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Achieve Incentives and Report Compliantly with Four CMS Quality Initiatives


As physicians continue to accurately report their data, compliantly file claims, and achieve success and incentives, it is important that they become aware of the measures and requirements surrounding CMS quality initiatives for 2013 and beyond. The Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) began launching quality initiatives in 2001 to assure quality healthcare for all Americans through accountability and public disclosure. The various quality initiatives touch every aspect of the healthcare system, many of which focus on publicly reporting quality measures for hospitals and physicians, including hospital-based physicians.

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The Physician Quality Reporting System

The mechanics of reporting quality data to CMS are much the same for 2013, but there are a few changes that providers need to be aware of. As in previous years, the claims-based, registry, and EHR-based methods of reporti

ng still exist, with the claims-based method still being the most popular. Each eligible professional (EP) needs to report on three individual measures to successfully achieve the incentive. EPs include both physicians and applicable non-physician practitioners (NPPs) such as nurse practitioners, physician assistants, and certified registered nurse anesthetists. EPs represent providers who are eligible to be paid on the Medicare Physician Fee Schedule (MPFS).

"Successful" reporting for EPs will be analyzed at the individual provider level, and for claims-based reporting, the success threshold remains at 50 percent. The claims-based reporting rules remain much the same as before (e.g., a $0.00 charge should still be applied to the quality code line items). One question that is frequently asked is whether or not Physician Quality Reporting System (PQRS) codes need to be submitted to Medicare HMOs; the PQRS program is applicable to Part B fee-for-service, which comprises Railroad Medicare, traditional fee-for-service Medicare, and Medicare secondary payors. It does not include Part C, which encompasses Medicare Advantage/HMOs, so quality codes should not be submitted to those payors.


Achieving the PQRS incentive has different requirements in order to avoid the 2015 PQRS penalty. The EP has to report on one measure in 2013; whether they do so successfully or not is not part of the criteria to avoid the 2015 penalty. In 2013, it seems that CMS is giving EPs credit for attempting to successfully report PQRS, but the EP must successfully report on three measures during 2013 to obtain the 2013 incentive and be paid out in the latter part of 2014 after CMS analyzes its success factor. The incentive/penalty schedule for PQRS participation is below (please note the -1.5% penalty for 2015 will be based on 2013 reporting results):

• 2012. . . . . . 0.5% incentive
• 2013. . . . . . 0.5% incentive
• 2014. . . . . . 0.5% incentive
• 2015. . . . . . -1.5% penalty (based on 2013 reporting results, will be paid at 98.5% of MPFS)
• 2016+. . . . . -2.0% penalty (based on 2014 reporting results, will be paid at 98.0% of MPFS)

The above is applicable for an EP's claims-based reporting of 259 potential quality individual measures. The EHR reporting option may be more prevalent for physicians moving forward, and registry reporting is a viable option that tends to have more reported "success" than claims-based reporting but may include a cost for usage of the registry.

There are also 22 measures groups, instead of individual measures, that providers could report on. The Group Practice Reporting Option (GPRO) became available in 2013 to smaller groups consisting of two to 99 EPs. These groups can now report as a group, whereas in 2012, only groups of 25 or more EPs could have reported in this fashion. Lastly, there is also an "administrative claims option" that individuals or groups can choose as a reporting option – one that does not require PQRS code submission. It would require the group to register for the option, and CMS will analyze quality data on its end. This option would only allow avoidance of the 2015 penalty, but would not suffice to obtain the incentive payment.

The Value Based Payment Modifier

The Value Based Payment Modifier (VBM) program, a separate program from PQRS, still hinges on PQRS reporting. According to CMS, it is a program implemented to assess both quality of care and cost of care using 2013 PQRS reporting data. The VBM will be applied to all groups of 100 or more EPs beginning in 2015 and in 2016 and will be implemented for all physicians by 2017. According to CMS, the VBM program is explained as such:

"Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). Both cost and quality data are to be included in calculating payments for physicians.

  • Physicians in groups of 100 or more eligible professionals who submit claims to Medicare under a single tax identification number will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
  • All physicians who participate in Fee-For-Service Medicare will be impacted by CMS's emphasis on reporting quality data through PQRS and by 2017 will be affected by the value modifier.

The biggest question that physicians ask is, "what is the potential monetary ramification of the VBM?" In 2015, physicians in groups of 100 or more EPs who submit claims to Medicare under a single tax identification number will be subject to the value modifier based on their performance in calendar year 2013. These groups will need to self-nominate in 2013 and choose one of three PQRS group reporting methods in order to avoid a negative -1.0% VBM adjustment to the 2015 payment under the fee schedule: the web interface group reporting option (web interface reporting, a limited number of composite measures applicable); a registry (a cost is associated with this option); or a request that CMS calculate the group's performance on quality measures from administrative claims.

Self-nominating/registering for and participating in any of the above-mentioned methods of reporting on clinical performance will result in a 2015 value modifier of zero, meaning there would be no economic impact on 2015 payments. The -1.0% VBM adjustment is potentially applicable to the larger groups of 100 or more EPs in 2015 in addition to the PQRS penalty. This means there is a potential -2.5% penalty at stake for larger groups if they do not meet the PQRS and/or VBM requirements. CMS realizes that many EPs prefer to participate in PQRS as individuals and report individual measures via claims to CMS. In order for the group to avoid the negative -1.0% payment adjustment under the VBM, an authorized group representative will need to commit the group as a whole (via a CMS-hosted registration process) to having CMS calculate a quality score from administrative, claims-based quality measures. In other words, the group must elect and register for the administrative claims option under PQRS in addition to their individual PQRS measure reporting.

From December 1, 2012 to January 31, 2013, groups could have self-nominated to participate in the 2013 PQRS web interface group reporting option (GPRO) or a registry. Beginning again in July 2013 and lasting until mid-October 2013, CMS will continue the self-nomination/registration process for groups of 100 or more EPs. They must inform CMS which of the three potential methods of group reporting they will use for 2013 (e.g., web interface, registry, or administrative claims option) to avoid a negative -1.0% payment adjustment under the VBM. For larger groups that continue to report PQRS as individual EPs throughout 2013, they will also need to elect the administrative claims option during the period of July through mid-October in order to avoid the VBM penalty.

Maintenance of Certification

CMS is continuing the Maintenance of Certification (MOC) program incentive that began in January 2011 and currently goes through 2014. EPs who were incentive-eligible in PQRS could receive an additional 0.5% incentive payment when MOC program incentive requirements are also met. The EP can choose to participate in MOC only if the board in which they are certified is on the CMS approved list. The board must nominate themselves to CMS and pass approval as an MOC entity. If the board they hold certification(s) through is not on the list, the EP cannot participate in the CMS MOC program or potentially obtain the incentive. Secondarily, the EP would have to meet the CMS requirements, one of which is successfully reporting PQRS in the year they also would like to obtain the MOC incentive.

Summarized per the CMS MOC program requirements, if a physician is board certified through one of the CMS approved entities as listed and satisfactorily participates in PQRS for the calendar year, they could potentially achieve a 0.5% incentive in addition to the PQRS incentive. Ultimately, CMS will pay the additional incentive if the physician participates through their board in the CMS MOC board program, which requires the EP to do "more than normal" to maintain their certification. Each board that is approved has different requirements based on their current program, so it would be advisable for the EP to contact their board representative to find out what they must do given their current certification status. The board reports the success or failure of the EP to CMS on whether or not they meet the established requirements.

Specialty-Specific Approved MOC Entities

The American Board of Radiology (ABR) and the American Board of Emergency Medicine (ABEM) were approved MOC entities for 2012 and in 2013. The American Board of Pathology (ABP) also became qualified in 2013. Although the American Board of Anesthesiology (ABA) in the past announced its intent to not participate, they are included in the CMS 2013 list of qualified entities. This is a program that ultimately requires the EP to communicate with their board to better understand the actions that need to be taken.


The CMS Electronic Prescribing Incentive Program (eRx) is described by CMS as a reporting program that uses a combination of incentive payments and payment adjustments to encourage electronic prescribing by EPs. A prescriber's ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care is an important element in improving the quality of patient care.

CMS has set up a few requirements to participate in the eRx program. First, every EP must have and use a qualified eRx system and report on his or her adoption and use of the eRx system via a quality code on the claim. Secondly, the EP must meet the criteria for a successful electronic prescriber specified by CMS for a particular reporting period. Finally, at least 10 percent of a successful electronic prescriber's Medicare Part B covered services must be comprised of codes that appear in the denominator of the eRx measure. The last analysis is an important distinction to determine inclusion/exclusion in the program and the ability to achieve an incentive or avoid penalties. The 2013 services included in the denominator of the eRx measure are below:

Denominator Criteria (Eligible Cases) 2013:

Patient visit during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

E-prescribing instances are similarly reported as PQRS measures, whereby the quality code (G8553) goes on the claim with the denominator eligible code from the list above when and if the provider e-prescribes.

There are also other considerations to take into account. A majority of hospital-based providers do not bill for many if any of the codes in the eRx measure as above. CMS has documented what an EP's "exclusion criteria" is for applying the 2014 adjustment.

Many hospital-based practices have a minimal, if any, percentage of charges that are attributable to the codes in the eRx measure, which is what has "automatically excluded" them from the adjustment. If an analysis of the EP's six month service offerings concludes that their allowed charges attributable to the encounter codes in the measure hover close to or exceed 10 percent, then the EP should be e-prescribing, reviewing other exclusion criteria, or manually claiming an applicable exemption.

The last year that a provider can achieve an incentive of 0.5 percent of allowed charges if the requirements are met is 2013. The adjustment schedule is below, and the penalties have been in place since the start of 2012:

  • -1.0 percent adjustment in 2012 (EP will receive 99 percent of their Medicare Part B PFS amount that would otherwise apply to such services);
  • -1.5 percent adjustment in 2013 (EP will receive 98.5 percent of their Medicare Part B PFS amount for covered professional services); and
  • -2.0 percent adjustment in 2014 (EP will receive 98 percent of their Medicare Part B PFS amount for covered professional services).

If an EP does not meet the exclusion criteria, then the EP will need to e-prescribe. The adjustment avoidance requirements mandate that the EP will need to report 10 cases of e-prescribing (e.g., the appropriate quality code (G8553) paired with an encounter code from the e-prescribing measure or other service) on applicable patients over the first half of 2013 to avoid the 2014 adjustment. Additionally, if the EP wants to achieve the incentive, they must report e-prescribing on 25 patients over the course of the year 2013. Achieving the e-prescribing incentive and avoiding the adjustment have different criteria to meet.

If an EP wanted to avoid the 2014 adjustment, he or she had to e-prescribe 10 times during the first half of 2013; if the EP met the criteria to obtain the eRx 2012 incentive for e-prescribing, they have already avoided the 2014 adjustment. To avoid the adjustment, CMS does allow the reporting of the e-prescribing quality code on any Part B billable service if e-prescribing was performed, and not just when a code from the measure denominator is billed. The EP must be aware that the e-prescribing in that case will not be counted towards the minimum needed for incentive purposes.

The following new 2014 eRx payment adjustment exemptions will be determined by CMS through review of the EHR Incentive Program Attestation and Registration system and will be automatically processed by CMS:

  • Those EPs and every member within a group practice participating in eRx GPRO who achieve Meaningful Use under the Medicare or Medicaid EHR Incentive Program during the 12-month eRx reporting period (1/1/2012–12/31/2012) or the six-month eRx reporting period (1/1/2013–6/30/2013)
  • Those EPs and every member within a group practice participating in eRx GPRO who demonstrate intent to participate in the Medicare or Medicaid EHR Incentive Program by registering, providing EHR certification ID, and adopting certified EHR technology by January 31, 2013.

In conclusion, there are many CMS sponsored quality initiatives and programs in place, and the programs discussed are relevant to hospital-based physicians and physician practices as they strive to report their data and meet quality reporting and performance standards. n­­

Missy Lovell, BSN, RN, MBA is the compliance manager with Medical Management Professionals, Inc. (MMP).

References SE1206.pdf

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