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Physician quality reporting system (pqrs)

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Jose Ivan Delgado, Ph.D.
Jose Ivan Delgado, Ph.D.

Basic explanation of the physician quality reporting system. Some of the due dates and actions that could be taken before Dec 31st to prevent losing money in the future.

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Physician Quality Reporting System (PQRS) Dr. Jose I. Delgado Taino Consultants Inc. www.tainoconsultants.com
Introduction • • • PQRS is a program designed to promote reporting of quality information by eligible professionals (EPs). Program uses financial incentives to promote participation − 2013 & 2014 incentive is 5% increase − 2015 incentive is 1.5% reduction − 2016 incentive is 2% reduction Program applies exclusively to Medicare EPs
Background Created in March 2007 as required by the 2006 Tax Relief and Health Care Act (TRHCA). • The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) extended the incentive payment for 2008 and 2009 PQRI . • The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) made the PQRI program permanent, with incentive payments authorized through 2010. • In 2011, the Affordable Care Act (ACA) renamed the program the Physician Quality Reporting System (PQRS). •
Eligible Professionals (EPs) 1 of 3 • Medicare physicians − − − − − − − Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic
Eligible Professionals (EPs) 2 of 3 • Practitioners − − − − − − − − − − − Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant) Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists *Includes Advanced Practice Registered Nurse (APRN)
Eligible Professionals (EPs) 3 of 3 • Therapists Physical Therapist − Occupational Therapist − Qualified Speech-Language Therapist −
Exceptions • • Eligible Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level Services payable under fee schedules or methodologies other than the Medicare Physician Fee Schedule (PFS) are not included in PQRS
Participation Requirement • Individual EPs do not need to register − • Incentive payment requires that EPs meet the criteria for satisfactory reporting Group Practice Reporting Option (GPRO) − Must register to participate in PQRS GPRO
Group Practice Reporting Option (GPRO) “Group Practice" Single Tax Identification Number (TIN) − 2 or more individual EPs participating − Have reassigned their billing rights to the TIN − Note: EPs may select group or individual reporting; however, the trend to report as individual eligible professionals is higher due to the increase choice in reporting mechanisms.
Electronic Submission Option for PQRS • Report chosen quality measures by submitting Quality Data Codes (QDC’s) that correspond to selected measures on an eligible billing claim form (such as Medicare 1500). • • Note: A claim is considered "eligible" when the ICD 9 and/or the CPT on the claim matches the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification. To qualify for the 2013 PQRS incentive, EPs must choose either three individual measures or one measures group via claims that is relevant to the EPs’ scope of practice.
Steps to avoid Payment reduction • Eligible Providers (EPs) 1. 2. 3. Meet requirements for satisfactorily reporting as defined in the 2013 PQRS measure specifications (same criteria as 2013 PQRS incentive eligibility). Report at least one valid measure via claims, participating registry, or participating/qualified EHR OR one valid measures group via claims or registry, regardless of incentive eligibility. Elect to participate in the administrative claims reporting mechanism July 15, 2013 through October 15, 2013.
Steps to avoid Payment reduction • Registered Groups (PQRS GPRO) 1. 2. 3. Meet the requirements for satisfactorily reporting to earn the 2013 PQRS incentive payment. Report at least one valid measure through the Web Interface (available to PQRS GPROs with 25+ EPs), OR through a registry Register to participate as a PQRS GPRO and elect the administrative claims reporting mechanism July 15, 2013 through October 15, 2013.
Avoiding Penalties in 2015 • • Must take action before the end of CY 2013 Submit at least one Quality Data Code (QDC) Submission must be done before Dec 31st, 2013 − Submit QDC on eligible Part B claim − • The PQRS registration system closed on October 15, 2013, but can be accessed at https://portal.cms.gov. The system requires an account number, which can be acquired at https://applications.cms.hhs.gov. − Additional information is available at the Self Nomination/Registration web page. −
Quality Data Codes • Quality measure No. 130 QDC G8427. Current medications documented − QDC G8430. Current medications not documented − • Quality measure No. 173 − • QDC 3016F: Patient screened for unhealthy alcohol use using a systematic screening method Quality measure No. 226 QDC 4004F: Patient screened for tobacco use AND received tobacco cessation intervention − QDC 1036F: Current tobacco non-user; patient screened for tobacco use and Identified as a nonuser of Tobacco −
Summary • • PQRS here to stay Lack of action will result in payment reduction − • • Different options for individual EPs vs Groups Measures and Methods of reporting changes annually − • Immediate action require before Dec 31, 2013 Specific measures based on specialty Alternative reporting methods available
Resources • Reporting requirements http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS. • Reporting 2013 PQRS through a registry http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Registry-Reporting.html. • Self-nomination/registering to report 2013 PQRS as a group http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html. • PQRS payment adjustment http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Payment-Adjustment-Information.html.
Physician Quality Reporting System (PQRS) www.tainoconsultants.com Dr. Jose I. Delgado Dec 2013

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Physician quality reporting system (pqrs)

  • 1. Physician Quality Reporting System (PQRS) Dr. Jose I. Delgado Taino Consultants Inc. www.tainoconsultants.com
  • 2. Introduction • • • PQRS is a program designed to promote reporting of quality information by eligible professionals (EPs). Program uses financial incentives to promote participation − 2013 & 2014 incentive is 5% increase − 2015 incentive is 1.5% reduction − 2016 incentive is 2% reduction Program applies exclusively to Medicare EPs
  • 3. Background Created in March 2007 as required by the 2006 Tax Relief and Health Care Act (TRHCA). • The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) extended the incentive payment for 2008 and 2009 PQRI . • The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) made the PQRI program permanent, with incentive payments authorized through 2010. • In 2011, the Affordable Care Act (ACA) renamed the program the Physician Quality Reporting System (PQRS). •
  • 4. Eligible Professionals (EPs) 1 of 3 • Medicare physicians − − − − − − − Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic
  • 5. Eligible Professionals (EPs) 2 of 3 • Practitioners − − − − − − − − − − − Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant) Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists *Includes Advanced Practice Registered Nurse (APRN)
  • 6. Eligible Professionals (EPs) 3 of 3 • Therapists Physical Therapist − Occupational Therapist − Qualified Speech-Language Therapist −
  • 7. Exceptions • • Eligible Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level Services payable under fee schedules or methodologies other than the Medicare Physician Fee Schedule (PFS) are not included in PQRS
  • 8. Participation Requirement • Individual EPs do not need to register − • Incentive payment requires that EPs meet the criteria for satisfactory reporting Group Practice Reporting Option (GPRO) − Must register to participate in PQRS GPRO
  • 9. Group Practice Reporting Option (GPRO) “Group Practice" Single Tax Identification Number (TIN) − 2 or more individual EPs participating − Have reassigned their billing rights to the TIN − Note: EPs may select group or individual reporting; however, the trend to report as individual eligible professionals is higher due to the increase choice in reporting mechanisms.
  • 10. Electronic Submission Option for PQRS • Report chosen quality measures by submitting Quality Data Codes (QDC’s) that correspond to selected measures on an eligible billing claim form (such as Medicare 1500). • • Note: A claim is considered "eligible" when the ICD 9 and/or the CPT on the claim matches the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification. To qualify for the 2013 PQRS incentive, EPs must choose either three individual measures or one measures group via claims that is relevant to the EPs’ scope of practice.
  • 11. Steps to avoid Payment reduction • Eligible Providers (EPs) 1. 2. 3. Meet requirements for satisfactorily reporting as defined in the 2013 PQRS measure specifications (same criteria as 2013 PQRS incentive eligibility). Report at least one valid measure via claims, participating registry, or participating/qualified EHR OR one valid measures group via claims or registry, regardless of incentive eligibility. Elect to participate in the administrative claims reporting mechanism July 15, 2013 through October 15, 2013.
  • 12. Steps to avoid Payment reduction • Registered Groups (PQRS GPRO) 1. 2. 3. Meet the requirements for satisfactorily reporting to earn the 2013 PQRS incentive payment. Report at least one valid measure through the Web Interface (available to PQRS GPROs with 25+ EPs), OR through a registry Register to participate as a PQRS GPRO and elect the administrative claims reporting mechanism July 15, 2013 through October 15, 2013.
  • 13. Avoiding Penalties in 2015 • • Must take action before the end of CY 2013 Submit at least one Quality Data Code (QDC) Submission must be done before Dec 31st, 2013 − Submit QDC on eligible Part B claim − • The PQRS registration system closed on October 15, 2013, but can be accessed at https://portal.cms.gov. The system requires an account number, which can be acquired at https://applications.cms.hhs.gov. − Additional information is available at the Self Nomination/Registration web page. −
  • 14. Quality Data Codes • Quality measure No. 130 QDC G8427. Current medications documented − QDC G8430. Current medications not documented − • Quality measure No. 173 − • QDC 3016F: Patient screened for unhealthy alcohol use using a systematic screening method Quality measure No. 226 QDC 4004F: Patient screened for tobacco use AND received tobacco cessation intervention − QDC 1036F: Current tobacco non-user; patient screened for tobacco use and Identified as a nonuser of Tobacco −
  • 15. Summary • • PQRS here to stay Lack of action will result in payment reduction − • • Different options for individual EPs vs Groups Measures and Methods of reporting changes annually − • Immediate action require before Dec 31, 2013 Specific measures based on specialty Alternative reporting methods available
  • 16. Resources • Reporting requirements http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS. • Reporting 2013 PQRS through a registry http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Registry-Reporting.html. • Self-nomination/registering to report 2013 PQRS as a group http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html. • PQRS payment adjustment http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Payment-Adjustment-Information.html.
  • 17. Physician Quality Reporting System (PQRS) www.tainoconsultants.com Dr. Jose I. Delgado Dec 2013