
Eligible but Not Able to Participate
EPs who bill Medicare Part B services, but do not fall into the denominator for any measures are not able to report PQRS. Additionally, some EPs may not be able to participate due to their billing methodologies. Following are different scenarios in which an eligible EP is not able to participate in PQRS:
Scenario 1: Does not bill services payable under the MPFS. An EP renders services under an organization that is registered as a federally qualified health center (FQHC) and only bills professional services that are payable under the FQHC methodology. Since the EPs professional services are not covered by the MPFS, then (s) he is not able to participate in PQRS.
Note: If an eligible PQRS EP renders services under the MPFS in addition to services under other billing schedules or methodologies, then (s) he must meet the PQRS reporting requirements for those services that fall under the MPFS in order to avoid future payment adjustments regardless of the organizations participation in other fee schedules or methodologies.
Scenario 2: Does not submit individual rendering National Provider Identifier (NPI). An EP who does not bill Medicare at an individual NPI level, where the rendering providers individual NPI is entered on the professional or institutional form associated with specific line item services, is not able to participate in PQRS. Independent Diagnostic Testing Facilities (IDTF) and Independent Laboratories (IL) are examples of organizations that fall into this category and would not be subject to the PQRS payment adjustment.