Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) was a reporting program of the Centers for Medicare and Medicaid Services (CMS). It gave eligible professionals (EPs) the opportunity to assess the quality of care they were providing to their patients, helping to ensure that patients get the right care at the right time. By reporting PQRS quality measures, providers also could quantify how often they are meeting a particular quality metric. Using the feedback report provided by CMS, EPs could compare their performance on a given measure with their peers. Starting from January 1, 2017, this program was rolled over into Merit-based Incentive Payment System (MIPS) under the new Quality Payment Program.

Links to Old PQRS Resources

• PQRS List of Eligible Professionals
• PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures
• PQRS Measures List
• PQRS Measures Groups Specifications Supporting Documents
• PQRS Implementation Guide

2017 Takeaways

PQRS:

• Avoiding the PQRS penalty now requires more measures, and higher stakes with up to 2% in PQRS penalties alone
• Quality scores of PQRS measures MATTER and will tie into payment under the VBM

VBM:

• VBM applies to all physicians and physician groups and the penalties are even higher this year
• Penalties for non-PQRS participation, in combination with VBM penalties are in the 2-6% range depending on practice size
• Those that DO report PQRS are automatically included in the VBM Quality-tiering process, which penalizes the low-performing providers and rewards the high-performing providers.

Background

The PQRS is one of several long-term quality initiatives developed by the Centers for Medicare and Medicaid Services (CMS). It is intended to, among other things; obtain information on the quality of care across the healthcare system.  Specifically, the program collects data submitted by Eligible Professionals (EP), on quality measures for covered services provided to Medicare part B fee for service (FFS) beneficiaries.

Why Participate?

Participating in the PQRS is not mandatory, it is voluntary.  However, the program used a combination of incentive payments and payment adjustments to promote reporting of quality information by EPs.  Those who participated and successfully met the measure reporting criteria of the program receive incentive payments (bonus).  EPs that decided not to report measures, or did not meet the programs’ reporting criteria, were subject to payment adjustments (penalty).  The table below describes the incentive/adjustment payment schedule.  


Eligibility

EPs are physicians and non-physicians providing services that are paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services which get paid under or based on the PFS, those services are eligible for PQRS incentive payments and/or payment adjustments. EPs include Medicare physicians (Doctors of Medicine), Practitioners (Nurse Practitioners), and Therapists (Physical Therapists).

A list of, and more details on, EPs can be found at CMS’s website.

PQRS 2016: Mechanisms and Criteria for Satisfactory Reporting (Individual EPs)

The most common method the Nuclear Medicine community has for reporting measures is individual measures reporting. The three mechanisms that can be used to report these measures are described below:

Claims-based reporting: Report at least 3 PQRS measures.  Each measure must be reported for at least 50% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Registry-based reporting: Report at least 3 PQRS measures. Each measure must be reported for at least 80% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

EHR-based reporting: Report at least 3 measures. Each measure must be reported for at least 80% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Group Practice reporting option:

What if fewer than three measures are applicable?

If fewer than three reportable measures are applicable to an EP, he/she can still qualify for incentive payments.  When this occurs, the only CMS-approved mechanism for reporting is claims-based reporting.  Claims-based reporting must be completed using a 50 percent sample of applicable Medicare Part B fee for service patients. CMS will then conduct a measure-applicability validation (MAV) process on the reports.  The MAV process verifies that no other measures could have been reported based on an EP’s billing claims (there are intentional overlaps among PQRS measures). During this validation process, CMS confirms that each case fits the description of the patient population for the measure (denominator eligibility) based on ICD-9 and/or CPT codes. If CMS finds an additional measure could have been reported, the EP will not qualify for an incentive payment.

Value-Based Modifier (VBM): Groups with 2-9 physicians and solo physicians: automatic-2.0% of MPFS downward adjustment. Groups with 10+ physicians: Automatic -4.0% of MPFS downward adjustment. These adjustments are additive to the 2% PQRS penalty

How to Avoid a Payment Adjustment

EPs can avoid payment adjustments in 2016 by reporting one valid measure, on one patient, one time in 2017. This must be done using the claims-based reporting mechanism.

*In 2016, the CAHPS for PQRS survey is mandatory for groups with 100 or more EPs and optional for groups with between 2 to 99 EPs. Groups with 2 or more EPs can elect whether to include the results of their CAHPS for PQRS survey in the calculation of their 2017 Value Modifier.

PQRS Reporting Compliance for Individual Providers and GPRO Practices

Individual Providers:

Measures Group: Report one (1) measure group (per eligible professional) for a 20 patient sample.

Individual Measures: Report on nine (9) individual measures, across at least three (3) NQS domains for fifty percent (50%) of eligible Medicare patients. CROSS CUTTING

Group Practice Reporting Option (GPRO):

Individual Measures: Report nine (9) individual measures, across at least three (3) NQS domains for fifty percent (50%) of eligible Medicare patients.¹ CROSS CUTTING

^[1]Eligible professionals with a specialty that has less than 9 measures or less than 3 domains would be subject to the Measure-Applicability Validation (MAV), but could still avoid the payment adjustment.

A list of, and more details on Cross-Cutting Measures can be found at CMS's website.

Measures to Consider

The table below is a composite of measures that several SNMMI members have identified as applicable to the nuclear medicine community.