PQRS program update

Sunday, January 01, 2012 12:22 PM

How to report and qualify for 2012

Marilyn Rissmiller, Senior Director, Health Care Finance

Background: The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the Centers for Medicare and Medicaid Services (CMS) to establish a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting Initiative (PQRI). The PQRI was further modified as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110-275) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275). In 2011, the program name was changed to Physician Quality Reporting System (PQRS).

For each program year, CMS implements Physician Quality Reporting through an annual rulemaking process published in the Federal Register. For 2012 the final rule was published on November 28, 2011 as part of the Medicare Physician Fee Schedule Final Rule. The Medicare Improvements for Patients and Providers Act (MIPPA) requires the Secretary to post on the CMS website, in an easily understandable format, a list of the names of eligible professionals (or group practices) who satisfactorily submitted data on quality measures for the Physician Quality Reporting System and the names of the eligible professionals (or group practices) who are successful electronic prescribers.

Going forward: As Medicare moves from a passive payer to an active purchaser of higher quality more efficient healthcare through the implementation of the Physician Value-Based Payment Modifier (PVBPM), there will be negative payment adjustments if quality reporting does not occur. PQRS will continue to provide incentive payments through 2014. However, in 2015 eligible professionals will receive a 1.5% reduction in charges if satisfactory reporting does not occur. In addition, the PVBPM will begin to affect physician payment starting in 2015, when payments for some physicians will be adjusted based on quality measures reported through PQRS.

The 2015 PVBPM will utilize 2013 PQRS reporting for determining who is eligible for payment adjustments – positive or negative. This means that 2012 is your last chance to become familiar with PQRS and learn how you can incorporate and capture the information within your practice and begin reporting it to Medicare without incurring a penalty. And if you successfully report, you could qualify for an incentive payment for 2012.

Program details can be found at http://www.cms.gov/PQRS/.

Dr. Mark Levine, Medicare’s chief medical officer for the Denver Region answers questions regarding the 2012 PRQS program:

Q: Who can participate in PQRS?
A: Eligible professionals who bill under the Medicare Part B Physician Fee Schedule (PFS) can participate. This includes physicians (MD’s/DO’s, etc.), practitioners (nurse practitioners, physician’s assistants, etc.) and therapists (physical therapists, etc.). A complete list of eligible professionals who can participate in PQRS can be found on the PQRS website at http://www.cms.gov/pqrs.

Q: What are the different reporting mechanisms?
A: For 2012 there are four options for reporting of individual measures by individual eligible professionals, five options for reporting of measures groups by individual eligible professionals, and one option for group practices. Depending on which option is selected, the measures must be reported for either a twelve-month reporting period that begins January 1, 2012 or a six-month reporting period that begins July 1, 2012.

Q: What is the reporting period for each?
A: A full year reporting period for 2012 (Jan. 1, 2012 to Dec. 31, 2012), exists for all reporting options but one. PQRS also has a 6-month reporting option (from July 1, 2012 to Dec. 31, 2012), though only for measure groups reported via a qualifying registry.

Q: How many patients/measures do I need to report on to be “successful”?
A: The criteria differ per reporting option selected. An implementation guide is available on the PQRS website that provides a decision tree that guides new users through PQRS reporting. This can be found at: http://www.cms.gov/PQRS/03_How_To_Get_Started.asp#TopOfPage.

Q: What is the bonus payment for this year and in 2013?
A: The incentive payment for 2012 through 2014 is 0.5% of the eligible professional’s, or group practice’s, estimated total allowed charges for covered Medicare Part B Physician Fee Schedule services provided during the reporting period.

Q: Have the quality measures changed for 2012?
A: Yes. There are now a total of 210 individual measures that can be reported as well as 22 measures groups.

Q: Explain the difference between individual measures and group measures.
A: Measures groups are a set of measures surrounding a particular condition, such as diabetes, heart failure, etc. Reporting with measures groups allows the eligible professional to report on the same measure group for either a percentage or a set of their patients throughout the year. Whereas with individual measures, an eligible professional can select any three that apply to their practice to report on a percentage of their patients throughout the year (the reporting requirements differ by reporting option).

Q: What would you tell physicians first if they are interested in participating in
PQRS?
A: First, no sign up or registration is required. All an eligible professional needs to do is select their measures, determine how they will report and start reporting. The best place to start is at the PQRS website with the 2012 PQRS Implementation Guide. This can be found at http://www.cms.gov/PQRS/03_How_To_Get_Started.asp#TopOfPage.