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2015 Physician Quality Reporting System

The Centers for Medicare and Medicaid Services (CMS) have  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 rewards physicians for providing 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 (now called Physician Quality Reporting System (PQRS)) with a bonus payment of 1.5 percent 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 PQRS program was made permanent. MIPPA also required CMS to post on a website the names of eligible professionals and group practices who have satisfactorily reported under the PQRS. This information, along with additional measure performance information, is now posted on the Medicare Physician Compare website.

Several PQRS program changes were included in health care reform legislation enacted in 2010. The Affordable Care Act (ACA) requires the implementation of timely feedback and the establishment of an informal appeals process by 2011. The ACA also calls for PQRS payment penalties starting in 2015. CMS finalized in its 2012 Medicare Physician Fee Schedule rule that 2015 program penalties are 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 percent payment penalty, and 2 percent thereafter. In the 2014 Medicare Physician Fee Schedule Rule, CMS finalized its proposal to base 2016 PQRS penalties off of 2014 reporting. Therefore, physicians who did not participate in PQRS in 2014 will receive a 2 percent penalty in 2016. 2014 was the last year a physician could receive an additional incentive for participating in the PQRS Maintenance of Certification (MOC) program or receive an incentive for participating in PQRS. In the 2015 Medicare Physician Fee Schedule Rule, CMS finalized its proposal to base 2017 PQRS penalties off of 2015 reporting.

The American Taxpayer Relief Act (ATRA) required the development of an additional PQRS reporting option in 2014. This option allows physicians to submit data to CMS through a qualified clinical data registry (QCDR) and physicians will once again have the QCDR option in 2015. View the National Quality Registry Network (NQRN®)’s Information Guide to the QCDR.

The chart below provides more information on the timing of PQRS penalties. Details regarding improved PQRS feedback, an informal appeals process, and PQRS penalties can be found on the CMS website.

Medicare Physician Quality Reporting System Incentives and Penalties

2013 0.5% (performance year for 2015 penalty)
2014 0.5% (performance year for 2016 penalty)
2015 -1.5%
2016 -2%
2017 -2%

2015 PQRS program overview

CMS finalized Calendar Year 2015 as the performance period for the 2017 PQRS penalties. Therefore, if CMS determines that an eligible professional or group practice has not satisfactorily participated through one of the finalized 2015 reporting options during the reporting period Jan. 1, 2015 through Dec. 31, 2015, the fee schedule amount for services furnished by the participating professional or group practice during 2017 would be 98.0 percent of the fee schedule amount that would otherwise apply to such services. 2015 is the first year that there are no incentives available for successful participation in PQRS.

CMS has established different reporting requirements for individual physician and non-physician providers, as well as group practices that elect to participate as a group in the 2015 PQRS program.

Despite strong AMA objection, CMS has drastically increased the PQRS requirements for avoiding the PQRS penalty, as well as eliminated 50 measures from the program. Eligible professionals will no longer have the option to report on three measures to avoid the penalty. In addition, CMS made CG-CAHPS mandatory for group practices of 100 or more participating under the group practice reporting option (GPRO) and the practice must cover the cost of administering CG-CAHPS. Once again, PQRS measures groups in 2015 will only be reportable through a registry.

(Note: A summary of the 2015 PQRS and VBM participation options for individual physicians vs. group practices is still under development and will be made available as soon as possible.)

Summary of requirements for 2017 payment adjustment

Background: If physicians do not successfully report in 2015, they face a two percent penalty on their 2017 Medicare Part B Fee Schedule payments. For 2015 (see below for breakdown of various requirements by reporting option), CMS has imposed a threefold increase in the requirements for avoiding a penalty; at the same time, CMS has reduced the number of measures available for reporting (removed 50 measures) and eliminated measures from the claims reporting option leaving a significant gap of clinically relevant and meaningful quality measures in PQRS.

Individual EP Reporting Options

Individual EP Reporting Options via Claims or Registry:

Report at least 9 measures, covering at least 3 National Quality Strategy Domains (NQS) AND report each measure for at least 50% of EP’s Medicare Part B FFS patients seen during the reporting period (Jan. 1-Dec. 31, 2015) to which the measure applies. Of the measures reported, if the EP sees at least 1 Medicare patient in a face-to-face encounter, the EP will report on at least 1 measure contained in the cross-cutting measure set.

*Note: If less than 9 measures apply to the EP, the EP would report up to 8 measure(s), AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted. EPs would also be subject to the measure applicability validation (MAV) process if they report less than 9 measures and do not report on 1 cross cutting measure.

Individual EP Reporting Options via Direct EHR or EHR Data Submission Vendor Product:

Report at least 9 measures, covering at least 3 National Quality Strategy Domains (NQS). If an EP’s direct EHR product or EHR data submission vendor product does not contain patient data for at least 9 measures covering at least 3 domains, then the EP would be required to report all of the measures for which there is Medicare patient data.

*Note: An EP would be required to report on at least 1 measure for which there is Medicare patient data. The MAV process does not apply to EHR reporting. An EP’s certified EHR technology (CEHRT) does not need to be tested and certified to the most recent version of CEHRT starting in 2015.

Individual EP Reporting Option via Registry for Measures Groups Reporting:

Report at least 1 measures group AND report each measures group for at least 20 patients, the majority (11 patients) of which are required to be Medicare part B FFS patients. Measures groups containing a measure with a 0 percent performance rate will not be counted.

Individual EP Reporting Option Via Qualified Clinical Data Registry (QCDR):

Report at least 9 measures available for reporting under a QCDR covering at least 3 of the NQS domains, AND report each measure for at least 50 percent of the EP’s patients. Of these measures, the EP would report on at least 2 outcome measures, OR, if 2 outcomes measures are not available, report on at least 1 outcome measures and at least 1 of the following types of measures – resource use, patient experience of care, efficiency/appropriate use, or patient safety.

Group Practice Reporting Options (GPRO)

Group Practice of 25-99 registered as a GPRO reporting via GPRO Web Interface:

Report on all measures included in the web interface; AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measures. If the pool of eligible assigned beneficiaries is less than 248, then the group practice must report on 100 percent of assigned beneficiaries.

Group Practice of 100 or more registered as a GPRO reporting via GPRO Web Interface, plus CG-CAHPS:

The group practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified survey vendor. In addition, the group practice must report on all measures included in the GPRO web-interface; AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, the group practice must report on 100 percent of assigned beneficiaries.

*Note: If a group practice of 100 or more and registered as a GPRO the group must report on CG-CAHPS via a CMS certified survey vendor.

Group Practice of 2-99 registered as a GPRO reporting via Registry:

Report at least 9 measures, covering at least 3 of the NQS domains. Of these measures, if a group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice would report on at least 1 measure in the cross-cutting measure set.

Group Practice of 100 or more registered as a GPRO reporting via Registry, plus CG-CAHPS:

The group practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified survey vendor, and report at least 6 additional measures, outside of CAHPS for PQRS, covering at least 2 of the NQS domains using the registry. Of the 6 measures, 1 must be from the cross cutting measure list.

*Note: If a group practice of 100 or more and registered as a GPRO the group must report on CG-CAHPS via a CMS certified survey vendor.

Group Practice of 2-99 registered as a GPRO reporting via Direct EHR Product or EHR Data Submission Vendor Product:

Report 9 measures covering at least 3 NQS domains. If the group practice’s direct EHR product or EHR data submission vendor product does not contain patient data for at least 9 measures covering at least 3 domains, then the group practice must report the measures for which there is patient data. A group practice must report on at least 1 measure for which there is Medicare patient data.

Summary of Finalized Data for Public Reporting

Starting in 2016, all 2015 PQRS measures for individual EPs collected through a registry, EHR or claims are subject to be reported on Physician Compare (if technically feasible by CMS).

Participation as an individual

Physician and non-physician providers may continue to participate as individuals in the 2015 PQRS program by reporting claims (paper), registry, qualified clinical data registry and electronic health records (EHRs).

Eligible professionals may potentially qualify as satisfactorily reporting individual quality measures (or in some instances measures groups) under more than one reporting criteria and/or reporting mechanism. Generally, eligible professionals need only report nine measures covering three National Quality Strategy (NQS) domains. However, newly required for 2015 is one of the nine measures must come from the new "cross-cutting" measure list.

Participation as a group practice

For group practices reporting through the Group Practice Reporting Option (GPRO), CMS finalized its proposal to require group practices of 100 or more participating as a GPRO to report on CG-CAHPS through a CMS certified survey vendor, as well as provide the option of groups of 2 or more registered as a GPRO to report on CG-CAHPS through a CMS certified survey. If a practice reports CG-CAHPS, they will need to report all CG-CAHPS survey measures via a certified CMS vendor, AND report at least six measures covering at least two of the National Quality Strategy (NQS) domains using a qualified registry, direct EHR product, EHR data submission vendor, or GPRO web-interface reporting mechanisms. Practices comprised of 25-99 EPs may satisfy PQRS reporting in 2015 through the GPRO web-interface. For group practices reporting individual measures via registry, CMS has increased the number of measures that must be reported from three to nine measures on 50 percent of applicable patients and of the 9, 1 must be from the new cross-cutting measure set.

CMS also modified the deadline for group practices to register as a GPRO to June 30, 2015 for 2015 PQRS reporting. Therefore, practices interested in participating in PQRS as a GPRO must register in the Physician Value-Physician Quality Reporting System (PV-PQRS) registration system by June 30th.

All practices must successfully participate in PQRS in 2015 to avoid the 2017 Value Based Modifier (VBM) penalty. For practices of 2 or more EPs, at least 50 percent of EPs must successfully participate in 2015 PQRS to avoid the VBM penalty in 2017, if they are not participating under the GPRO option.

It is important to note that regardless of the size of a group practice, the group practice has the choice of participating in PQRS as a group, or allowing its physician and non-physician providers to participate as individuals in PQRS through the reporting mechanism of their choice. Please note that the claims based (paper) reporting option is not available to group practices in 2015; if reporting as a group.

More information about the 2015 PQRS GPRO option is available under the Group Practice Reporting page under the CMS PQRS website.

(Note: A chart outlining the 2015 PQRS and VBM considerations for large group practices (100 eligible professionals or more) is still under development and will be made available as soon as possible.)

PQRS measures and measures groups

For 2015, the CMS are adding 20 new individual measures, two measures groups to fill existing measure gaps and removed 50 measures from the program. These changes bring the PQRS individual measure set to 255 measures. To the AMA’s dismay, CMS moved forward with its proposal to modify the definition of existing measures groups, from a minimum of four to a minimum of six measures per measures group. CMS has maintained its policy from 2014 to only allow reporting of a measures group through a registry in 2015.

Additionally, CMS has created a list of cross-cutting measures for use in the PQRS 2015 program. To learn which measures are categorized as cross-cutting, please visit the following link to CMS’s published list.

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.

Previously, the AMA has developed participation tools for PQRS measures reportable via claims in an effort to create a user friendly format for the measure specifications. However, as the number of measures reportable via claims continues to diminish from one program year to the next, the AMA has determined it will no longer create the participation tools for the PQRS program.

PQRS informal review process

For 2015, an eligible professional or group practice may seek an informal review of the CMS determination of a PQRS payment adjustment. Starting in 2015, eligible professionals or group practices will have 60-days upon release of their PQRS Feedback Reports to request a PQRS informal review, irrespective of when the participant/group practice actually accesses their feedback report. Feedback Reports are typically released by CMS in late summer/early fall.

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 are included in the 2015 PQRS for purposes of reporting data on quality measures under the EHR-based reporting options. To further align the programs, group practices may report via the PQRS EHR based reporting option. Please check with your EHR vendor to ensure they will support your preferred EHR reporting option.

CMS also established an option for EPs to submit clinical quality measure (CQM) information using qualified clinical data registries (as defined for PQRS) for purposes of meeting the CQM reporting component of meaningful use (MU) for the Medicare EHR Incentive Program beginning in 2014. Among other requirements for this reporting option, EPs would have to use certified EHR technology, as required under the Medicare EHR Incentive Program, and report on CQMs that were included in the EHR Incentive Program Stage 2 final rule.

While CMS is still requiring EPs who report clinical quality measures electronically for the Medicare EHR Incentive Program to use the most recent version of electronically specified clinical quality measures (eCQMs), EPs are no longer required to use the most recent version of Certified EHR Technology (CEHRT) to report eCQMs.

PQRS qualified clinical data registries

Once again EPs will have the option to participate in PQRS by reporting through a qualified clinical data registry (QCDR) which allows physicians to report quality measures within a QCDR instead of those on the traditional PQRS measures list. To avoid a penalty through a QCDR in 2015, the EP must report at least nine measures covering at least three of the National Quality Strategy (NQS) domain AND report each measure for at least 50 percent of the EP’s patients during the reporting period (Jan. 1-Dec. 31, 2015). Of those measures, the EP would report on at least 2 outcomes measures, OR, if 2 outcomes measures are not available, report on at least 1 outcome measure and at least 1 of the following types of measures – resource use, patient experience of care, efficiency/appropriate use, or patient safety.

View the National Quality Registry Network (NQRN®)’s Information Guide to the QCDR.

Additional information

For additional information on PQRS including measures, measures groups, reporting options and periods, please refer to the "2015 PQRS Implementation Guide" found under the of the CMS website. "How to Get Started" page of the CMS website.

For questions or comments related to AMA stewarded measures included in the PQRS 2015, please contact cpe@ama-assn.org.