By Michelle Trandel, CPC, CFPC
Is your practice currently reporting quality measures for the Physician Quality Reporting System (PQRS)? If so, good job and keep reporting! If not, your providers are missing out on their share of incentive dollars and soon may face a penalty for failure to report. It's not too late to start reporting for 2012 so let's review some PQRS basics and get you on the road to successful reporting!
PQRS Primer
The Centers for Medicare and Medicaid Services (CMS) established the PQRS program (formerly PQRI or Physician Quality Reporting Initiative) as part of the 2006 Tax Relief and Health Care Act. This act created a voluntary program where eligible professionals could report on quality health measures for covered professional services provided to Medicare beneficiaries and in return, earn an incentive for successful reporting. Right now PQRS is a pay-for-reporting system in which incentive payments are based on reporting quality measures instead of achieving clinical outcomes.
Why Report?
Eligible professionals who successfully report PQRS measures are eligible to receive 0.5% of their total estimated Medicare Part B Physician Fee Schedule allowed charges for covered professional services furnished during 2012. The incentive will remain at 0.5% in 2013 and 2014 before being eliminated in 2015.
On the flip side, failure to successfully report on quality measures will result in a payment adjustment or reduction of your Medicare Part B Physician Fee Schedule amounts beginning in 2015. 2015 may be a few years away; however, the 2015 payment adjustment will be based on PQRS performance in 2013. In other words, providers must be successful PQRS reporters in 2013 or face a 1.5% fee schedule reduction in 2015. This payment adjustment will increase to 2% in 2016 and subsequent years.
Another reason providers should participate in PQRS is that consumers will be able to compare PQRS measure performance rates of providers and group practices on the CMS Physician Compare website by 2013. Although it would be inaccurate to associate successful PQRS reporting with higher quality care, consumers may perceive it that way and seek care from providers with higher PQRS scores. Finally, another bonus of participating in PQRS is that physicians may earn an additional 0.5% Maintenance of Certification (MOC) incentive by satisfactorily reporting PQRS measures for a 12 month reporting period and meeting other MOC requirements such as completing a program practice assessment more frequently than is required to qualify for or maintain board certification. Contact your specialty group to see if your physicians are eligible for this additional incentive or go to http://www.cms.gov/PQRS/23_Maintenance_of_Certification_Program_Incentive.asp#TopOfPage.
Steps for Successful Reporting
Your providers can be successful PQRS reporters by following these easy steps:
Determine Eligibility
The PQRS program is open to many different professionals including Doctors of Medicine, Osteopathy, Podiatry, Optometry, Oral Surgery, Chiropractic, and Dental Medicine. Practitioners including Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Clinical Social Workers are also eligible. For a complete list of eligible professionals, visit
http://www.cms.gov/PQRS/Downloads/Eligible_Professionals03-08-2011.pdf.
Determine How You will Participate
A provider has the option of participating either as an individual professional or as part of a group under the GPRO option. For 2012 the GPRO option has been redefined as a group of 25 or more eligible professionals who have reassigned their billing rights to the Tax Identification Number (TIN). No registration is required to participate as an individual eligible professional but is required for the GPRO option. Additional information regarding
GPRO reporting is available at
http://www.cms.gov/PQRS/22_Group_Practice_Reporting_Option.asp#TopOfPage.
Determine How You will Report
You can choose from three different reporting mechanisms in 2012: claims, qualified registry, and qualified electronic health record (EHR) either through a direct EHR vendor or EHR data submission vendor. If choosing a registry or EHR, make sure it is on the CMS approved list available in the Downloads section at
http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp#TopOfPage.
Select Your Measures
For 2012 there are 210 individual measures available for claims and/or registry reporting and 51 measures that can be reported via an EHR including all 44 of the EHR incentive program clinical quality measures. In addition to individual measures, providers also have the option of reporting on 22 measures groups which are collections of related individual measures such as diabetes, sleep apnea, dementia, and hypertension. If reporting as an individual provider, select three or more individual measures or at least one measures group to ensure successful reporting. A complete list of PQRS measures can be retrieved in the Downloads section at http://www.cms.gov/PQRS/15_MeasuresCodes.asp#TopOfPage.
Review Measure Specifications and Reporting Criteria
After you have selected your measures, carefully review the specifications. CMS has two specifications manuals - one for individual measures and another for measures groups. These manuals provide important information such as the reporting method, reporting frequency, eligible cases for the measure (denominator), specific clinical actions required by the measure for performance (numerator), and which quality data codes (QDCs) need to be reported if applicable. Failure to carefully review these documents may result in unsuccessful reporting.
The reporting rate you must achieve to be considered a successful PQRS reporter depends upon the reporting mechanism you select as well as the type of measures you report - individual measures or measures groups. For example, for claims-based reporting of individual measures, an eligible professional should report at least three measures for at least 50% of their eligible Medicare Part B fee-for-service patients in order to qualify for the 2012 incentive. For a complete listing of PQRS reporting options and criteria, review the "2012 Physician Quality Reporting System Implementation Guide." Both this document and the measures specifications manuals can be retrieved in the Downloads section at http://www.cms.gov/PQRS/15_MeasuresCodes.asp#TopOfPage.
Ready, Set, Report!
For claims-based reporting, report the quality data codes (QDCs) on your claims for all eligible encounters. QDCs are either CPT category II codes or HCPCS "G" codes that have been created for PQRS reporting. It is imperative that the billing staff reports the QDCs at the time the claim is entered, as claims may not be resubmitted to only add or correct QDC codes. Also, the QDCs must be entered with a line amount of $0.00 or a nominal amount such as a penny depending on your system. For registry or EHR reporting, contact your vendor for reporting instructions.
Check Feedback Reports
A common complaint about the PQRS program has been the lack of timely feedback. Feedback reports typically are not available until at least six months after the end of the reporting period. CMS has heard the complaints and in 2012 will provide interim feedback reports to eligible professionals who report individual measures or measures groups via the claims-based reporting method. Claims with dates of service on or after January 1, 2012 and processed by March 31, 2012 will be included in these reports later this summer.
Individual National Provider Identifier (NPI) feedback reports for the entire reporting period can be retrieved via the Physician and Other Health Care Professionals Quality Reporting portal at http://www.qualitynet.org/pqrs or by requesting them via the CMS Communication Support Page. TIN level reports must be accessed via the portal. You no longer may request feedback reports from your carrier.
Tips for Successful Reporting
Improve your chances of earning the PQRS incentive by following a few easy tips:
Report more than the minimum
Report more than the minimum number of measures to give yourself a buffer. For example, if you are an individual professional who is reporting measures via claims, report four measures instead of three in case you are unsuccessful with one.
Check for remark code N365
After you submit your claims with the PQRS quality data codes, check your remittance advices for remark code "N365" which indicates that the PQRS data was submitted to the National Claims History file. It does not mean that the quality data codes reported were accurate or that you're guaranteed to receive an incentive but does indicate that the transmission was successful.
Review the measures each year
PQRS measures are added, retired, and modified each year. Stay up-to-date with these changes so there will be no surprises. CMS annually releases two manuals, one for individual measures and another for measures groups, which outline all changes. These release notes can be retrieved in the Downloads section at
http://www.cms.gov/PQRS/15_MeasuresCodes.asp#TopOfPage.
Call for Help!
Contact the CMS QualityNet Help Desk with your PQRS questions. They can be reached at 866-288-8912 or qnetsupport@sdps.org. They should be your primary PQRS resource along with the CMS PQRS website, http://www.cms.gov/PQRS/, which was the source of information for this article.
In this age of declining reimbursement, your practice cannot afford to pass up on incentive programs such as PQRS. Start reporting today so that your practice can claim its share of incentive dollars and become a PQRS success!
Michelle Trandel, CPC, CFPC is a Billing and Coding Consultant with VEI Consulting where she conducts chart audits and provides coding education to staff and physicians. She also assists providers with Medicare incentive programs such as PQRS, E-Prescribing, and the Electronic Health Record. She is an AAPC member (www.aapc.com).
