2016 Physician Quality Reporting Program (PQRS)

The Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) is a reporting program that currently uses incentives and payment adjustments (penalties) to promote reporting of quality information to CMS. Calendar year 2014 was the last year to earn an incentive through PQRS. However, additional incentives and penalties are possible through the Value-based Payment Modifier (VM), a program directly tied to PQRS that looks at quality and cost performance. All incentives and payment adjustments are applied to payments for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer, Medicare Part C–Medicare Advantage beneficiaries are not included).

PQRS Payment Adjustments
Eligible professionals (EPs) who do not report data on quality measures in 2015 will receive an automatic payment adjustment on their 2017 reimbursements of -2%. Additionally, an automatic -2% payment adjustment will also be applied under the VM for individuals and groups of two-nine providers and -4% for groups of 10+ EPs. Combined, EPs could see a -4% or -6% loss in 2017 reimbursements for not participating in PQRS. EPs can avoid the payment adjustment by satisfactorily reporting quality measures data through one of the following reporting mechanisms:

• Reporting electronically using an electronic health record (EHR)
• Qualified Registry
• Qualified Clinical Data Registry (QCDR)
• PQRS Group Practice Reporting Option (GPRO) via Web Interface
• CMS-Certified Survey Vendor
• Claims

Participation during a calendar year will affect payments adjustments after two years (i.e. 2015 program participation will affect 2017 payments). The PQRS negative payment adjustment applies to all of the individual EP’s or group practice’s Part B covered professional services under the Medicare Physician Fee Schedule (MPFS). Learn more: CMS Payment Adjustment Information.

Therefore, a negative payment adjustment in 2015 will be based on participation in 2013. Providers who did not report or did not successfully report would be paid 1.5% less than the MPFS amount for that service. For 2016 (based on participation in 2014) and subsequent years, the negative payment adjustment is 2.0% for PQRS. This does not take into account the VM.


Getting Started

The following four steps can help you get started with PQRS reporting for 2016:

1. Determine if you are eligible to participate in PQRS
Physicians, practitioners, and other EPs providing covered professional services paid under or based on the Medicare Physician Fee Schedule are eligible under PQRS. Review CMS’ list of eligible professionals here (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]).

2. Determine which PQRS reporting method is best for you (Individual or Group)
Several reporting options are available to you whether you decide to report as an individual or as a group practice. Review the options and individual and group reporting requirements  to determine which one is best for you and your practice. Reporting requirements are updated annually through the Physician Fee Schedule Final Rule and should be reviewed on a yearly basis.

Note: Reporting through the group practice reporting option (GPRO), available for groups of 2+ EPs, requires prior registration with CMS through the PV-PQRS registration portal. The 2015 GPRO Web interface submission period is from January 18 to March 11, 2016. Groups that register as a GPRO will not be able to change or update their registration after the deadline and are encouraged to review the measures available under each reporting option to prior to registering.

Review the 2015-2017 PQRS Timeline.

3. Select measures to report to CMS
Review measures and their specifications (the coding associated with each measure) to determine if they are applicable to you and your practice. Measures are updated on an annual basis and are subject to removal from the program. Further, new measures may be added to the program by CMS. Be sure to review the measures you have selected on an annual basis. Individual measures for qualified registry and claims based reporting can be reviewed here. NEW for 2016, The PQRS Individual Measure Specifications for Claims and Registry Reporting can be viewed on the CMS  PQRS web-based tool. Reporting a PQRS measures group, such as the asthma or sinusitis measures groups (individual EPs only), requires reporting on all measures within the group. Similarly, the GPRO Web Interface (groups of 25+ only) requires reporting on all measures within the web interface.

PQRS 2016 criteria
Measure Classification and the National Quality Strategy (NQS)
Measures are classified according to one of six National Quality Strategy (NQS) domains that are based on the NQS’ priorities. PQRS reporting options typically require an EP or PQRS group practice to report nine or more measures covering at least three NQS domains. Measures are further classified according to their type, process or outcome. Finally, some measures that are broadly applicable have been classified by CMS as cross-cutting measures and must be reported for certain reporting methods.

Note: Not all measures are available through each reporting method. CMS publishes a list of all measures available in the PQRS program for each reporting method on the Measures Codes section of their website. If you are interested in reporting through a qualified registry, check the CMS Qualified Registry posting here. Similarly, qualified clinical data registries (QCDRs) may contain measures not within the traditional PQRS program that have been approved by CMS specifically for inclusion in the QCDR (referred to as non-PQRS measures). Review the measure specifications for the QCDR you are interested in to determine which measures are available. Read more about the AAAAI QCDR here.

4. Collect your data and report!
Once you determine which method and measures you would like to report, begin collecting data for the January 1, 2016 – December 31, 2016 reporting year. Reporting deadlines can vary depending on which method you select and your specific vendor if applicable.

For more information, visit the CMS Getting Started page and additional resources. 

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