What is PQRS
The Physician Quality Reporting System (PQRS) was designed by the Centers for Medicaid and Medicare Services (CMS) to incentivize eligible professionals (like physicians) to assess the quality of care you give your Medicare patients. When you use one of the PQRS measures and report it by billing it on HCFA 1500 forms for your patients, you allow the CMS to track and measure how often you are screening your patients for various conditions and issues. This is an effort to improve the quality of care among patients, basically by ensuring you screen for issues beyond your typical clinical focus of interest. Thus a pain specialist might use a PQRS measure (also called a metric) to assess a patient for depression or smoking; i.e., an area s/he might not have explored before in their typical exam and treatment procedure.
Who Must Use PQRS Measures?
Just about anyone who is eligible to bill Medicare must use and report PQRS measures. And they must do it on at least 50% of the patients you bill traditional Medicare for. CMS specifies a list of eligible Professionals (EPs) for using PQRS:
The Physician Quality Reporting System (PQRS) was designed by the Centers for Medicaid and Medicare Services (CMS) to incentivize eligible professionals (like physicians) to assess the quality of care you give your Medicare patients. When you use one of the PQRS measures and report it by billing it on HCFA 1500 forms for your patients, you allow the CMS to track and measure how often you are screening your patients for various conditions and issues. This is an effort to improve the quality of care among patients, basically by ensuring you screen for issues beyond your typical clinical focus of interest. Thus a pain specialist might use a PQRS measure (also called a metric) to assess a patient for depression or smoking; i.e., an area s/he might not have explored before in their typical exam and treatment procedure.
Who Must Use PQRS Measures?
Just about anyone who is eligible to bill Medicare must use and report PQRS measures. And they must do it on at least 50% of the patients you bill traditional Medicare for. CMS specifies a list of eligible Professionals (EPs) for using PQRS:
Medicare Physicians
• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Pediatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Doctor of Chiropractic
Therapists
* Physical Therapist
• Occupational Therapist
• Qual Speech-Lang Therapist
Practitioners
• Physician Assistant
• Nurse Practioner/APRN
• Clin Nurse Specialist/APRN
• Cert Reg Nurse Anesthetist
• Anesthesiologist Assistant
• Certified Nurse Midwife/APRN
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional
• Audiologist
What do PQRS Measures Entail?
The approximate 250 measures available and approved by CMS are organized into domains based on specific types of patient care. Each test (called a metric by CMS) is assigned to one of six domains; Patient Safety, Patient and Caregiver Experience, Care Coordination, Clinical Care, Population Health, Efficiency and Cost Reduction. If possible, each EP is required to give at least nine different metrics covering at least three domains to 50% or more of the patients they bill (traditional) Medicare for in a year. In 2015 there were 27 “Non-PQRS” measures spread among the six domains that could also be used and covered issues like; mortality, cardiac arrest, corneal abrasions, reintubations, adverse complications, etc.
This gets more complicated by far and CMS admits it will get even more complicated in the future. For example, they can change all or some of the 250 metrics on the first day of the year and the provider is required to self-educate on any changes which must be done quickly as you have to give the right measures and report them correctly on more than half of your Medicare covered patients. At the moment, they have promised to use the same metrics for 2016 as they did in 2015, but again that can change at any time.
Incentives (better called Penalties)
In 2013 each EP was required to bill PQRS (sort of a practice run) on one patient to be considered complaint with CMS requirements. A penalty of 1% of billings was assessed; e.g., 319 large anesthesia providers did not do this, or were noncompliant, which created an $11,000,000 pool that was split among the 14 groups that did successfully report 9 measures. This also gives you an idea about how well CMS has gotten out the word and how easy it has been to adopt PQRS, as even when just one measure on one patient was required only 4% of these large scale providers were compliant. If you did not participate in PQRS in 2013 you have seen a 1.5% reduction in your allowed payments in 2015. In 2016 and beyond if you fail to participate in PQRS your rate will be decreased by 2%, and this is based on your participation performance two years prior to the penalty.
In 2015 if you bill for just one face-to-face encounter with a traditional* Medicare Part B covered patient, you will have to report at least one PQRS measure (you have until Feb, 2016) in order to avoid a 2% payment reduction for all your Medicare patients in 2017 and thereafter. For large practices that reduction is 4%. If you bill Medicare Part B for more than one patient, you must submit (e.g., directly on the HCFA 1500 billing form) CPT codes indicating that you did ≥9 PQRS measures over ≥3 domains on at least 50% of those patients.†
The measures have to be appropriate for your practice’s specialty and they must be valid tests; e.g., normed tests where available, screenings when tests are not available, or less formal checklists and documented interview-based procedures when that is all that is available. Your professional organization participated in the choice of measures that Medicare will require from you.
*The PQRS procedure does not yet apply to Railroad Retirement Board, Medicare Advantage plans or other Medicare replacement plans. It is expected that all insurances will eventually copy and require these Medicare rules at some point in the future.
†There are additional systems such as private Registries you have to pay and then inform them of your PQRS compliance so they can notify CMS on your behalf. It gets very complex very fast.