PQRS reporting in 2013

The Centers for Medicare & Medicaid Services (CMS) has continued the Physician Quality Reporting System (PQRS) into 2013 as required under the Medicare Improvements for Patients and Providers Act of 2008. PQRS is the first CMS-crafted national program to link the reporting of quality data to physician payment. The Affordable Care Act authorized incentive payments for eligible professionals (EPs) who successfully participate in the program through 2014.

The incentive payment for the 2013 reporting year is 0.5 percent of the total allowed charges for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period.

For reporting year 2014, EPs may earn an incentive payment of 0.5 percent of their total estimated allowed charges for Medicare Part B physician fee schedule-covered professional services furnished during the respective reporting periods. If EPs are unsuccessful PQRS participants in 2013, they will be subject to a penalty in 2015. Table 1 summarizes the payments during these years.

Table 1. PQRS Payment Incentives and Penalties

Reporting Year Incentive Penalty
2013 0.50% -
2014 0.50% -
2015 - 1.50%
2016 and beyond - 2.00%

What are some of the differences between the requirements in the 2012 PQRS and the 2013 PQRS?

CMS released the Medicare physician fee schedule final rule for calendar year (CY) 2013 on November 1, 2012. In the final rule, CMS finalized several changes to the PQRS for 2013. Major program changes are highlighted in Table 2.

Table 2. 2013 PQRS Changes

2012 PQRS 2013 PQRS
CMS sought to eliminate the distinction between group practice reporting option (GPRO) GPRO I and GPRO II for group practices. The two groups will instead be consolidated such that a group practice GPRO will consist of 25 or more eligible professionals. CMS finalized its proposal to define a group practice as one having a single tax identification number (TIN), with two or more EPs as identified by their individual national provider identification number who have reassigned their Medicare billing rights to the TIN.
CMS required a minimum patient sample of 30 Medicare patients for reporting measure groups via registry and claims. CMS required a minimum patient threshold of 20 patients for reporting measure groups via registry and claims. For reporting measure groups via registry only, 11 of the 20-patient threshold must be Medicare beneficiaries, and the rest can be non-Medicare.
CMS finalized the claims, registry, electronic health records (EHR), and GPRO methods to earn the 2012 PQRS incentive. In addition to retaining the 2012 methods to earn the 2013 PQRS incentive payment, CMS also finalized two additional methods that will help EPs avoid the 2015 PQRS penalty. These two additional methods include the administrative claims reporting option and reporting on one measure or measures group.

It is important to note that the 2013 PQRS includes 259 quality measures (individual measures) and 22 measures that are part of a 2013 measures group. Whereas 2012 PQRS quality measures may be continued in the 2013 PQRS, measure specifications may have been updated for the new program year. Surgeons who are currently reporting in 2012 PQRS should review the 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures for updates and changes. Surgeons can also visit the American College of Surgeons (ACS) PQRS website for more information on the program.

How do I use the measure specifications manual?

The 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures should be used to identify measures applicable for professional services that a practice routinely provides. The manual can be accessed at the CMS website. Next, select those measures that make sense based upon prevalence and volume in the practice, as well as your individual or practice performance analysis and improvement priorities.

How do I report PQRS measures?

There are a number of ways that EPs can report in PQRS 2013 in order to receive an incentive payment and/or avoid the 2015 payment penalty. A matrix that lists all six options for reporting under PQRS 2013 is available. Moreover, the 2013 physician fee schedule also finalized two methods by which EPs can simply avoid the 2015 PQRS penalty without receiving an incentive payment for PQRS 2013. The two methods are outlined in Table 3.

Table 3. 2013 reporting options to avoid 2015 PQRS penalty but not receive 2013 incentive

Administrative claims reporting option Under this option, CMS will analyze each EP’s or group practice’s Medicare claims to determine whether the EP or group has performed any of the clinical quality actions indicated in a specific set of measures.
Alternative reporting option In this method, required data submission must be for at least one applicable patient using any of the available methods (claims, EHR, or registry).

These two options are currently only available for 2013 and are intended for practices that may be overwhelmed with attempting to comply with other reporting programs. Successful PQRS compliance will still be required after 2013, and it is possible that CMS may finalize other reporting methods in future rulemaking.

The ACS has developed useful PQRS resources for surgeons, including the 2013 PQRS flow sheets for claims-based reporting. The flow sheets are categorized by procedure codes relating to various surgical procedures for the perioperative measures set. The perioperative measures set includes measures #20, #21, #22, and #23. This flow sheet provides the corresponding current procedural terminology II code that should be used on the Claims 1500 form as shown in the figure below. The flow sheets should be used as a reference only and should not be submitted to CMS. The flow sheets are available for review. Additional background information regarding the PQRS program can be found on the CMS and ACS websites. If you have questions regarding PQRS, contact Sana Gokak in the ACS Division of Advocacy and Health Policy at sgokak@facs.org.

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Contact

Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611