Physician Quality Reporting System (PQRS)

The Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) program provides incentive payments to eligible health care professionals who satisfactorily report specific data on quality measures to Medicare.

By reporting on PQRS quality measures, individual eligible professional (EPs) and group practices can also quantify how often they are meeting a particular quality metric. In 2015, the program began to apply a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment.

2016-2017 PQRS Timeline

Steps to Help EPs Participate Successfully in PQRS

More information and educational materials can be found on the CMS PQRS site. Here are a few basic steps to help eligible professionals successfully participate in PQRS in 2016.

Step 1: Determine Eligibility

Under PQRS, eligible professionals include doctors, therapists, and other practitioners who provide covered PFS services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries, including Railroad Retirement Board and Medicare Secondary Payer. The following professional are PQRS eligible:

Medicare Physicians	Practitioners	Therapists
Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic	Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant) Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists *Includes Advanced Practice Registered Nurse (APRN)	Physical Therapist Occupational Therapist Qualified Speech-Language Therapist

Note: Professionals who reassign benefits to a Critical Access Hospital (CAH) that bills professional services at a facility level, such as CAH Method II billing, can participate via all reporting mechanisms. To do so, the CAH must include the individual provider NPI on their Institutional (FI) claims.

Step 2: Determine if you participate as an Individual EP or as Part of a Group Practice

Individual EPs are identified by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN)
Group practice is defined as a single TIN with 2 or more individual EPs who have reassigned their billing rights to the TIN. Group practices can register to participate in PQRS via the group practice reporting option (GPRO) to be analyzed at the group TIN level.

Step 3: Choose Reporting Method

Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An individual EP may choose from the following methods:

Qualified PQRS Registry
Medicare Part B Claims
Electronic Health Record (CEHRT)
CEHRT via Data Submission Vendor
Qualified Clinical Data Registry (QCDR)

Groups of two or more eligible professionals may choose from the following methods:

Qualified PQRS Registry
Web Interface (for groups of 25+ only)
CEHRT
CEHRT via Data Submission Vendor
CG CAHPS CMS-Certified Survey Vendor (for groups of 25+ only)

Step 4: Select Measures

The quality measures adopted under PQRS are developed by provider associations, quality groups, and CMS. Quality measures generally are used to assign a quantifiable score—based on a standard set by the developers—to the quality of care provided by the eligible professional or group practice.

The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method. When selecting measures for reporting, eligible professionals should consider factors such as their quality improvement goals and the types of care they frequently deliver.

To view the complete list of measures reportable in 2014 and 2015 in the nursing home setting click here.

To view a complete list of CMS Individual Measure Specifications please click here.

Step 5: Review Payment Adjustment Information

For 2016 (based on participation in 2014) and subsequent years, the negative payment adjustment is 2.0%. EPs and groups who do not satisfactorily report data on quality measures for covered professional services will be subject to a negative payment adjustment under PQRS beginning in 2015. The PQRS negative payment adjustment applies to all of the EP’s or group practice’s Part B covered professional services under the Medicare Physician Fee Schedule (MPFS). Review information on the CMS PQRS Payment Adjustment page for complete information on how to avoid future PQRS payment adjustments.

AMDA’s Quality Committee vetted
all eligible PQRS measures relevant to the skilled nursing facility setting.
AMDA Member Exclusive: PQRS Measure Tool Kit

To view a complete list of CMS Individual Measure Specifications please click here

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