PQRS Participation Guide

What is PQRS?

  • The Physician Quality Reporting System (PQRS) is CMS' pay for performance program, which began in 2007
  • PQRS provides for a combination of incentive payments and payment adjustments to eligible providers to encourage participation in the program
  • A program that provides an incentive for eligible providers reporting on clinical quality measures via claims, qualified registry, or qualified Electronic Health Record (EHR)
  • A program with clinical quality measures reportable as individual measures or as measures groups
  • A program with different reporting periods depending on the type of reporting done

How do I Participate?

How can I avoid the payment penalty in 2015?

Those eligible providers who do not successfully report on quality measures in 2013 will be subject to a 1.5% payment penalty in 2015. An eligible provider must successfully report on at least one individual measures in order to avoid this penalty. If the eligible provider wishes to also earn an incentive payment for the 2013 program year they must report on 3 or more individual measures or 1 or more measures group.

Individual Measures

  • Prior to the start of each program year eligible providers should review the most recent measure documentation; measures from prior program years may have been updated or deleted since the prior program year or new measures may have been added
  • For details on each individual measure or measures group an eligible provider can access the Physician Quality Reporting System Measure Specifications Manual for Claims and Registry
    • It should be noted that not all individual measures are reportable via the claims based reporting mechanism
  • Eligible providers should choose 3 or more individual measures which will impact clinical quality within their practice
    • If 3 or less measures apply to your practice you will be subject to the Measure Applicability Validation process; more information on what is involved in this process is available through CMS or on AAN's PQRS webpage
    • Consider the following when choosing measures to report on: clinical conditions treated, types of care provided (e.g. chronic conditions, acute conditions), Settings where care is provided (e.g. inpatient, outpatient office), Quality improvement goals
    • Review the specifications for each measure you are considering and select those measures which apply to the services most frequently provided to your Medicare patients
    • Determine the appropriate reporting option for the measures selected (claims, registry, or EHR)

PQRS Implementation Guide

Reporting Via a Qualified Registry:

Reporting Via a Qualified EHR:

Claims-Based Reporting

  • Reference the measure specifications to determine the appropriate quality data code to report on your claims and the numerator and denominator coding that apply
  • The appropriate quality data is recorded on the claim form as an additional line with a charge of $.00 or $.01
  • Keep in mind that whenever the coding for the numerator and denominator appear on a claim form you will need to report the appropriate quality data code in order to receive credit for performing the work required for the measure selected
  • The line item containing the quality data code will be denied for payment and will pass through the claims processing system to be counted in the PQRS analysis
    • Eligible providers will receive a Remittance Advice for the claim which contains the PQRS quality data code with a standard remark code which states, "This procedure code is not payable. It is for reporting/information purposes only." The receipt of this remark code does not indicate that the QDC is accurate for the claim the EP is trying to report.
    • The EP should keep track of all QDCs reported against the Remittance Advice received from the Carrier or A/B MAC.
    • Some measures require the use of multiple QDCs to properly report, each QDC should be reported as a separate line item in this instance.
    • In some instances there may be an appropriate exception/exclusion or reason for not performing the measure. In this instance you would report the QDC with the appropriate modifier indicating the reason for not performing the measure (1P–medical exclusion, 2P–patient exclusion, 3P–system reason, 8P–exclusion not specified)
      • If there is a zero percent reporting rate due to the use of an eligible exclusion modifier the EP will not be deemed eligible for an incentive payment
  • Multiple measures can be submitted on a claim using multiple QDCs
  • If a claim is denied and ultimately corrected through the appeals process with accurate codes corresponding to the measure denominator a QDC corresponding to the measure numerator should also be included on the resubmitted claim
    • Claims may not be resubmitted for the sole reason of including the QDCRegistry Based Reporting

Registry Based Reporting

  • Those EPs choosing to report on PQRS through a CMS qualified registry they should review the list of qualified registries and choose a registry which incorporates those individual measures or the measures group the EP has chosen to report on:
  • Submit data on either 3 or more individual measures OR 1 or more measures group selected from the list of individual measures or measures group
  • If choosing 3 or more individual measures submit data on those individual measures for 12 months on 80% or more applicable patients
  • If choosing 1 or more measures groups submit data on the measures group(s) for 6 or 12 months for 20 or more eligible patients through a qualified registry
  • Note: Measures with a 0% performance rate will not be counted; measures groups with a 0% performance rate on a measure will not be counted
    EHR Based Reporting

EHR Based Reporting

  • Three methods available for reporting on PQRS measures through an EHR: Direct EHR-Based Reporting, PQRS-Medicare Incentive Pilot Program and EHR Data Submission Vendor Reporting
  • Those participating in this method of reporting on measures for PQRS can opt to do PQRS reporting only or register to report on measures via the EHR pilot program and receive credit for the PQRS and demonstrate Meaningful Use for the Clinical Quality Measure (CQM) component of the EHR Incentive Program
  • There is a specific set of measures which can be reported using this option, not all measures in the PQRS are eligible for EHR Based Reporting
  • Must use a CMS Qualified Electronic Health Record in order to use this reporting option

Direct EHR-Based Reporting

  • For those using the Direct EHR-Based Reporting option and reporting on PQRS only submit 3 or more individual measures for 12 months on 80% or more eligible patients
  • For those using the Direct EHR-Based Reporting option and participating in PQRS and the Medicare EHR Incentive Pilot report on a total of 3 HITECH Core Measures
    • If the denominator for 1 or more of the core measures is 0 then substitute 1 alternate core measure (up to a total of 3 alternate core measures) plus 3 additional HITECH measures for 12 months
    • Successful submission of HITECH data will qualify EPs for the PQRS incentive and demonstrate Meaningful Use for the CQM portion of the EHR Incentive Program

EHR Data Submission Vendor Reporting

  • If using direct EHR-based reporting submit 3 or more individual measures for 12 months on 80% or more of applicable patients
  • For those using the Direct EHR-Based Reporting option and participating in PQRS and the Medicare EHR Incentive Pilot report on a total of 3 HITECH Core Measures
    • If the denominator for 1 or more of the core measures is 0 then substitute 1 alternate core measure (up to a total of 3 alternate core measures) plus 3 additional HITECH measures for 12 months
    • Successful submission of HITECH data will qualify EPs for the PQRS incentive and demonstrate Meaningful Use for the CQM portion of the EHR Incentive Program

Group Practice Reporting Option (GPRO)

  • Available to group practices of 2 or more
  • Those wishing to participate in PQRS utilizing this reporting option must self-nominate or register their group
  • Once a group has self-nominated or registered this will be the only reporting option available for all individual NPIs who bill Medicare under the Group's TIN
  • GPRO Measure Specifications

GPRO Made Simple

12 Month Reporting Option

  • Applies to claims, registry, EHR, and Group Practice Reporting Option (GPRO)
  • See information on claims based reporting for information on reporting via this method
  • See information on registry based reporting for information on reporting via this method
  • See information on EHR based reporting for information on reporting via this method
  • See information on GPRO reporting for information on reporting via this method

6 Month Reporting Option

  • Only applies to measures groups reported through a CMS Qualified Registry
  • See information on registry based reporting for information on reporting via this method
  • Participants choosing to report for 6 months should check with the registry they have chosen to report through to make sure they allow this option as not all registries report using the 6 month option

For More Information
Gina Gjorvad

Senior Program Manager, Performance Measurement
ggjorvad@aan.com
(612) 928-6123