PQRS

Physician Quality Reporting System (PQRS)- Program in which eligible professionals report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Patients.

For more information visit: www.cms.gov/pqrs

2013 Physician Quality Reporting System (PQRS)

*No PQRS incentive payments are scheduled past 2014.

Incentive Payments

• Incentive payments for each program year are issued separately as a single consolidated payment for the past years successful reporting.
• The Medicare claims-processing contractors (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 submits claims to multiple 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: The PQRS incentive payment can be offset by an outstanding debt for the TIN.

Payment Adjustments

• For 2015 and subsequent years, a payment adjustment with respect to covered professional services furnished by an eligible professional will be applied if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year.

Applicable adjustment amount:

•  2015: 1.5%, based on reporting year 2013
•  2016 and subsequent years: 2.0%, based on reporting year 2014

• There are 3 ways an individual eligible professional may avoid the 2013 PQRS payment adjustment:

1. Meet the criteria for satisfactory reporting for the 2013 PQRS Incentive
2. Report at least 1 instance of a measure or measures group using the claims, registry, or EHR-based reporting mechanisms
3. Elect to be analyzed under the administrative claims-based reporting mechanism

*Note: If participating in PQRS through another CMS program (such as the Medicare Shared Savings Program), please check the program’s requirements for information on how to simultaneously report under PQRS and the respective program.

• There is 1 way an eligible professional may meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment:

1. Meet the criteria for satisfactory reporting for the 2014 PQRS Incentive

*Note: We may establish additional ways to meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment in future rulemaking.

Reporting Mechanisms

• Electronic Health Record (EHR)
  • Each eligible professional must satisfactorily report on at least THREE measures for at least 80% of eligible instances.

OR

• Claims
  • Each eligible professional must satisfactorily report on at least THREE measures for at least 50% of eligible instances.
    • PQRS code(s) must be selected during the encounter AND listed on the transmitted claim.

Determine Eligibility

• Determine if you are eligible to participate: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/List-of-EPs_PQRS_12-19-2012.pdf

Getting Started (EHR)

• EHR will gather data based on data points within application, create QRDA (Quality Reporting Document Architecture) file and upload to CMS on provider/clinic’s behalf.

*The following PQRS Measures will become available in MEHR for 2013: 53, 112, 163, 237, 309, 310, 311, and 312.

Getting Started (Claims)

• Registration is NOT required
• Decide  which measures to participate in:
  • “2013 Physician Quality Reporting System Measure Specifications Manual  for Claims and Registry” document at  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
• EHR/Billing Set up
• Steps to report measure within EHR (Office Workflow)
• Add PQRS code(s) to claim.
• Review Remits for indication codes (N365) that were submitted

Quick Tips (Claims)

• If all billable services on the claim are denied for payment by the carrier or A/B Medicare Administrative Contractor (MAC), the CPT II codes will not be included in Physician Quality Reporting analysis.
  • If the denied claim is subsequently corrected and paid through an adjustment, re-opening, or the appeals process by the carrier or A/B MAC, with accurate codes that also correspond to the measure’s denominator, then any applicable CPT II codes that correspond to the numerator should also be included on the corrected claim.
  • The Remittance Advice (RA)/Explanation of Benefits (EOB) for the denial code N365 is your indication that the Physician Quality Reporting codes were received into the National Claims History (NCH).
  • Claims may not be resubmitted only to add or correct CPT II codes, and claims with only CPT II codes on them with a zero total dollar amount may not be resubmitted to the carrier or A/B MAC.
  • The N365 denial code is just an indicator that the CPT II codes were received. It does not guarantee the CPT II was correct or that reporting thresholds were met. However, when a CPT II is reported satisfactorily (by the individual eligible provider), the N365 denial code can indicate that the claim will be used in calculating incentive eligibility.
• All claims adjustments, re-openings, or appeals processed by the carrier or A/B MAC must reach the national Medicare claims system data warehouse (NCH file) by February 22, 2013, to be included in the 2012 Physician Quality Reporting analysis.

Need Assistance?

QualityNet Help Desk

7:00 AM – 7:00 PM CT

Phone: 1-866-288-8912

TTY: 1-877-715-6222

Email: qnetsupport@sdps.org

Sign in to our website (www.medisysinc.com) and click on EHR Resources at the top to download material/guides for PQRS.