physician quality measure reporting

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Physician Quality Measure ReportingThe Centers for Medicare and Medicaid Services (CMS) has developed several quality initiatives that provideinformation on the quality of care across different settings, including hospitals, skilled nursing facilities, home healthagencies, and dialysis facilities for end-stage renal disease. The CMS believes these quality initiatives aim toempower providers and consumers with information that would support the overall delivery and coordination ofcare, and ultimately would support new payment systems that provide more financial resources to provide improvedquality care, rather than simply paying based on the volume of services.

Under the Tax Relief and Health Care Act of 2006 (TRHCA), CMS implemented the Physician Quality ReportingInitiative (now called Physician Quality Reporting System (PQRS)) for the reporting period of July 1, 2007 throughDec. 31, 2007, with a bonus payment of 1.5 percent for successful participation based on the estimated total allowedcharges for all cover services during the reporting period. Physicians and nonphysician providers who participate inthe program transmit data to CMS regarding the quality measures reported on in caring for their Medicare patients.Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA), the PQRS program was madepermanent and increased PQRS incentive payments to percent for successful participation in both the 2009 and 2010program years. MIPPA also required CMS to post on a website the names of eligible professionals and group practiceswho have satisfactorily reported under the PQRS. This information, along with additional measure performanceinformation, is now posted on the .Medicare Physician Compare website

Several PQRS program changes were included in health care reform legislation enacted in 2010. The Affordable CareAct (ACA) requires the implementation of timely feedback and the establishment of an informal appeals process by2011. The ACA also calls for PQRS payment penalties starting in 2015. CMS finalized in its 2012 Medicare PhysicianFee Schedule that 2015 program penalties will be based on 2013 performance. Therefore, those physicians who electnot to participate or are found unsuccessful during the 2013 program year, will receive a 1.5 percent paymentpenalty, and 2 percent thereafter.

The ACA also required the development of an additional PQRS reporting option in 2011. This option allows physiciansto submit data to the HHS Secretary through a Maintenance of Certification (MoC) program. Physicians who elect thisoption can receive an additional PQRS incentive payment. The chart below provides more information on the timingof PQRS penalties and additional payments for MoC participation. Details regarding the MoC reporting option,improved PQRS feedback, an informal appeals process, and PQRS program incentives and penalities can be found onthe CMS website.

Medicare Physician Quality Reporting System Incentives and Penalties

2013 0.5% if no MoC, 1% if MoC (performance year for 2015 penalty)

2014 0.5%

2015 -1.5%

2016 -2%

Physician Quality Measure Reporting http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-...

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2013 PQRS program overview

Despite strong opposition from the physician community, CMS finalized Calendar Year 2013 as the performanceperiod for the 2015 PQRS penalties. Therefore, if CMS determines that an eligible professional or group practicehas not satisfactorily reported through one of the finalized 2013 reporting options for avoiding a paymentadjustment or qualifying for a payment incentive for the Jan. 1, 2013 through Dec. 31, 2013 reporting period, thefee schedule amount for services furnished by the participating professional or group practice during 2015 wouldbe 98.5 percent of the fee schedule amount that would otherwise apply to such services.

CMS has established different reporting requirements for individual physician and nonphysician providers, as wellas group practices for participating in the 2013 PQRS program. Participation requirements to qualify for apayment incentive differ from requirements for avoiding a payment penalty. However, qualifying for an incentiveallows the individual or group practice to avoid the payment adjustment. In addition, those physician practiceswho are comprised of 100 or more eligible professionals (EPs) must self-nominate by Oct. 15, 2013 if they are toavoid application of the value based payment modifier.

of 2013 PQRS and VBM participation options for individual physicians vs. grouppractices.View a summary chart

Participation as an individual

Physician and nonphysician providers may continue to participate as individuals in 2013 PQRS program byreporting claims (paper), registry, Electronic Health Records (EHRs), Administrative Claims, measures group, orone measure. Please note that electing the Administrative Claims option, where CMS will calculate the grouppractices billing claims against a pre-determined set of quality measures, or the reporting of one measure, willonly prevent the group from receiving a PQRS penalty in 2015. In addition, reporting one measure, one measuresgroup will only prevent the individual from receiving a PQRS penalty. To qualify for an incentive, the individualmust successfully report via claims, registry, or EHR.

Eligible professionals may potentially qualify as satisfactorily reporting individual quality measures (or in someinstances measures groups) under more than one reporting criteria, reporting mechanism, and/or for more thanone reporting period. However, only one incentive payment will be made to an eligible professional based on thelongest reporting period for which the eligible professional satisfactorily reports.

Participation as a group practice

CMS finalized its proposal for 2013 to change the definition of "group practice" from 25 or more eligibleprofessionals to 2 or more to allow all groups of smaller sizes to participate as a group.

Those practices comprised of 2 to 99 physician and nonphysician providers that wish to participate in PQRS as agroup practice must self nominate by Oct. 15, 2013, and indicate their chosen reporting mechanism. For groups of2-24, these reporting mechanisms include: registry, EHRs (starting in 2014), Administrative Claims, or onemeasure. Please note that electing the Administrative Claims option, where CMS will calculate the grouppractices billing claims against a pre-determined set of quality measures, or the reporting of one measure, willonly prevent the group from receiving a PQRS penalty in 2015. To receive an incentive, a group of 2-24 mustreport via registry. Please note that the claims based (paper) reporting option is not available to group practicesstarting in 2013. For practices comprised of 25-99 physicians and nonphysician providers, they have the samereporting options of registry, EHR (starting in 2014), one measure, or Administrative Claims. In addition, they mayalso report via the GPRO web interface tool.

For those practices with 100 or more physicians and nonphysicians providers, they have the same PQRS reporting


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options as those practices with 24-99 individuals, but will be subject to the value based payment modifier if theydo not self-nominate as a group to CMS. Group practices of 100 or more physician and nonphysician providershave the option of requesting to seek quality tiering evaluation by CMS, which may result in an incentivepayment based on the practices cost and quality scores compared with other practices comprised of 100 or morephysician and nonphysician providers. It is important to note that regardless of the size of a group practice, thegroup practice has the choice of participating in PQRS as a group, or allowing its physician and nonphysiciansproviders to participate as individuals in PQRS through the reporting mechanism of their choice. If the latter, thegroup practice must elect the Administrative Claims reporting option to avoid the value based payment modifieradjustment.

More information about the 2013 PQRS GPRO option is available under the under the CMS PQRS website.

Group Practice Reporting page

outlining PQRS and VBM considerations for large group practices (100 eligible professionals ormore).View a chart

PQRS measures and measures groups

The 2013 PQRS program will include 259 quality measures. 241 of these measrues are reportable via claims and/orregistry. There are 9 new claims and/or registry measures for 2013. CMS did not add any new EHR measures for2013, resulting in a total number of 51 EHR-based measures. A 6-month reporting period remains for reporting onmeasures groups via a registry. CMS finalized 22 measures groups for the 2013 PQRS program, which arereportable via claims or registry.

These include: Diabetes Mellitus, Chronic Kidney Disease, Preventive Care, CABG, Rheumatoid Arthritis,Perioperative Care, Back Pain, CAD, Heart Failure, IVD, Hepatitis C, HIV/AIDS, Asthma, COPD, IBD, Sleep Apnea,Dementia, Parkinsons, Hypertension, Cardiovascular Prevention, Cataracts, and Oncology. In 2014, CMS will addOsteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology to the list ofreportable PQRS measures groups. Due to the limitations of claims-based reporting, some measures groups areonly reportable through registries. Please note that some of the proposed measures included within a final PQRSquality measures group may also be available for reporting as an individual measure. In addition, please notethat the Osteoporosis and Preventive Cardiology measures groups contain composite measures. Since compositemeasures must be reported as a group, similar to reporting measures within a measures group, CMS classifiedthese two composite measures as measures groups.

Measures are reported through either temporary G-codes or CPT II codes on the claim form, whereas measuresgroup reporting is indicated by reporting a G-code, and also reporting the relevant quality data codes required bythe measure specifications. In addition, the physician will select the appropriate quality data codes representingthe clinical services furnished with regard to a specific measure.

Proposed PQRS quality measures and measures groups are published in the Federal Register as a part of theannual Medicare Physician Fee Schedule (PFS) Proposed Rule. The PQRS measures are finalized in the annual PFSFinal Rule, and posted to the CMS website.

PQRS informal review process

For 2013, an eligible professional or group practice may seek an informal review of the CMS determination aroundboth PQRS incentives and payment adjustments. For incentives, eligible professionals or group practices mustsubmit a request to CMS via the Web within 90 days of the release of the feedback reports, irrespective of whenthe participant/group practice actually accesses their feedback report. CMS will provide a written responsewithin 90 days of the receipt of the original request. For payment adjustments, and eligible professional or group


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practice must submit a request to CMS via the Web by February 28 of the year in which the eligible professional isreceiving the applicable payment adjustments. CMS will provide a timely, written response after the receipt ofthe original request.

PQRS and EHR incentive programs

To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reportingunder the Medicare EHR Incentive Program will be included in the 2013 PQRS for purposes of reporting data onquality measures under the EHR-based reporting option. To further align the programs, group practices starting in2014 may report via the PQRS EHR based reporting option. This facilitates alignment with Stage 2 of the MedicareEHR Incentive Program, which begins in 2014.

PQRS-medicare EHR incentive pilot

: Continuing from 2012, CMS will continue to allow eligible professionals to report clinical quality measures forthe Medicare EHR Incentive Program through a voluntary PQRS-Medicare EHR Incentive Pilot for the 2013payment year. There are two options for participating in this pilot: 1) EHR Data Submission Vendor-BasedReporting Option; and 2) Direct EHR-based Reporting option. More details regarding participation in this 2013 pilotis available under the " section of the CMS PQRS website."Electronic Health Record Reporting

Additional information

For additional information on PQRS including measures, measures groups, reporting options and periods, pleaserefer to the "2013 PQRS Implementation Guide" found under the of the CMS website. pageof the CMS website.

"How to Get Started"

For questions or comments on AMA PQRS participation tools, please contact [email protected].

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