he 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) established a physician quality reporting system,

with an incentive payment for eligible professionals (EPs) who satisfactorily reported quality measure data for covered professional services (based on the Medicare Physician Fee Schedule or PFS) furnished to Medicare beneficiaries during the 2007 reporting period.

The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS), initially named this program the Physician Quality Reporting Initiative (PQRI).

PQRI was further modified by Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 (MMSEA), (Pub. L. 110-275) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA),(Pub. L. 110-275).

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What is PQRS 1

In 2011, the program name was changed to Physician Quality Reporting System (PQRS). For each program year, CMS implements quality reporting through an annual rulemaking process published in the Federal Register.

MIPPA required the Health and Human Services Secretary to post on the CMS Web site a list of EPs or group practices who satisfactorily submit quality measure data for PQRS and who are successful electronic prescribers.

Eligible Professionals (EPs) Under PQRS, covered professional services are those paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that EPs are providing services which get paid under or based on the PFS, those services are eligible for PQRS.

The following professionals are eligible to participate in PQRS:

1. Medicare physicians Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic

Individual EPs do not need to sign up or pre-register to participate in the PQRS. However, to qualify for an incentive payment, an EP must meet the criteria for satisfactory reporting as specified by CMS for a particular reporting period. Requirements and measure specifications may differ from year to year. EPs are responsible for ensuring that they are using the PQRS documents for the correct program year.

2. Practitioners 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 Audiologist

3. Therapists Physical Therapist Occupational Therapist Qualified Speech-Language Therapist

What is PQRS 2

2012 Reporting To participate in the 2012 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measure group(s) to CMS via one of the following reporting mechanisms:

Medicare Part B claims that include PQRS codes,

PQRS-qualified registry,

PQRS-qualified electronic health record (EHR) product,

PQRS-qualified EHR Data Submission Vendor,

PQRS-Medicare EHR Incentive Pilot

Individual EPsIndividual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms for services furnished during a 2012 reporting period will qualify to earn a PQRS incentive payment equal to 0.5 percent of their total estimated Medicare Part B PFS allowed charges during that same reporting period.

Group PracticesA group practice may also potentially qualify to earn the same incentive if the group meets the criteria for satisfactory reporting as specified by CMS.

Go to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html to learn more about this option.

This section of the CMS Web site will also provide instructions on how a group practice can sign up to participate in GPRO and provides details for the 2012 PQRS measures.

What is PQRS 3

Supporting more and better clinical quality dataUntil recently, physician practices that wanted to participate in the CMS PQRS had to submit claims or registry data. Now practices can report data directly from their EHR systems via a PQRS-qualified product. Local QIOs are providing technical assistance to accurately capture the required data elements and extract them for reporting. This qualifies practices for incentive payments that add to their usual annual Medicare reimbursement amounts.

Successfully complete a qualified Maintenance of Certification Program practice assessment

Participate in a Maintenance of Certification Program and

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

ANDMore frequently than is required to qualify for ORmaintain board certification:

Maintenance of Certification Program Incentive As of 2011, physicians now have the opportunity to earn an additional incentive of 0.5 percent by working with a Maintenance of Certification entity and by completing the following:

What is PQRS 4

This guide focuses on the direct EHR and claims-based reporting methods.

Step 1: Determine if you are eligible for the PQRS Incentive Program

EPs include Medicare physicians, practitioners and therapists.

A complete eligibility re-quirement list can be found on the CMS Web site under the PQRS/Downloads section.

Steps to PQRS Participation 5

Step 2: Determine if you are eligible to report via EHR

If you are using a PQRS-qualified EHR, you will likely want to use it to report PQRS measures to CMS instead of reporting through claims or the PQRS registry. Check the list of PQRS-qualified EHRs to determine if you are eligible. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/Downloads/2012QualifiedEHRDirectVendors_03-05-2012-.pdf

Note: If you are NOT elligible to report via EHR, please skip to Step 4.

Step 3:Register for an Individual Authorized Access for CMS Computer Services (IACS) account, if you do not already have one. You will need an IACS account to view TIN-level feedback reports and to upload data for EHR submissions. To establish your IACS account, go to the CMS Applications Portal online at https://applications.cms.hhs.gov/warning.html.

Select Account Management, then New User Registration, and select the Physician Quality Reporting Systems/eRx link. Be sure to remember your IACS account information.

See the IACS Quick Reference Guides at https://www.qualitynet.org/portal/server.pt/community/pqri_home/212# for more information

Please go to Step 5.

Steps to PQRS Participation 6

Step 4: Consider using Claims, Registry, EHR Data Submission Vendor or Medicare EHR Incentive Pilot reporting if you can’t submit via EHR

Claims Reporting — With claims reporting, specific PQRS codes called Quality Data Codes (QDCs) must be reported on each Medicare Part B PFS eligible claim at the time it is submitted for payment.

Registry Reporting — A listing of qualified registries for 2012 reporting should be available soon (available online at https://www.cms.gov/PQRS/Downloads/2012_RegistrySubmissionRequirements.pdf). A 12-month reporting period is available for individual measures and both 6- and 12-month reporting periods for measure groups may be available, depending on your specific registry. The qualified registry will submit data to Medicare on behalf of the provider after the close of the reporting period. Contact the registry for additional instructions.

EHR Data Submission Vendor (DSV) — This vendor collects an eligible professional’s clinical quality data (at least the numerator data) directly from the eligible professional’s EHR. DSVs will be responsible for submitting PQRS measures data from an EP’s EHR system to CMS in a CMS-specified format(s) on behalf of the eligible professional for the respective program year. The list of 2012 EHR DSVs will be available on the CMS website in Summer 2012.

PQRS-Medicare EHR Incentive Pilot — Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report CQMs (See Appendix A for a list of the 44 CQMs) to CMS by reporting them through participation in the PQRS-Medicare EHR Incentive Pilot that utilizes the 2012 PQRS EHR Measure Specifications.

https://www.cms.gov/PQRS/Downloads/2012PQRS_MedicareEHR-IncentPilot_Final508_1-13-2012.pdf

Steps to PQRS Participation 7

Steps to PQRS Participation 8

#110 Influenza Immunization for Patients 50+#111 Pneumonia Vaccination for Patients 65+#112 Screening Mammography for Women 40-69#113 Colorectal Cancer Screening for Patients 50-75#226 Tobacco Use Screening and Cessation Intervention for

Patients 18+#237 Hypertension: Blood Pressure Measurement for Patients

50+

Choose a minimum of 3 measures for selected reporting methodQsource provides assistance with the following measures related to Preventive Care

Claims Reporting Method

EHR Reporting Method

Step 5:

#110: Influenza Immunization for Patients 50+#111: Pneumonia Vaccination for Patients 65+#112: Screening Mammography for Women 40-69#113: Colorectal Cancer Screening for Patients 50-75#201: Ischemic Vascular Disease (IVD): Blood Pressure Management

Control#241: Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low

Density Lipoprotein (LDL-C) Control#226: Tobacco Use Screening and Cessation Intervention for Patients

18+

Steps to PQRS Participation 9

Patient encounter data collectionStep 7:

EHR Reporting Method

Capture patient-level data on the three selected measures for 80 percent of your Medicare Part B PFS patients seen for 12 months (1/1/2012-12/31/2012)

Helpful tip: Use the clinical decision support function of your EHR to set alerts to identify all eligible cases for your measures. Many vendors have pre-defined alerts that align with PQRS measures. Work with your vendor to activate or define selected alerts.

Step 6:

For Individual PQRS Measures:https ://www.cms.gov/apps/ama/license.asp?f i le=/PQRS/downloads/2012_EHR_Documents_for_Eligible_Professionals-Nov2011_1215111.zip

Review measure specifications for the 3 selected measures in Step 5

Claims Reporting Method

EHR Reporting Method

For Individual PQRS measures: https://www.cms.gov/apps/ama/license.asp?file=/PQRS/down-loads/PQRS2012_PhysQualRptg_IndividualClaimsRegistry.zip

For Measures Groups:https://www.cms.gov/apps/ama/license.asp?file=/PQRS/down-loads/2012_PhysQualRptg_MeasGroups_Specs_SupportingDoc_121511.zip

Steps to PQRS Participation 10

Run monthly monitoring reports on the status of your PQRS patientsIf possible, track your performance by running monthly reports for each of the measures from your Practice Management or EHR system. You may be able to schedule a task to automatically run the reports on the same day every month. (Qsource can also help you establish these reports.)

After identifying patients that have not met the measure, follow up using reminders. Discuss results with staff and other practice physicians, if applicable, at monthly or regularly scheduled meetings, and establish a plan and process for improvement.

Performance in quality measures will soon be publicly reported, so you’ll want your rates to be as high as possible.

Step 8:

Refer to the online CMS 2012 PQRS Implementation Guide for details at:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2012_PhysQualRptg_ImplementationGuide_MeasuresList_12152011.zip

QDCs should be submitted on the line item as a zero charge, or with a nominal amount if billing software does not permit a zero charge. The charge field cannot be left blank. QDCs will be denied and then passed on for PQRS analysis and payment. You will see a denial code N365 on the Remittance Advice. This code does not mean the data was submitted correctly, only that it was passed on for PQRS analysis. You cannot submit a bill for the sole purpose of PQRS reporting or to correct a PQRS code.

Report PQRS G-Codes for the three selected measures for 50 percent of your Medicare Part B PFS patients seen for 12 months (1/1/2012-12/31/2012)

Claims Reporting Method

Step 7 (cont.):

For claims reporters, stop here.

Steps to PQRS Participation 11

Step 9:

This will allow you to track your performance, establish benchmarks and compare your performance with other physicians in Tennessee and nationwide.

Such data will be useful for identifying opportunities for improvement and may be helpful when applying for ACO, medical home, or preferred provider status with payers.

Record the correct diagnosis, Current Procedural Terminology (CPT), and Quality Data Code (QDC) for each measure on the patient bill and submit as usual

Report selected numerators and denominators for each provider to Qsource

EHR Reporting Method

Create the required reporting file from your EHR and participate in required testing

Step 10:

Work with your PQRS-qualified EHR vendor to create the required reporting file from your EHR system, so it can be uploaded through the PQRS Portal using IACS. If you are using a PQRS-qualified electronic health record product, it should already be programmed to allow generating this file.

As soon as available, participate in required testing for data submission prior to actual production submissions to ensure that data errors do not occur.

Speak with your EHR vendor to discuss any data submission issues.

EHR Reporting Method

Steps to PQRS Participation 12

Step 11:

Final EHR reporting files with quality measure data must be submitted by the February 28, 2013 deadline to be analyzed and used for 2012 PQRS EHR measure calculations.

File uploads will be limited to 10 MB. Complete data submission may require several files to be uploaded to the PQRS Portal.

Following a successful file upload, notification will be sent to the IACS user’s e-mail address indicating the files were submitted and received.

After receiving submission, reports will be available to indicate file errors, if applicable. Feedback reports will be available in the fall 2013.

Submit final EHR reporting files to CMS

EHR Reporting Method

Incentive Payments 13

PQRS incentive payments for each program year are issued separately as a single consolidated incentive payment in the following year. Incentive payments are issued to the first valid group location listed under the Taxpayer Identification Number (TIN), or for solo practitioners, to the first valid practice location listed under the TIN.

The Medicare claims-processing contractors (Carrier or Part A/B) Medicare Administrative Contractor (MACs) will make the payment electronically or via check, based on how the TIN normally receives payment for Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished to beneficiaries.

If a TIN submits claims to multiple Carriers or A/B MACs, each contractor may be responsible for a proportion of the TIN incentive payment equivalent to the proportion of Medicare Part B, PFS-claims the contractor processed during the applicable reporting period.

If splitting an incentive across contractors would result in any contractor issuing a PQRS incentive payment less than $20 to the TIN, the incentive will be issued by fewer contractors than may have processed PFS claims from the TIN for the reporting period.

The PQRS incentive payment can be offset by an outstanding debt for the TIN.

The incentive payment, with the remittance advice, will be issued by the Carrier or A/B MAC and identified as a lump-sum(LS) PQRS incentive payment.

Incentive Payments 14

The electronic remittance advice has sent only a two-character code in the PLB03-1 section on the outgoing 835. The paper remittance advice states, “This is a Physician Quality Reporting System incentive payment.”

CMS has instructed Medicare contractors to use a new indicator of LE to indicate incentive payments, instead of LS. Therefore, LE will appear on future electronic remittances. In an effort to further clarify the type of incentive payment issued (PQRS or eRx), CMS created a four-digit code to indicate the type of incentive and reporting year.

For the 2010 PQRS incentive payments, the four-digit code was PQ10. This code was displayed on the electronic remittance along with the LE indicator. For example, eligible professionals will see the LE to indicate an incentive payment, along with PQ10 that identified it as 2010 PQRS incentive payment.

The paper remittance advice will not include the year and will read, “This is a PQRS incentive payment.” Once CMS begins distributing incentive payments for a particular program year and your LS incentive does not arrive or the incentive payment amount does not match what is reflected in your PQRS feedback report, contact the QualityNet Help Desk.

Due to rounding, the incentive amount may differ by a penny or two from what is reflected in your feedback report.

For 2012, the Affordable Care Act authorizes a 0.5 percent incentive payment for physicians, group practices, and other EPs who successfully participate in PQRS. In 2015 and beyond, a payment adjustment will apply under PQRS if an EP does not satisfactorily submit quality measure data.

CMS is proposing that the reporting period for the 2015 payment adjustment be January 1, 2013-December 31, 2013. The incentive payment amount is calculated using estimated Medicare Part B PFS allowed charges for all covered professional services, not just those charges associated with the reported quality measures.

Allowed charges include the beneficiary deductible and coinsurance. The incentive payment will be paid to individual EPs at the TIN/NPI level. Those group practices that successfully report will be paid the 0.5 percent incentive payment based upon the qualified charges for the group practice TIN.

Incentive Payments 15

Harnessing Health IT for Better Care• Increasing rates of preventive screenings• Reducing cardiac risk factors• Connecting EHRs to quality improvement