PQRS and What you Need to Know

PQRS and What you Need to Know


What is the Physician Quality Reporting System (PQRS)? 

The Physician Quality Reporting System (PQRS) was first introduced a decade ago by the Centers for Medicare and Medicaid Services (CMS) as a quality reporting program. When first started, CMS offered payment incentives to all Medicare providers who agreed to report on quality performance measure. Formerly known as the Physician Quality Reporting Initiative (PQRI). The PQRS was initially a voluntary reporting program that provided a financial incentive for certain health care professionals, including psychologists, who participated in Medicare to submit data on specified quality measures to the Centers for Medicare and Medicaid Services (CMS). In 2015, the reporting program  shifted from voluntary program to a mandatory one in which penalties will be assessed for failure to participate.

What does PQRS involve?

The PQRS involves the reporting of designated administrative codes on billing claims, through a certified electronic health record (EHR), or a similar qualified registry. In 2016, Healthcare providers who successfully participate in this program will be listed on the new public Physician Compare Web page. One can find the exact specifications for the PQRS on the CMS PQRS webpage.  Eligible professionals (EP) will receive this downward payment adjustment in 2017.

Current Year’s Performance Measures

The PQRS program will continue throughout 2016 with reporting of 284 individual measures and 11 measured groups.  For healthcare providers in the mental health specialities, this will also include measures on depressive disorder, medication reconciliation and screening for substance abuse. In addition, there is a dementia measure set available for use as a measure group.

What financial implications exist with PQRS?

To avoid being penalized, healthcare providers must report on a minimum of nine individual measures or one measure group that encompasses three of the ten National Quality Strategy domains, applicable to their medical or surgical practice for at least 50% of their eligible patients for 2016 (Jan. 1 to  Dec. 31). CMS has set a penalty of 2% of the total Medicare allowed charges for the period.

If the healthcare provider feels that 9 measures cannot be reported on, and he or she would like to avoid being penalized in 2017, the healthcare provider may volunteer to participate in the Measures Applicability Validation (MAV) process. The healthcare provider can then have the MAV process completed by CMS upon request. This pathway permits CMS to designate the appropriate measures for the provider.  Any measure with a 0% performance will be disregarded and not counted to report on a group, CMS has specific measure group requirements that must be followed.

What are the mechanisms for participation in PQRS?

There is no formal registration protocol to participate in the 2016 PQRS. Once one submit quality data codes for the 2016 PQRS quality measures to CMS through claims,  an electronic health record or a qualified registry, this satisfies the criteria for participation in the 2016 program . Reporting for the PQRS is not meant to be complex or time consuming. One only has to add a few codes to the electronic  claim form that is used to submit to Medicare. More details are available on the CMS website. Information is also available from your local Medicare carrier.

Is the reporting done at the end of the year?

No, if you decide to report, you should start soon since you must report on 50% of the applicable cases during the 12 month reporting period. If you start late, then this may prevent you from achieving this threshold, resulting in a failure to be eligible for the bonus payment.

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