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Nine Important Facts About PQRS


PQRS is extremely complicated and in a state of flux. These measures are not going away and are already seeing uptake with private payers.

In the last few weeks I have run into significant misconceptions about Medicare's Physician Quality Reporting System (PQRS). There's no way to comprehensively explain PQRS in a blog, but some information could be useful as a starting point.

1. Payment adjustments

There is no longer the potential for an eligible professional (EP) or group to increase Medicare Part B payments via PQRS. Any non-zero adjustments to Medicare Part B payments for services rendered in 2015 will be a negative 1.5 percent, applied to the physician fee schedule (PFS) allowed reimbursement. The adjustment for 2016 goes to a negative 2 percent. Both are independent of downward adjustments related to sequestration and meaningful use.

2. Reporting period

The payment year lags the reporting year by two years. That is, to avoid being penalized in 2015, EPs and groups must have been successful PQRS participants in 2013. To avoid penalties in 2016 an EP or group must successfully report PQRS data in 2014 by the end of February 2015. (The reporting deadline for the previous calendar year extends to March 31 in 2016 and subsequent years.) It is probably worthwhile to say explicitly that the window of opportunity to avoid 2015 penalties has closed, and it is about to close for 2016 payments. 2015 participation and reporting will affect only 2017 payments. The reporting period for 2015 is the full calendar year, although there is still time for EPs and groups to participate successfully in 2015.


Reporting and, therefore, penalties are based upon the TIN/NPI combination. If a provider files Medicare Part B claims under more than one TIN, it is possible to be subject to a penalty on the claims assigned to one TIN and not on those assigned to another. I have not been able to find an explicit statement, but it appears that TINs that did not exist in 2013 are not subject to the 2015 payment adjustments.

4. EPs vs. groups

Two or more NPI numbers filing claims with payment assigned to a single TIN is a group. A PQRS group practice must register for its selected reporting mechanism by June 30, 2015.

A TIN with only a single NPI associated is an EP. It is an important distinction because participation can be easier for a solo practitioner.

5. Reporting options

There are six reporting options: EHR, Qualified Registry, Qualified Clinical Data Registry (QCDR), PQRS Group Practice Reporting Option (GPRO, for 25+ providers), CMS-Certified Survey Vendor, and Claims. Not all of the quality measures can be reported through all of the reporting options, and the reporting criteria for a quality measure can change across reporting options. It is essential to be certain that any quality measure chosen can be reported via the selected reporting option and is calculated according to that option's criteria. Only individual EPs are allowed to report via Claims.

6. Selecting PQRS measures

The CMS guidance is that the measures selected should "apply to services most frequently provided to Medicare patients by the EP or PQRS group practice." In other words, each practice should select a set of measures that make sense for it, and there are plenty of options.

CMS has proposed two sets of recommended quality measures, one for adults and one for pediatric patients. These are not applicable to every practice, and they are merely recommendations.

7. Required PQRS quality measures

There are six NQS domains: Patient Safety, Person and Caregiver-Centered Experience and Outcomes, Communication and Care Coordination, Effective Clinical Care, Community/Population Health, and Efficiency and Cost Reduction.

In 2015, successful PQRS participation requires reporting on at least nine measures covering at least three NQS domains. In addition, providers who bill for any Medicare Part B face-to-face services must also report on cross-cutting measures.

Some forbearance is available to providers whose EHR does not contain patient data for at least nine measures covering three domains, and providers who report on less than nine measures across three domains may be subject to special review.

8. Consumer Assessment of Healthcare Providers and Systems (CAHPS)

CAHPS is a lengthy survey that asks patients to report on and evaluate their healthcare experience. Unlike 2014, CMS will not pay for the survey and analysis in 2015 and later years. In 2015, PQRS requires the survey for patients with more than 99 providers. CAHPS is not currently required for smaller groups or individual EPs. A CAHPS survey and analysis counts as three PQRS measures over one domain.

9. Threshold for successful reporting of a measure

The 2015 reporting period is the full calendar year. An EP or group has successfully reported a measure if the associated activity was performed for at least 50 percent of the applicable Medicare Part B patients seen in 2015. Applicability depends on a variety of factors which may or may not include diagnosis, gender, or age.

Sad to say, these are just the highlights. The topic is extremely complicated and in a state of flux. What can be said with certainty is that quality measures are not going away and we are already beginning to see private payers require PQRS participation.

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