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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 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 do not participate in PQRS in 2014 will receive a 2 percent penalty in 2016.

2014 is the last year a physician can receive an additional incentive for participating in the PQRS Maintenance of Certification (MOC) program.

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.

The chart below provides more information on the timing of PQRS penalties. Details regarding improved PQRS feedback, an informal appeals process, and PQRS program incentives and 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%

2014 PQRS program overview

Despite strong opposition from the physician community, CMS finalized Calendar Year 2014 as the performance period for the 2016 PQRS penalties. Therefore, if CMS determines that an eligible professional or group practice has not satisfactorily reported through one of the finalized 2014 reporting options for avoiding a payment adjustment or qualifying for a payment incentive for the Jan. 1, 2014 through Dec. 31, 2014 reporting period, the fee schedule amount for services furnished by the participating professional or group practice during 2016 would be 98.0 percent of the fee schedule amount that would otherwise apply to such services.

CMS has established different reporting requirements for individual physician and non-physician providers, as well as group practices for participating in the 2014 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.

CMS has eliminated the Administrative Claims or the option of reporting one measure or measures group for avoiding the 2016 PQRS penalty. In addition, PQRS measures groups in 2014 will only be reportable through a registry and eliminated the six-month reporting option.

View a summary chart PDF of 2014 PQRS and VBM participation options for individual physicians vs. group practices.

Participation as an individual

Physician and non-physician providers may continue to participate as individuals in the 2014 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. However, only one incentive payment will be made to an eligible professional or group practice.

Participation as a group practice

For group practices reporting through the Group Practice Reporting Option (GPRO), CMS did not finalize its proposal to eliminate the GPRO web-interface option for practices comprised of 25-99 eligible professionals (EPs). Practices comprised of 25-99 EPs may satisfy PQRS reporting in 2014 through the GPRO web-interface. CMS will also allow groups of 25 or more EPs to count reporting CG-CAHPS survey measures towards meeting the criteria for satisfactory reporting for the 2014 PQRS incentive and avoiding the PQRS penalties. If a practice of 25-99 EPs chooses to report CG-CAHPS to earn an incentive, 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.

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.

Practices comprised of 10 or more EPs must successfully participate in PQRS in 2014 to avoid the 2016 Value Based Modifier (VBM) penalty of two percent. For practices of 10 or more EPs, at least 50 percent of EPs must successfully participate in 2014 PQRS to avoid the two percent VBM penalty in 2016.

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 2014; if reporting as a group.

More information about the 2014 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).

PQRS measures and measures groups

For 2014, CMS is adding 57 new individual measures and two measures groups to fill existing measure gaps and plans to retire a number of claims-based measures to encourage reporting via registry and EHR-based reporting mechanisms. Therefore, the PQRS will contain a total of 287 measures and 25 measures groups in 2014. As a result of AMA advocacy, CMS did not move forward with its proposal to modify the definition of existing measures group, from a minimum of four to a minimum of six measures per measures group. Unfortunately, contrary to AMA objections, CMS adopted its proposal to eliminate the reporting of a measures group via claims based reporting. Thus, the only way to report a measures group in 2014 is through a registry. CMS has stated that it will work with measure developers and owners of measures groups to appropriately add measures to measures groups that only contain four measures within the measures group for inclusion in future program years.

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.

PQRS informal review process

For 2014, 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.

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 2014 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.

CMS is establishing 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.

CMS also finalized its proposal for EPs who seek to report CQMs under the Medicare EHR Incentive Program to require the use of the most recent version of the electronic specifications for the clinical quality measures and have certified EHR technology (CEHRT) that is tested and certified to the most recent version of the electronic specifications for the clinical quality measures. EPs who do not wish to report clinical quality measures electronically using the most recent version of the electronic specifications (for example, if their CEHRT has not been certified for that particular version) would be allowed to report clinical quality measure data to CMS by attestation for the Medicare EHR Incentive Program.

PQRS qualified clinical data registries

For 2014, physicians have a new clinical data registry reporting option to report quality measures within a clinical data registry instead of those on the PQRS measures list. To earn an incentive through a qualified clinical data registry in 2014, the EP must report at least nine measures and one measure must be an outcomes measure covering at least three NQS domains AND report each measure for at least 50 percent of an EP’s applicable patients seen during the reporting period (Jan. 1-Dec. 31, 2014) to which the measure applies. For purposes of avoiding the payment adjustment, an EP must report at least three measures covering at least one NQS domain for at least 50 percent of EPs applicable patients seen during the reporting period to which the measure applies through a qualified clinical data registry.

Additional information

For additional information on PQRS including measures, measures groups, reporting options and periods, please refer to the "2014 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 cpe@ama-assn.org.