PQRS: The Other Reporting Initiative

Many providers received letters from the Centers for Medicare & Medicaid Services (CMS) stating they will incur a payment adjustment in 2015 for not successfully reporting to the Physician Quality Reporting System (PQRS) in 2013. Since this came as a surprise to many, we wanted to take this time to review the nuts and bolts of this CMS program.

What is it?

The Physician Quality Reporting System (PQRS) is a CMS program to promote the submission of quality data by Medicare providers through incentives and penalties. Eligible Professionals (EPs) can register individually or with a group and report on quality measures for covered PFS services furnished to Medicare Part B Fee-for-Service beneficiaries. EPs who did not successfully submit data in 2013 will be subject to a 1.5% negative payment adjustment in 2015. The payment adjustment is applied two years after the reporting period, and beginning in 2016, it will increase.

Are you eligible?

PQRS has an extensive list of eligible professionals.

Even though a provider may meet the initial criteria listed above, there are certain instances in which they are not eligible to participate. One example – if the provider does not bill Medicare at an individual NPI level. It’s important to thoroughly review the criteria before jumping on board.*

Group versus Individual Submission?

Unlike Meaningful Use, EPs can submit data individually using their own NPI number OR as a group practice. CMS defines a group practice as a single Tax Identification Number (TIN) with 2+ individual EPs that have assigned their billing rights to the TIN. Once the group registers for the group practice reporting option (GPRO), individuals cannot participate separately. Registration occurs in the PV-PQRS registration system. Since this is a time-sensitive registration you’ll want to make sure you complete it between April 1, 2015 and June 30, 2015. This is an important decision to make as soon as possible.

Options to Submit Data:

Selecting Quality Measures:

It’s important to carefully select your quality measures each year as requirements and measures change. According to CMS, at a minimum the following should be considered when selecting measures:

  • Clinical conditions usually treated
  • Types of care typically provided – e.g., preventive, chronic, acute
  • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
  • Quality improvement goals for 2015
  • Other quality reporting programs in use or being considered

For 2015 a new requirement was added for the claims and registry reporting of individual measures. EPs and Group Practices will be required to report one cross-cutting measure if they have at least one Medicare patient with a face-to-face encounter.**

While it may seem overwhelming to prepare for PQRS this year, you are not alone! Let our experienced team help you get on the right track to successfully participate this year and avoid a future payment adjustment!

Cody Simpson
Consultant, MBA HealthGroup