Published 7/1/2014
Douglas W. Lundy, MD, FACS

PQRS: How You Can Participate

Nonparticipants who treat Medicare patients will be penalized

The Physician Quality Reporting System (PQRS), administered by the Centers for Medicare & Medicaid Services (CMS), is being used to determine whether physicians will receive an incentive payment or a payment penalty next year.

Satisfactory participation in PQRS during 2014 can generate an incentive payment of 0.5 percent of Part B submitted charges, but—depending on their performance in 2013—physicians could see up to a 0.5 percent decrease in their Medicare payments in 2015. Performance results this year (2014) could generate up to a 0.5 percent decrease in Medicare payments in 2016, and penalties continue to increase in 2017 and 2018. These potential reductions in payment make physician participation and accurate reporting imperative.

Participation in PQRS
Orthopaedic surgeons can participate in PQRS using several methods. Because the nomenclature and description of these programs are unclear, the potential for confusion is high. Physicians should automatically assume that any material from CMS that refers to “an eligible professional” (EP) applies to them.

Physicians may use the following methods to submit data to CMS:

  • claims-based reporting of Medicare Part B claims
  • registry-based reporting
  • qualified electronic health record (EHR) reporting using certified EHR technology (CEHRT) or a data submission vendor
  • qualified clinical data registry (QCDR) reporting
  • group practice reporting

Claims-based reporting
CMS believes that claims-based reporting is the simplest method for physicians to use. They recommend that physicians review the measures list and select appropriate measures based on their most frequently performed professional services. Physicians should review the measures closely to make sure they understand how the measures work.

The American Medical Association (AMA) has developed a data collection worksheet that can be accessed from the AMA website and used to record the specifics of the measure. Physicians should then enable their billing software and clearinghouse to submit the associated quality-data codes to the carrier to complete the reporting process.

Registry-based reporting
When physicians or groups decide to use the registry option to report their quality data, they need to determine whether to use Individual Measures or Measures Groups. Physicians must select nine different measures that span at least three of the National Quality Strategy (NQS) domains to completely qualify under the registry-based reporting option.

If physicians choose fewer than nine measures or three domains, CMS will use a Measure Applicability Validation process to determine eligibility for the incentive. Physicians would then report their performance on those selected nine measures through a registry that will notify CMS.

Qualified EHR reporting
Individual physicians have been able to use EHR reporting via CEHRT or a data submission vendor since 2010; this year, this method was expanded to allow groups to report using it as well. CMS requires that groups register if they plan to use this method.

However, physicians can no longer use data submission vendors to submit quality data; all EHR reporting from now on must be done through CEHRT. Physicians and groups must ensure that their EHR is certified to submit quality data.

As in registry-based reporting, physicians must select nine different measures that span at least three NQS domains. Physicians must document the required information regarding these measures in the EHR; CMS also suggests that groups participate in testing projects to ensure that the submissions are complete.

This pathway also allows physicians to qualify for the Meaningful Use program.

QCDR reporting
This option just recently became available. A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. It differs from a qualified registry in that the data in a QCDR is not limited to only PQRS data. (See
“AJRR Designated as Approved QCDR.”)

The QCDR is a flexible option because it can report both recognized and nonrecognized PQRS measures. Testing of the systems recently began and by the end of this year, the QCDR must “have provided feedback, at least four times, on the measures at the individual participant level for which the QCDR reports on the EP’s behalf for purposes of the individual EP’s satisfactory participation in the QCDR.” The QCDR is an exciting option because it mandates and makes available benchmarking and quality improvement data.

Group practice reporting option
A group practice is defined as two or more physicians who are practicing under the same taxpayer identification number. In 2014, groups may report using the following options:

  • qualified PQRS registry
  • web interface (for groups of 25+ only)
  • CEHRT via data submission vendor
  • Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CAHPS) via CMS-certified survey vendor (for groups of 25+ only)

Group practices are also subject to the Value-Based Modifier (VBM) that was mandated by the Affordable Care Act. The VBM now directly affects groups of more than 100 eligible professionals (Table 1) that bill under the Physician Fee Schedule to Part B of Medicare.

CMS will prepare quality resource and use reports that will analyze physicians’ quality and cost to determine the overall value of the care that they are providing. Starting in 2015, to avoid a negative 1 percent value modifier adjustment to 2015 Medicare payments, groups of more than 100 will need to self-nominate and choose from one of the following PQRS group reporting methods:

  • web-interface group reporting option
  • registry option
  • request that CMS calculate the group’s performance on quality measures from administrative claims

Groups that use one of these methods will have a 2015 value modifier of zero (that is, no economic impact on 2015 payments). In January 2014, the eligibility was expanded to all eligible professionals regardless of whether they participate in Medicare.

In 2014, groups of more than 100 can voluntarily participate in quality tiering. In this scenario, the groups are benchmarked against national standards to determine if the value of the care provided was above or below the national standards. The outcome from this decision could result in an increase or decrease in payments.

Douglas W. Lundy, MD, FACS, is the Council on Advocacy liaison to the Communications Cabinet and a member of the AAOS Now editorial board.

Editor’s Note: This is the second of two articles on the Physician Quality Reporting System (PQRS). The first article covered the background of the program, its current structure, and the various types of measures included in the program.

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