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Physician Quality Measure Reporting

The CMS has developed several quality initiatives that provide information on the quality of care across different settings, including hospitals, skilled nursing facilities, home health agencies, and dialysis facilities for end-stage renal disease. The CMS believes these quality initiatives aim to empower providers and consumers with information that would support the overall delivery and coordination of care, and ultimately would support new payment systems that provide more financial resources to provide improved quality care, rather than simply paying based on the volume of services. Under the Tax Relief and Health Care Act of 2006 (TRHCA), CMS implemented the Physician Quality Reporting Initiative (PQRI) for the reporting period of July 1, 2007 through December 31, 2007, with a bonus payment of 1.5% for successful participation based on the estimated total allowed charges for all cover services during the reporting period. Physicians and nonphysician providers who participate in the program transmit data to CMS regarding the quality measures reported on in caring for their Medicare patients. Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA), the PQRI program was made permanent and increased PQRI incentive payments to 2% for successful participation in both the 2009 and 2010 program years. MIPPA also required CMS to post on a website the names of eligible professionals and group practices who have satisfactorily reported under the PQRI. This information is now posted on the Medicare Physician Compare website.

Several PQRI program changes were included in health care reform legislation enacted in 2010. The Affordable Care Act requires the implementation of timely feedback and the establishment of an informal appeals process by 2011. There is no current requirement to participate in the PQRI. However, CMS finalized in its 2012 Medicare Physician Fee Schedule that 2015 program penalties will be based on 2013 performance. Therefore, those physicians who elect not to participate or are found unsuccessful during the 2013 program year, will receive a 1.5% payment penalty, and 2% thereafter. The AMA is strongly advocating for removal of PQRI penalties, and specifically the linking of 2015 program penalties with 2013 performance.

Medicare Physician Quality Reporting System Incentives and Penalties

2012 0.5% if no MoC, 1% if MoC
2013 0.5% if no MoC, 1% if MoC (performance year for 2015 penalty)
2014 0.5%
2015 -1.5%
2016 -2%

The Affordable Care Act also required the development of an additional PQRI reporting option in 2011. This option allows physicians to submit data to the HHS Secretary through a Maintenance of Certification (MoC) program. Physicians who elect this option can receive an additional PQRI incentive payment for 3 years. The chart below provides more information on the timing of PQRI penalties and additional payments for MoC participation. Details regarding the MoC reporting option, improved PQRI feedback, and an informal appeals process can be found on the CMS website.

2012 Overview

To recognize that the PQRI is no longer an “initiative,” CMS renamed the program the “Physician Quality Reporting System” (PQRS) in 2011. Individual physician and nonphysician providers do not need to sign-up or pre-register in order to participate in the 2012 PQRS. Submission of quality data codes for the 2012 PQRS quality measures to CMS through claims, a qualified registry, or Electronic Health Record (EHR) will indicate your intent to participate in the 2012 program. As explained below, only those physician practices wishing to participate in the Group Practice Reporting Option must self-nominate.

PQRS Measures and Measures Groups: The 2012 PQRS program will include 210 quality measures available for claims and/or registry reporting; 26 of these measures are new to the PQRS program. There are an additional 51 measures available for EHR-based reporting, which includes all the Medicare EHR Incentive Program measures (44), the other PQRS measures that CMS had available for reporting in 2011 EHR reporting option (5), and two new additional CMS-developed measures. CMS has eliminated the 6 month reporting period for claims and registry reporting (for reporting individual measures via registry). A 6-month reporting period remains for reporting on measures groups via a registry.

CMS has also added eight measures groups for the 2012 program, bringing the total number of reportable PQRS measures groups to 22. These include: Diabetes Mellitus; Adult Kidney Disease; Preventive Care; CABG, Rheumatoid Arthritis; Perioperative Care; Back Pain; CAD; Heart Failure; IVD; Hepatitis C; HIV/AIDS; CAP; Asthma; COPD; IBD; Sleep Apnea; Dementia; Parkinson’s; Elevated Blood Pressure; Cardiovascular Prevention; and Cataracts. Specifically, measures contained in the following measures groups will be available for reporting as individual measures: Diabetes Mellitus; Adult Kidney Disease; Preventive Care; CABG; Rheumatoid Arthritis; Perioperative Care; CAD; Heart Failure; IVD; Hepatitis C; HIV/AIDS; CAP, and Asthma. Further, due to the limitations of claims-based reporting, some measures groups are only reportable through registries.

Measures are reported through either temporary G-codes or CPT II codes on the claim form, whereas measures group reporting is indicated by reporting a G-code, and also reporting the relevant quality data codes required by the measure specifications. The physician will select the appropriate quality data codes representing the clinical services furnished with regard to a specific measure.

Proposed PQRS quality measures and measures groups are published in the Federal Register as a part of the annual Medicare Physician Fee Schedule (PFS) Proposed Rule. The PQRS measures are finalized in the annual PFS Final Rule, and posted to the CMS website.

Eligible professionals may potentially qualify as satisfactorily reporting individual quality measures under more than one reporting criteria, reporting mechanism, and/or for more than one reporting period. However, only one incentive payment will be made to an eligible professional based on the longest reporting period for which the eligible professional satisfactorily reports.

Reporting Threshold: As the AMA advocated, CMS decreased the threshold for successful PQRS claims-based reporting from 80% to 50% starting in 2011. This reporting threshold will continue for the 2012 program year.

Group Practice Reporting Option: CMS finalized its proposal for 2012 to remove the Group Practice Reporting Option (GPRO) II (2 to 199 individuals) and change the definition of “group practice” to 25 or more eligible professionals. For 2012, group practices will report 29 quality measures on a certain number of consecutive patients, such as 218 for a group practice with 25-99 professionals, or 411 consecutive patients for group practices with 100 or more professionals. CMS will allow the “skipping” of patients for valid reasons, such as a beneficiary’s medical records not being found or not being able to confirm diagnosis. Unlike PQRS participation for individual physicians, group practices will be required to submit a self-nomination letter indicating its interest in participation. More information about the 2012 GPRO option is available under the Group Practice Reporting page of the CMS PQRS website.

Informal Appeals Process: For 2012, an eligible professional electing to utilize the informal appeals process must request an informal review within 90 days of the release of his or her feedback report, irrespective of when the participant actually accesses their feedback report. CMS has extended the time the agency has to respond to the request for an informal review from 60 days in 2011 to 90 days for 2012.

PQRS Payment Adjustment: Despite strong opposition from the physician community, CMS finalized that it will use CY2013 as the reporting period for the 2015 PQRS payment penalty. Therefore, if CMS determines that an eligible professional or group practice has not satisfactorily reported data on quality measures for the January 1, 2013 through December 31, 2013 reporting period for purposes of the 2015 payment penalty, then the fee schedule amount for services furnished by the participating professional or group practice during 2015 would be 98.5 percent of the fee schedule amount that would otherwise apply to such services.

Alignment of Medicare PQRS and EHR Incentive Programs: To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reporting under the Medicare EHR Incentive Program will be included in the 2012 PQRS for purposes of reporting data on quality measures under the EHR-based reporting option.

 

PQRS-Medicare EHR Incentive Pilot: CMS will allow eligible professionals to report clinical quality measures for the Medicare EHR Incentive Program through a voluntary PQRS-Medicare EHR Incentive Pilot for the 2012 payment year. There are two options for participating in this pilot: 1) EHR Data Submission Vendor-Based Reporting Option; and 2) Direct EHR-based Reporting option.

More details regarding 2012 PQRS reporting criteria, mechanisms, and periods are below.

Individual Quality Measures

2012 Criteria for Satisfactory reporting Individual Quality Measures, by Reporting Mechanism and Reporting Period

Reporting Mechanism Reporting Criteria Reporting Period
Claims-based reporting
  • Report at least 3 PQRS measures, or 1-2 measures* if less than 3 measures apply to the eligible professional; AND
  • Report each measure for at least 50% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom the measure applies.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
Registry-based reporting
  • Report at least 3 PQRS measures; AND
  • Report each measure for at least 80% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom the measure applies.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
EHR-based reporting aligning with the Medicare EHR Incentive Program
  • Report on ALL three Medicare EHR Incentive Program core measures. If the denominator of one or more of the Medicare EHR Incentive Program core measures is 0, report on up to three Medicare EHR Incentive Program alternate core measures (as identified in Table 48 of the 2012 Medicare Physician Fee Schedule Final Rule)
  • Report on three (of the 38) additional measures available for the Medicare EHR Incentive Program.
 January 1, 2012 – December 31, 2012
EHR -- Direct EHR-based reporting & EHR data submission vendor
  • Report at least 3 PQRS measures AND
  • Report each measure for at least 80% of the eligible professional'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.		 January 1, 2012 – December 31, 2012
* Eligible professionals who report on fewer than 3 measures may be subject to the CMS Measure Applicability Validation process.

Measures Groups

2012 Criteria for Satisfactory Reporting on Measures Groups, by Reporting Mechanism and Reporting Period

Reporting Mechanism Reporting Criteria Reporting Period
Claims-based reporting
  • Report at least 1 PQRS measures group; AND
  • Report each measures group for at least 30 Medicare Part B FFS patients.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
Claims-based reporting
  • Report at least 1 PQRS measures group; AND
  • Report each measures group for at least 50% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT
  • Report each measures group on no less than 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
Registry-based reporting
  • Report at least 1 PQRS measures group; AND
  • Report each measures group for at least 30 Medicare FFS patients.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
Registry-based reporting
  • Report at least 1 PQRS measures group; AND
  • Report each measures group for at least 80% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT
  • Report each measures group on at least 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.
Measures with a 0% performance rate will not be counted.		 January 1, 2012 – December 31, 2012
Registry-based reporting
  • Report at least 1 PQRS measures group; AND
  • Report each measures group for at least 80% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT
  • Report each measures group on at least 8 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.
Measures with a 0% performance rate will not be counted.		 July 1, 2012 –December 31, 2012

Group Practice Reporting Option (GPRO)

Group Practice Size Reporting Mechanism Reporting Criteria Reporting Period
25-99 Eligible Professionals A submission web interface provided by CMS
  • Report on all measures included in the web interface; AND
  • Populate data field 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 327) for each disease module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100% of assigned beneficiaries.
 January 1, 2012 – December 31, 2012
100+ Eligible Professionals A submission web interface provided by CMS
  • Report on all measures included in the web interface; AND
  • Populate 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 616) for each disease module or preventive care measures. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries.
 January 1, 2012 – December 31, 2012

AMA PQRS Participation Tools

Participation tools: Individual measures for 2012 Physician Quality Reporting System (PQRS)
The participation tools for the 144 individual quality measures eligible for claims-based reporting in the 2012 Physician Quality Reporting System program are available by viewing the "Individual Measures." The measures are sorted alphabetically by clinical topic and can be searched by measure number, title or keywords.

Participation tools: Measures groups for 2012 Physician Quality Reporting System (PQRS)
The participation tools for the 12 measures groups eligible for claims-based reporting in the 2012 Physician Quality Reporting System program are available by viewing "Measures Groups." Individual measures comprising each measures group are also listed. (Note: there are additional measures groups for coronary artery bypass graft, coronary artery disease, heart failure and HIV available for the 2012 Physician Quality Reporting System, including several measures that can only be reported via registry-based submission.) The measures are sorted alphabetically by clinical topic and can be searched by measure number, title or keyword.

Participation tools
Individual measures for 2012 Physician Quality Reporting System

Measures groups for 2012 Physician Quality Reporting System

Participation tools disclaimer
These participation tools include measures and specifications ("Participation Tools"). The American Medical Association, the Physician Consortium for Performance Improvement® (PCPI™), its members and other measures and specifications developers ("Measure Developers") do not guarantee that the information contained in the Participation Tools is in every respect accurate and/or complete.

The Measure Developers assume no responsibility for use of the information contained in the Participation Tools. The Measure Developers assume no responsibility for and expressly disclaim liability for damages of any kind arising out of the use of, reference to or reliance on the content of the Participation Tools.

Questions?

For additional information on the Physician Quality Reporting System, please visit the CMS website.

For questions or comments on AMA PQRS participation tools, please contact cpe@ama-assn.org.