Basic explanation of the physician quality reporting system. Some of the due dates and actions that could be taken before Dec 31st to prevent losing money in the future.

1. Physician Quality Reporting
System (PQRS)
Dr. Jose I. Delgado
Taino Consultants Inc.
www.tainoconsultants.com

2. Introduction
•
•
•
PQRS is a program designed to promote
reporting of quality information by eligible
professionals (EPs).
Program uses financial incentives to promote
participation
− 2013 & 2014 incentive is 5% increase
− 2015 incentive is 1.5% reduction
− 2016 incentive is 2% reduction
Program applies exclusively to
Medicare EPs

3. Background
Created in March 2007 as required by the 2006
Tax Relief and Health Care Act (TRHCA).
• The Medicare, Medicaid, and SCHIP Extension
Act of 2007 (MMSEA) extended the incentive
payment for 2008 and 2009 PQRI .
• The Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) made the PQRI
program permanent, with incentive payments
authorized through 2010.
• In 2011, the Affordable Care Act (ACA)
renamed the program the Physician Quality
Reporting System (PQRS).
•

4. Eligible Professionals (EPs)
1 of 3
• Medicare physicians
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Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic

5. Eligible Professionals (EPs)
2 of 3
• Practitioners
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−
−
−
−
−
−
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−
−
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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
Audiologists
*Includes Advanced Practice Registered Nurse (APRN)

6. Eligible Professionals (EPs)
3 of 3
•
Therapists
Physical Therapist
− Occupational Therapist
− Qualified Speech-Language Therapist
−

7. Exceptions
•
•
Eligible Professionals who do not bill Medicare
at an individual National Provider Identifier
(NPI) level
Services payable under fee schedules or
methodologies other than the Medicare
Physician Fee Schedule (PFS) are not included
in PQRS

8. Participation Requirement
•
Individual EPs do not need to register
−
•
Incentive payment requires that EPs meet the
criteria for satisfactory reporting
Group Practice Reporting Option (GPRO)
−
Must register to participate in PQRS GPRO

9. Group Practice Reporting Option
(GPRO)
“Group Practice"
Single Tax Identification Number (TIN)
− 2 or more individual EPs participating
− Have reassigned their billing rights to the TIN
−
Note: EPs may select group or individual reporting; however, the
trend to report as individual eligible professionals is higher due to
the increase choice in reporting mechanisms.

10. Electronic Submission Option for PQRS
•
Report chosen quality measures by submitting
Quality Data Codes (QDC’s) that correspond to
selected measures on an eligible billing claim form
(such as Medicare 1500).
•
•
Note: A claim is considered "eligible" when the ICD 9
and/or the CPT on the claim matches the applicable
diagnosis and encounter codes listed in the denominator
criteria of the measure specification.
To qualify for the 2013 PQRS incentive, EPs must
choose either three individual measures or one
measures group via claims that is relevant to the
EPs’ scope of practice.

11. Steps to avoid Payment reduction
•
Eligible Providers (EPs)
1.
2.
3.
Meet requirements for satisfactorily reporting as
defined in the 2013 PQRS measure
specifications (same criteria as 2013 PQRS
incentive eligibility).
Report at least one valid measure via claims,
participating registry, or participating/qualified
EHR OR one valid measures group via claims
or registry, regardless of incentive eligibility.
Elect to participate in the administrative claims
reporting mechanism July 15, 2013 through
October 15, 2013.

12. Steps to avoid Payment reduction
•
Registered Groups (PQRS GPRO)
1.
2.
3.
Meet the requirements for satisfactorily
reporting to earn the 2013 PQRS incentive
payment.
Report at least one valid measure through the
Web Interface (available to PQRS GPROs with
25+ EPs), OR through a registry
Register to participate as a PQRS GPRO and
elect the administrative claims reporting
mechanism July 15, 2013 through October 15,
2013.

13. Avoiding Penalties in 2015
•
•
Must take action before the end of CY 2013
Submit at least one Quality Data Code (QDC)
Submission must be done before Dec 31st, 2013
− Submit QDC on eligible Part B claim
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•
The PQRS registration system closed on October 15,
2013, but can be accessed at https://portal.cms.gov.
The system requires an account number, which can be
acquired at https://applications.cms.hhs.gov.
− Additional information is available at the Self
Nomination/Registration web page.
−

14. Quality Data Codes
•
Quality measure No. 130
QDC G8427. Current medications documented
− QDC G8430. Current medications not documented
−
•
Quality measure No. 173
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•
QDC 3016F: Patient screened for unhealthy alcohol
use using a systematic screening method
Quality measure No. 226
QDC 4004F: Patient screened for tobacco use AND
received tobacco cessation intervention
− QDC 1036F: Current tobacco non-user; patient
screened for tobacco use and Identified as a nonuser of Tobacco
−

15. Summary
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PQRS here to stay
Lack of action will result in payment reduction
−
•
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Different options for individual EPs vs Groups
Measures and Methods of reporting changes
annually
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•
Immediate action require before Dec 31, 2013
Specific measures based on specialty
Alternative reporting methods available

16. Resources
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Reporting requirements
http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS.
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Reporting 2013 PQRS through a registry
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Registry-Reporting.html.
•
Self-nomination/registering to report 2013 PQRS
as a group
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html.
•
PQRS payment adjustment
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Payment-Adjustment-Information.html.

17. Physician Quality Reporting System (PQRS)
www.tainoconsultants.com
Dr. Jose I. Delgado
Dec 2013