Jackie Coult, CHBC

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Overview3

Physician Quality Reporting System (PQRS) formerly known as the Physician Quality Reporting Initiative (PQRI) is a  reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs). 

Incentive Payment or Penalties are tracked by practices EP’s individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on clinical quality measures (CQM) 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). 

PQRS Payment & Penalty4

YearYear Data Collected

to Inform Payment/Penalty

Bonus/Adjustment

Incentive Payment  2013 2013 + 0.5%2014 2014 + 0.5%

Payment Adjustment  2015 2013 - 1.5%2016 2014 - 2.0%2017 2015 - 2.0%

Incentive Eligibility by Reporting Options

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Reference: United States Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS); 2011 Reporting Experience Including Trends (2008-2012). CMS, 26 Mar. 2013. Web. 11 Apr 2013. (www.cms.gov/pqrs)

PQRS - How To Get Started

STEP 1: Determine if you are eligible to participate or group participate

STEP 2: Determine which PQRS reporting method best fits your practice. Claims-based, or Registry-based, or Qualified Electronic Health Record (EHR), or Group Practice Reporting Option (GPRO)

STEP 3: Review the specific criteria for the chosen reporting option in order to satisfactorily report.  

STEP 4: Individual Measures or Measures Group STEP 5:Review information on the PQRS Payment Adjustment

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PQRS - Who’s Eligible? 7

Medicare Physicians

Practitioners Therapists

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 WorkerClinical Psychologist Registered Dietician

Physical Therapist Occupational Therapist

Qualified Speech-Language Therapist

Providers payable under Medicare Physician Fee Schedule are Eligible to Participate “EP’s” in the PQRS program:

PQRS Program - Who’s NOT Eligible? 8

Services not payable under Physician Fee Schedules are not included in Physician Quality Reporting Requirements.

•Federally Qualified Health Centers (FQHCs)•Independent Diagnostic Testing Facilities (IDTF)•Independent Laboratories•Hospitals (including critical access hospitals)•Rural Health Clinics•Ambulance Providers•Ambulatory Surgical Centers

How to Report PQRS Measures9

2013 PQRS Reporting Options for Incentive Payment

(Dates of Service 1/1/2013-12/31/2013)

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Reporting Mechanism

 Group Practice Size

 2013 Registered Group (PQRS GPRO) Reporting Options for Incentive Payment

Registry All Group PracticesReport at least 3 measures, ANDReport each measure for at least 80% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.Measures with a 0% performance rate will not be counted.

GPRO WebInterface

25-99 EPs onlyReport on all measures included in the Web Interface; ANDPopulate data fields for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample (with an over-sample of 283) for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100% of assigned beneficiaries.

GPRO WebInterface

100+ EPs onlyReport on all measures included in the Web Interface; ANDPopulate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample (with an over-sample of 534) for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries.

Claims Submission: For the 2015 PQRS payment adjustment only.

Report: 1 Medicare PT, 1 Measure, on 1 Claim, 1 time before 12/31/2013

NEW 2013 Group Reporting Definition

A “group practice” under 2013 Physician Quality Reporting consists of a physician group practice, as defined by a single TIN, with 2 or more individual eligible professionals (as identified by individual NPIs) who have reassigned their billing rights to the TIN.

This definition of group practice is different from the definition of group practice that was applicable for the 2012 Physician Quality Reporting System, which defined a group practice as 25 or more eligible professionals.

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Factors to Consider12

At a minimum, EPs should consider the following factors when selecting measures for reporting:

•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

22 Measures Groups13

247 Individual Groups14

PQRSNumber

NQFNumber

Measure Title & Description

1 0059

Diabetes Mellitus: Hemoglobin A1c Poor Control

2 0064 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

3 0061Diabetes Mellitus: High Blood Pressure Control

*5 0081

Individual MeasuresReporting: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

*5 0081

Measures Group Reporting:Heart Failure: Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Sample of Individual Measures

PQRI/PQRS WAS DEVELOPED BY CMS IN 2007

VOLUNTARY PAY-FOR-REPORTING PROGRAM

Payment Incentives

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Reporting Periods16

There are 2 reporting periods available for eligible professionals to report 2013 PQRS measures groups: 12- month reporting period from January 1 through December 31, 2013, ORa 6-month reporting period from July 1 through December 31, 2013 (available only via Registry). Registry Closed on October 18th, 2013.

The 6-month reporting period allows those eligible professionals who may have decided to participate later in the year to begin reporting.

Claims Reporting17

Claims-Based Reporting18

Claims-based reporting of individual measures on 50% of Medicare patients (within 12 months period) 138 individual quality measures eligible for claims-based reporting

Claims-based reporting of at least one measures group for 20 unique Medicare Part B FFS patients (12 months) 12 measures groups eligible for claims-based reporting

Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group.

EPs may choose to submit Quality Data Codes (QDC) either on a current claim or on a claim representing a subsequent visit, particularly if the quality action has changed. For example, a new laboratory value may be available at a subsequent visit.

Group Measures Reported via Claims & Registry

G-codes – intended to report the following Groups:G8485: Diabetes Mellitus (DM) Measures GroupG8487: Chronic Kidney Disease (CKD) Measures Group G8486: Preventive Care Measures GroupG8490: Rheumatoid Arthritis Measures Group G8492: Perioperative Care Measures GroupG8493: Back Pain Measures GroupG8545: Hepatitis C Measures GroupG8547: Ischemic Vascular Disease (IVD) Measures GroupG8645: Asthma Measures GroupG8898: Chronic Obstructive Pulmonary Disease (COPD) Measures GroupG8902: Dementia Measures GroupG8905: Cardiovascular Prevention Measures Group

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Individual Measures20

PQRSNumber

Measure Title & Description

Meets Performanc

e

Medical Performance

Exclusion

Patient Performance

Exclusion

System Performanc

eExclusion

Other Performan

ceExclusion

PerformanceNot Met

  Perioperative Care: Meets all measures 20, 21, 22, 23

G8510          

20 Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician

G8629 G8630

N/A N/A N/A G8631No Report

G8632

21Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

4041F 4041F-1P N/A N/A No Report 4041F-8P

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Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non- Cardiac Procedures)

4049F & 4046F

4049F-1P & 4046F

N/A N/A 4042FNo Report

4049F-8P & 4046F

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Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

4044F 4044F-1P N/A N/A No Report 4044F-8P

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Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older

5015F 5015F-1P 5015F-2P N/A No Report 5015F-8P

Measures Reported via Claims21

Registry Based Reporting22

Registration Closed

10/18/2013

Registry Based Reporting23

At least 3 individual PQRS measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)

 At least one measures group for 20

patients, the majority of which must be Medicare Part B FFS patients (12 months)

 At least one measures group for 20

patients, the majority of which must be Medicare Part B FFS patients (6 months)

Group Measures Reported via Registry ONLY

G-codes – intended to report the following Groups: G8544: Coronary Artery Bypass Graft (CABG) Measures GroupG8548: Heart Failure (HF) Measures GroupG8489: Coronary Artery Disease (CAD) Measures GroupG8491: HIV/AIDS Measures GroupG8899: Inflammatory Bowel Disease (IBD) Measures GroupG8900: Sleep Apnea Measures Group G8903: Parkinson’s Disease Measures Group G8904: Hypertension (HTN) Measures Group G8906: Cataracts Measures Group G8977: Oncology Measures Group

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Payment Adjustment (Only)

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EP’S FROM 1-99 CAN AVOID THE -1.5%PAYMENT A ADJUSTMENT IN 2015

DATE OF SERVICE: JANUARY 1ST-DECEMBER 31ST, 2013

CLAIM MUST PROCESS BY: FEBRUARY 28TH, 2014

How to avoid 2015 PQRS Payment Adjustment - Individuals

EPs

EPs can avoid the 2015 payment adjustment (-1.5%) by meeting one of the following criteria during the 2013 PQRS program year:

1.EP reports at least:1. One valid individual measure via claims,

or through a qualified Electronic Health Record (EHR), OR

2. One valid group measure via claims

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How to avoid 2015 PQRS Payment Adjustment - Group

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Group practices (2-99 EP’s) can avoid 2015 payment adjustments of (-1.5%) by meeting one of the following criteria during the 2013 PQRS program year. NOTE: If you have NOT registered through the registry, GPRO or PV-PQRS (closed October 18, 2013), see option 4:

1.Group meets the following requirements, outlined in the 2013 PQRS measure specification for satisfactorily reporting:

Reports specific ACO/GPRO measures through the Web Interface based on a pre-populated patient sample (only available to group practices of 25 or more EPs) OR

Reports at least 3 registry measures (for 80% of the group’s eligible patients for each measure)  for the GPRO outlined in the 2013 PQRS Measure Specification for Claims/Registry Reporting of Individual Measures (available to all group practices of 2 or more EPs)

Group reports at least one valid measure through:1. Web Interface (only available to group practices of 25 or more EPs) OR2. Participating Registry (available to all GPRO participants)

a)Group elects to participate as a GPRO in the administrative claims-based reporting mechanism by October 18, 2013.

b)EP reports at least: One valid individual measure via claims, or through a qualified Electronic Health Record

(EHR), OR One valid group measure via claims

Conclusion28

Avoid -1.5% Payment Penalty in 2015:Report on: 1 Medicare PT, 1 Measure, on 1 Claim, 1 time before 12/31/2013. Note: Claim must be processed by no later than 2/28/2014 Obtain +.5% Incentive Payment in 2013:Report on: 50% Medicare PT’s, 1-3 Measures, on all Claims or reporting option selected (the applicable 50%), for 6 months, before 12/31/2013. Although, CMS proposal for PQRS in 2014, to avoid 2% Penalty in 2016 is:Report on: 50% Medicare PT, 3 Measures, on all Claims, for 1 yr.

ON JULY 8, 2013, THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) ISSUED A PROPOSED RULE THAT WOULD UPDATE PAYMENT POLICIES AND PAYMENT RATES FOR SERVICES FURNISHED UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) ON OR AFTER JAN. 1, 2014.  

THE PROPOSED RULE ALSO PROPOSES CHANGES TO SEVERAL OF THE QUALITY REPORTING INITIATIVES THAT ARE ASSOCIATED WITH PFS PAYMENTS, INCLUDING THE PHYSICIAN QUALITY REPORTING SYSTEM (PQRS), AS WELL AS CHANGES TO THE PHYSICIAN COMPARE TOOL ON THE MEDICARE.GOV WEBSITE.  

FINALLY, THE PROPOSED RULE INCLUDES PROPOSALS FOR IMPLEMENTING THE VALUE-BASED PAYMENT MODIFIER (VALUE MODIFIER) REQUIRED BY THE AFFORDABLE CARE ACT THAT WOULD AFFECT PAYMENT RATES TO CERTAIN GROUPS BASED ON THE QUALITY AND COST OF CARE THEY FURNISH TO BENEFICIARIES ENROLLED IN THE TRADITIONAL MEDICARE FEE-FOR-SERVICE PROGRAM.

Proposed Changes for 2014 Physician Quality Programs and The

Value Based Payment Modifier

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PQRS – What’s to come in 2014?30

In an effort to consolidate, CMS will begin to incorporate PQRS Measures into Meaningful Use Stage 2 by reducing claims-based reporting.

Add and Delete Measures 47 new individual Measures 3 Measure groups Retire a number of claims-based measures (encourage reporting via registry & EHR-

based mechanisms)

Individual EPs Increase the number of measures that must be reported from 3-9 (for both claims &

registry) Reduce a reporting threshold via registry from 80% to 50% for all applicable patients

on individual measures Eliminate the reporting option to report on claims-based measure groups

PQRS reporting utilizing the Clinical Data Registries Report at least 9 measures to the registry covering 3 of the National Quality Strategy

domains Report at least 50% of the applicable patients Individual EPs

MEANINGFUL USE IS THE SET OF STANDARDS DEFINED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) INCENTIVE PROGRAMS THAT

GOVERNS THE USE OF ELECTRONIC HEALTH RECORDS AND ALLOWS ELIGIBLE PROVIDERS AND HOSPITALS TO

EARN INCENTIVE PAYMENTS BY MEETING SPECIFIC CRITERIA.

E-Prescribe & Meaningful Use 2013/2014

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Electronic Prescribing Incentive Program

For years 2012 through 2014, eligible professionals who are not successful electronic prescribers will receive a payment adjustment under the eRx Incentive Program are as follows:

Utilizing e-Prescribing Not Utilizing e-Prescribing

+1.0% in 2012 -1.0 % in 2012+0.5% in 2013 -1.5 % in 2013

-2.0 % in 2014

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Meaningful Use Incentive

For the most part, EPs may participate in more than one incentive program at the same time. However, there are some limitations. This table outlines the programs that EPs may participate in at the same time:Table 1: Maximum EHR Incentive Payments by Program Based on the First Calendar Year (CY) for Which the EP Receives Payment

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CYCY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016

Medicare Medicaid Medicare Medicaid Medicare Medicaid Medicare Medicaid Medicar

eMedicaid

Medicare

Medicaid

2011 $18,000 $21,250                    

2012 $12,000 $8,500 $18,000 $21,250                

2013 $8,000 $8,500 $12,000 $8,500 $15,000 $21,250            

2014 $4,000 $8,500 $8,000 $8,500 $12,000 $8,500 $12,000 $21,250        

2015 $2,000 $8,500 $4,000 $8,500 $8,000 $8,500 $8,000 $8,500   $21,250    

2016   $8,500 $2,000 $8,500 $4,000 $8,500 $4,000 $8,500   $8,500   $21,250

2017       $8,500   $8,500   $8,500   $8,500   $8,500

2018           $8,500   $8,500   $8,500   $8,500

2019               $8,500   $8,500   $8,500

2020                   $8,500   $8,500

2021                       $8,500

Total (if EP does not

switch programs)

$44,000 $63,750 $44,000 $63,750 $39,000 $63,750 $24,000 $63,750 $0 $63,750 $0 $63,750

NOTE: Medicare EPs may not receive EHR incentive payments under both Medicare and Medicaid. NOTE: The amount of the annual EHR incentive payment limit for each payment year will be increased by 10 percent for EPs who predominantly furnish services in an area that is designated as an HPSA.

Summary of Proposed Stage 2 Rule of Meaningful Use

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To avoid penalties starting in 2015, EPs need to: Attest to meaningful use in 2013; or Have achieved and attested to the first year of

meaningful use by October 1, 2014The requirement as to when different stages of

meaningful use need to be met was officially relaxed. Those that attest to meaningful use in 2011 must meet

Stage 2 criteria in 2014 and Stage 3 in 2016Quality measures are still not final.The proposed rule generally makes Stage 1

optional (menu) items required (core) in Stage 2

Multiple Incentive Programs at the Same Time

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Payments Based on the First Year Calendar Year (CY) for Which an EP Receives an EHR Incentive Payment* This table identifies the maximum incentive payments available by year depending on whether the EP chooses to participate in either the Medicare or Medicaid EHR Incentive Program. It also shows payment adjustments for not meeting these criteria.

Need Medicare Assistance

Contact the Quality Net 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

PQRS Registry website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.htmlPQRS EHR: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Electronic-Health-Record-Reporting.htmlPQRS GPRO website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

Monday – Friday; 7:00 a.m.–7:00 p.m. CSTPhone: 1-866-288-8912

TTY: 1-877-715-6222Email: qnetsupport@sdps.org

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Q & A37

Jackie Coult, CHBC801-550-5058

Jgc.coult@comcast.netP.O. Box 171004

Holladay, UT 84117-1004