PQRS Measuring Value Today and Tomorrow CHANGES YOUR CLIENTS NEED TO KNOW ABOUT By Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H hysician quality programs are expanding as the shift to collaborative care, outcome-based payment and new benefit designs transforms how healthcare is delivered and paid for. Billing companies must assist and guide their clients to ensure successful participation. If not, the client and the billing company will see financial consequences. The majority of arrangements continue to be based on fee-forservice; however, evolving payment models are moving toward various levels of providers’ risk using capitation, episode-based payment, or global payments. Physicians need to understand how the programs are measured and how each measure is calculated. It is also important to understand the contracts and program methodology documents for quality and cost performance measures. PQRS The Physician Quality Reporting System (PQRS) began in 2007 as the Physician Quality Reporting Initiative (PQRI). It started as an incentive-based reporting program for eligible providers (EPs) to report quality data to the Centers for Medicare & Medicaid Services (CMS) via claims. In past years, physicians could earn incentive payments for successfully reporting quality data, but physicians are now subject to a penalty (“payment adjustment”) if they fail to successfully report. Physicians’ payments will be reduced by 1.5 percent in 2015 if they did not successfully report quality data for their 2013 services. The payment reduction increases to 2 percent in 2016, based on reporting for 2014 services. For successful reporting on 2015 services, physicians must report on at least nine measures. If nine measures are not available, the EPs must choose all that are applicable. The measures must be across three National Quality Strategy Domains. Practices must report each measure for at least 50 percent of the Medicare Part B fee-for-service patients seen during the reporting period. Additionally, if the physician sees one or more Medicare patients in a face-to-face encounter during the reporting period, the physician must report on at least one of the “cross-cutting” measures, which are nonspecialty measures, such as influenza immunization. The cross-cutting measure can count as one of the nine required measures. Measures with 0 percent performance rate will not be counted. There are several methods that can be used for the submission of PQRS data. Currently, you can utilize one of the following methods, depending on the size of the practice: • Report special quality codes to CMS on Part B claims • Submit through a qualified Physician Quality Reporting registry • Submit data from a qualified electronic health record (EHR) • Use the Group Practice Reporting Option (GPRO) web interface • Use a qualified clinical data registry • Use a CMS-certified survey vendor Most small physician practices participate in PQRS by P SUMMARY OF BONUS/PENALTY FOR REPORTING QUALITY DATA THE JOURNAL OF THE HEALTHCARE BILLING AND MANAGEMENT ASSOCIATION 17 MOC = Maintenance of Certification FEATURE STORY Year 2010 2011 2012 2013 2014 2015 2016 Bonus/Penalty 2% 1% (+.5% for MOC) .5% (+.5% for MOC) .5% (+.5% for MOC) .5% (+.5% for MOC) -1.5% -2%
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