Physician Quality Measure Reporting
The Centers for Medicare and Medicaid Services (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 (now called Physician Quality Reporting System (PQRS)) for the reporting period of July 1, 2007 through Dec. 31, 2007, 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 and increased PQRS incentive payments to percent 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 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 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 percent payment penalty, and 2 percent thereafter.
The ACA also required the development of an additional PQRS 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 PQRS incentive payment. The chart below provides more information on the timing of PQRS penalties and additional payments for MoC participation. Details regarding the MoC reporting option, improved PQRS feedback, an informal appeals process, and PQRS program incentives and penalities can be found on the CMS website.
Medicare Physician Quality Reporting System Incentives and Penalties
|2013||0.5% if no MoC, 1% if MoC (performance year for 2015 penalty)|
Despite strong opposition from the physician community, CMS finalized Calendar Year 2013 as the performance period for the 2015 PQRS penalties. Therefore, if CMS determines that an eligible professional or group practice has not satisfactorily reported through one of the finalized 2013 reporting options for avoiding a payment adjustment or qualifying for a payment incentive for the Jan. 1, 2013 through Dec. 31, 2013 reporting period, 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.
CMS has established different reporting requirements for individual physician and nonphysician providers, as well as group practices for participating in the 2013 PQRS program. Participation requirements to qualify for a payment incentive differ from requirements for avoiding a payment penalty. However, qualifying for an incentive allows the individual or group practice to avoid the payment adjustment. In addition, those physician practices who are comprised of 100 or more eligible professionals (EPs) must self-nominate by Oct. 15, 2013 if they are to avoid application of the value based payment modifier.
View a summary chart of 2013 PQRS and VBM participation options for individual physicians vs. group practices.
Physician and nonphysician providers may continue to participate as individuals in 2013 PQRS program by reporting claims (paper), registry, Electronic Health Records (EHRs), Administrative Claims, measures group, or one measure. Please note that electing the Administrative Claims option, where CMS will calculate the group practice’s billing claims against a pre-determined set of quality measures, or the reporting of one measure, will only prevent the group from receiving a PQRS penalty in 2015. In addition, reporting one measure, one measures group will only prevent the individual from receiving a PQRS penalty. To qualify for an incentive, the individual must successfully report via claims, registry, or EHR.
Eligible professionals may potentially qualify as satisfactorily reporting individual quality measures (or in some instances measures groups) 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.
CMS finalized its proposal for 2013 to change the definition of "group practice" from 25 or more eligible professionals to 2 or more to allow all groups of smaller sizes to participate as a group.
Those practices comprised of 2 to 99 physician and nonphysician providers that wish to participate in PQRS as a group practice must self nominate by Oct. 15, 2013, and indicate their chosen reporting mechanism. For groups of 2-24, these reporting mechanisms include: registry, EHRs (starting in 2014), Administrative Claims, or one measure. Please note that electing the Administrative Claims option, where CMS will calculate the group practice’s billing claims against a pre-determined set of quality measures, or the reporting of one measure, will only prevent the group from receiving a PQRS penalty in 2015. To receive an incentive, a group of 2-24 must report via registry. Please note that the claims based (paper) reporting option is not available to group practices starting in 2013. For practices comprised of 25-99 physicians and nonphysician providers, they have the same reporting options of registry, EHR (starting in 2014), one measure, or Administrative Claims. In addition, they may also report via the GPRO web interface tool.
For those practices with 100 or more physicians and nonphysicians providers, they have the same PQRS reporting options as those practices with 24-99 individuals, but will be subject to the value based payment modifier if they do not self-nominate as a group to CMS. Group practices of 100 or more physician and nonphysician providers have the option of requesting to seek quality tiering evaluation by CMS, which may result in an incentive payment based on the practice’s cost and quality scores compared with other practices comprised of 100 or more physician and nonphysician providers. 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 nonphysicians providers to participate as individuals in PQRS through the reporting mechanism of their choice. If the latter, the group practice must elect the Administrative Claims reporting option to avoid the value based payment modifier adjustment.
More information about the 2013 PQRS GPRO option is available under the Group Practice Reporting page under the CMS PQRS website.
View a chart outlining PQRS and VBM considerations for large group practices (100 eligible professionals or more).
The 2013 PQRS program will include 259 quality measures. 241 of these measrues are reportable via claims and/or registry. There are 9 new claims and/or registry measures for 2013. CMS did not add any new EHR measures for 2013, resulting in a total number of 51 EHR-based measures. A 6-month reporting period remains for reporting on measures groups via a registry. CMS finalized 22 measures groups for the 2013 PQRS program, which are reportable via claims or registry.
These include: Diabetes Mellitus, Chronic Kidney Disease, Preventive Care, CABG, Rheumatoid Arthritis, Perioperative Care, Back Pain, CAD, Heart Failure, IVD, Hepatitis C, HIV/AIDS, Asthma, COPD, IBD, Sleep Apnea, Dementia, Parkinson’s, Hypertension, Cardiovascular Prevention, Cataracts, and Oncology. In 2014, CMS will add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology to the list of reportable PQRS measures groups. Due to the limitations of claims-based reporting, some measures groups are only reportable through registries. Please note that some of the proposed measures included within a final PQRS quality measures group may also be available for reporting as an individual measure. In addition, please note that the Osteoporosis and Preventive Cardiology measures groups contain composite measures. Since composite measures must be reported as a group, similar to reporting measures within a measures group, CMS classified these two composite measures as measures groups.
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. In addition, 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.
For 2013, an eligible professional or group practice may seek an informal review of the CMS determination around both PQRS incentives and payment adjustments. For incentives, eligible professionals or group practices must submit a request to CMS via the Web within 90 days of the release of the feedback reports, irrespective of when the participant/group practice actually accesses their feedback report. CMS will provide a written response within 90 days of the receipt of the original request. For payment adjustments, and eligible professional or group practice must submit a request to CMS via the Web by February 28 of the year in which the eligible professional is receiving the applicable payment adjustments. CMS will provide a timely, written response after the receipt of the original request.
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 2013 PQRS for purposes of reporting data on quality measures under the EHR-based reporting option. To further align the programs, group practices starting in 2014 may report via the PQRS EHR based reporting option. This facilitates alignment with Stage 2 of the Medicare EHR Incentive Program, which begins in 2014.
: Continuing from 2012, CMS will continue to allow eligible professionals to report clinical quality measures for the Medicare EHR Incentive Program through a voluntary PQRS-Medicare EHR Incentive Pilot for the 2013 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 participation in this 2013 pilot is available under the "Electronic Health Record Reporting" section of the CMS PQRS website.
For additional information on PQRS including measures, measures groups, reporting options and periods, please refer to the "2013 PQRS Implementation Guide" found under the of the CMS website. "How to Get Started" page of the CMS website.
For questions or comments on AMA PQRS participation tools, please contact firstname.lastname@example.org.