How to Participate in the 2011 Physician Quality Reporting System (PQRS)

The 2011 Physician Quality Reporting System (PQRS) will have two reporting periods: January 1, 2011 - December 31, 2011 and July 1, 2011 - December 31, 2011. To participate, eligible professionals (EPs) may choose to report information on individual PQRS quality measures or measures group to: 1) CMS on their Medicare Part B claims (Figure 1); 2) a qualified PQRS registry (Figure 2); 3) CMS via a qualified electronic health record (EHR) product (Figure 3); Group Practice Reporting Option (GPRO) I (Figure 4); or GPRO II (Figure 5). Please note GPRO I and II may be difficult options due to the number of relevant measures required to report.

Individual EPs who satisfactorily submit PQRS quality measures data via one of the reporting mechanisms above for services furnished during the 2011 reporting period will qualify to earn an incentive payment of 1.0% of their total allowed Medicare Part B Physician Fee Schedule (PFS) charges for covered professional services furnished during that same reporting period. The bonus calculation does not include charges for x-rays, MRI, DME, or PT. Bonus payments for reporting in 2011 will be issued in a lump sum, in the following year. Payments will be made to the holder of the taxpayer identification number (TIN).

Reporting Criteria for Individual Measures (claims-based)

For the January 1, 2011 through December 31, 2011 reporting period:

• Report on at least 3 individual PQRS measures on 50% of the applicable patients

For the July 1, 2011 through December 31, 2011 reporting period:

• Report on at least 3 individual PQRS measures on 50% of the applicable patients

NOTE: Reporting on less than 3 individual measures via claims is subjected to the Measure Applicability Validation Process (see MAV section below).

Reporting Criteria for Measures Group

For 2011, there are fourteen (14) Measure Groups: Asthma; Back Pain; Chronic Kidney Disease (CKD); Community-Acquired Pneumonia (CAP); Coronary Artery Bypass Graft (CABG); Coronary Artery Disease (CAD); Diabetes Mellitus; Heart Failure; Hepatitis C; HIV/AIDS; Ischemic Vascular Disease (IVD); Perioperative Care; Preventive Care; and Rheumatoid Arthritis.

Reporting criteria for claims-based reporting of a Measures Group:

For the January 1, 2011 through December 31, 2011 reporting period:

• Report on 50% of applicable patients for a measure group and must report each measure group on a minimum of 15 applicable patients OR
• Report 1 measure group for at least 30 applicable patients

For the July 1, 2011 through December 31, 2011 reporting period:

• Report on 50% of applicable patients for a measure group and must report each measure group on at least 8 applicable patients.

Orthopaedic surgeons may choose to report on Perioperative Care and Back Pain Measures Groups.

Worksheet for Back Pain Measure Group

Worksheet for Perioperative Care Measure Group

Reporting Quality Measures

First, orthopaedic surgeons should review the 2011 PQRS Measures List or the Orthopaedic Specific Measures section and decide which are applicable to their practice. For individual measures, select the top 3 measures that apply to your patient cases. Once you have selected your measures, review the detail coding specifications of those measures. Select the best reporting option that suits your practice (claims, registry, or GPRO). Ensure that your computerized practice management system or clearinghouse will accept CPT Level II or G-codes. These codes are alpha-numeric and some systems may not accept them. Another potential problem is that some systems will not accept a zero dollar amount in the field following a CPT code. If that is the case, it is easily solved by inserting a small amount, like $0.01. Be sure to develop a systematic method to instruct your billing clerk to append the appropriate CPT Level II or G-codes to the CMS 1500 forms.

To report individual measures or measures group on a claim, physicians should append the appropriate CPT Level II or G-codes to the CMS 1500 form used to report the service or procedure for which the measures are appropriate. After you have submitted your claim to the Medicare carrier or A/B MAC with the diagnosis, CPT I service codes or procedure codes related to the encounter and corresponding quality data code(s) on it, you will receive a Remittance Advice (RA) from your Medicare carrier or A/B MAC. The line items containing a quality data code (QDC) are submitted with a zero dollar amount and will be denied for payment, but are then passed through the claims processing system for PQRS analysis. The RA associated with the claim containing the quality data code line-item will include a standard remark code (N365) and a message that confirms that the QDCs passed into the National Claims History (NCH) file. The N365 will read: “This procedure code is not payable. It is for reporting/information purposes only.” Keep in mind that the N365 remark code does not indicate whether the QDC is accurate for that claim or for the measure the physician is attempting to report.

Please see the following six worksheets.

1. The first is a 37-page worksheet that includes all of the technical information that is also available on the CMS PQRS web site.
2. The second worksheet lists the coding information for measures applicable to orthopaedics.
3. The third contains the coding information for the four measures that apply to operative procedures. These are the ones that will be most used by orthopaedic surgeons.
4. A worksheet listing the CPT Level II and G codes with appropriate modifiers.
5. This worksheet provides detailed information on the Back Pain Measures Group.
6. The sixth worksheet list the Perioperative Care Measures Group along with specifications.

We suggest you read the first worksheet so you will have a full understanding of the requirements for each measure. Then have your billing clerk use one of the coding worksheets as a reference as he/she appends the appropriate CPT Level II and G-codes to your claim form.

Additional tips:

1. You must report using your National Provider Identifier (NPI). Each physician or other health care provider should have already obtained an NPI. If you do not have an NPI, or need to update information, visit the National Plan and Provider Enumeration System (NPPES).
2. You should notify your patients that you are participating in PQRS. A sign in your waiting room might be appropriate.
3. Claims may not be resubmitted for the sole purpose of adding or correcting QDCs.

Analysis and Payment

As mentioned earlier, EPs who satisfactorily report quality-measures data for services furnished during a PQRS reporting period are eligible to earn an incentive payment of 1.0% of their estimated total allowed charges for covered Medicare Part B PFS services provided during the reporting period.  Incentive payments will be issued separately as a “lump sum” incentive payment in the following year. Payments will be issued to the first valid group location listed under the TIN or for solo practitioners, to the first valid practice location listed under the TIN. The carrier or A/B MAC will make the payment electronically or via check, based on how the TIN normally receives payment for Medicare Part B PFS covered professional services furnished to Medicare beneficiaries. If a TIN submit claims to multiple Medicare claims-processing contractors (Carriers or A/B MACs), each contractor may be responsible for a proportion of the TIN incentive payment equivalent to the proportion of Medicare Part B PFS claims the contractor processed during the applicable reporting period. (Note: If splitting an incentive across contractors would result in any contractor issuing a PQRS incentive payment less than $20 to the TIN, the incentive will be issued by fewer contractors than may have processed PFS from the TIN for the reporting period).

The incentive payment, with the RA, will be issued by the carrier or A/B MAC and identified as a lump-sum PQRS incentive payment. The electronic RA sends only a 2-character code ("LS" – lump sum). This code will appear in PLB03-1 on the outgoing 835. The paper RA states, "This is a PQRS incentive payment.” Once the distribution of incentive payments has began for a particular program year and your lump-sum incentive does not arrive or the incentive payment amount does not match what is reflected in your PQRS feedback report, contact your Carrier or A/B MAC. Note: The incentive amount may differ by a penny or two from what is reflected in your feedback report due to rounding.

Measure Applicability Validation (MAV)

In 2011, if you report on one or two PQRS measures for at least 50% of the eligible patient encounters, you may still qualify for the incentive payment. However, CMS will subject these claim based submitted QDCs to the two step MAV process to determine whether you should have submitted QDCs for additional measures. Those who fail the validation process will not earn the PQRS incentive payment. For detailed information on the validation process, please review the 2011 PQRS MAV Process for Claims-based Reporting of Individual Measures or the MAV Process Flow Chart.

PQRS Feedback Reports

Each year, the PQRS incentive payment and the PQRS feedback report are issued through separate processes. PQRS feedback report availability is not based on whether or not an incentive payment was earned. Feedback reports will be available for every TIN under which at least one eligible professional (identified by his or her NPI) submitting Medicare Part B PFS claims reported at least one valid PQRS measure a minimum of once during the reporting period. Please note that PQRS participants will not receive claim-level details in the feedback reports. For more information on feedback reports, visit the Analysis and Payment section at www.cms.hhs.gov/PQRI.