MIPS consolidates Medicare MU and PQRS penalties and VBM incentives and penalties, while continuing to measure provider performance as specified by those three component programs.


Published 6/1/2016
Warren Dunn, MD, MPH; Jackie Ryan, MPA

More about PQRS 2016: What You Need to Know

As we move through the final year of the Physician Quality Reporting System (PQRS) in 2016, some physicians may be looking forward to saying goodbye to this program forever. Those sentiments may be a bit premature. Although the PQRS program in its current form will be ending, PQRS will continue as part of the Merit-Based Incentive Payment System (MIPS). (See cover story, "CMS Releases MACRA Proposed Rule). Key components of the PQRS, the Medicare Electronic Health Record (EHR) Incentive Program, and the Value Based Payment Modifier (VBPM) serve as the foundation for MIPS and Advanced Alternative Payment Models (APMs). Thus, it is important for physicians and other PQRS-eligible providers to participate in PQRS in 2016—not just to avoid payment penalties, but to prepare for Medicare payment reform requirements. The work that physicians put into participating in PQRS now will not be wasted.

The following questions and answers outline how orthopaedic surgeons can succeed under the current program and prepare for the future.

1. What do I need to know about current reporting programs?
Providers must continue to participate in the PQRS and VBPM programs in 2016, which will determine payment in calendar year 2018. Orthopaedic surgeons have several options for participating in PQRS. Their options depend on how they bill, the size of their practice, and whether their practice's members want to report individually or as a group. Measures are classified according to the six National Quality Strategy (NQS) domains based on the NQS priorities. In 2016, providers are required to report at least nine measures across three domains or face nonreporting penalties in 2018. The reporting period for 2016 is Jan. 1, 2016, to Dec. 31, 2016.

2. Which patients do I actually have to report?
Physicians only report on Medicare Part B patients for PQRS. This can be confusing because the measure specifications often say "regardless of age" in reference to which patients need to be reported. However, this language exists only to account for younger patients (eg, those with disabilities) who may be on Medicare.

3. How much will I be penalized if I don't report PQRS in 2016?
The potential payment reduction for not reporting PQRS in 2016 could be up to 6 percent of Medicare Part B payments, depending on the size of the practice, with the reduction to be applied in 2018. The penalties include a 2 percent PQRS payment reduction plus an additional 2 percent value-based payment modifier (VBPM) reduction for solo practitioners and groups of up to nine providers. Group practices with 10 or more providers, on the other hand, will automatically receive a 4 percent VBPM reduction.

4. Which measures are eligible for PQRS?
The Academy has identified an Orthopaedic Preferred Specialty Measure Set for 2016 PQRS reporting, available on the AAOS website.

5. Do I really have to report nine quality measures?
In 2016, eligible professionals (EPs) must report at least nine quality measures that cover at least three of the NQS domains, one of which must be a cross-cutting measure.

6. What is a cross-cutting measure and why do I have to report one?
According to CMS, cross-cutting measures are broadly applicable measures that are meant to drive quality and improvement across the house of medicine. Cross-cutting measures are required for all eligible professionals (EPs) who have face-to-face encounters with patients. Physicians should choose the most applicable cross-cutting measure to their practice, but per PQRS requirements, at least one cross-cutting measure must be reported in order to satisfactorily report. For example, a good cross-cutting measure to report for physicians who already screen patients' body mass index may be Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. AAOS staff members can help orthopaedists determine how to integrate at least one cross-cutting measure into their practice or capture one they may already be doing.

7. I can't reach the required nine measures. Now what?
If you cannot reach the required nine measures, the Measure Applicability Validation (MAV) exception will apply to you. The Centers for Medicare & Medicaid Services (CMS) uses this process to evaluate whether EPs could have reported on additional measures, and determines whether reporting requirements have been satisfied. Medicare encourages providers to report measures that they consider relevant to them and that work within the flow of their practice.

8. Can I report as a group practice?
Medicare allows practices of two or more eligible providers to report PQRS as a group (known as the Group Practice Reporting Option, or GPRO). To participate, registration with CMS must be completed between April 1, 2016, and June 30, 2016. More information about participating as a group is available on the CMS website. As an eligible professional or group practice, one option you have to report quality measures for PQRS is by using a qualified registry. CMS designates "qualified registries" as entities that can collect clinical data from providers or group practices and submit that data to CMS on behalf of PQRS participants.

Warren Dunn, MD, MPH, is chair of the AAOS Performance Measures Committee. He can be reached at dunn@ortho.wisc.edu Jackie Ryan is manager, performance measures, at AAOS. She can be reached at ryan@aaos.org

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