PQRS reporting in 2014

The Centers for Medicare & Medicaid Services (CMS) released revised guidelines for 2014 participation in the Physician Quality Reporting System (PQRS) program. PQRS is the first CMS-crafted national program to link the reporting of quality data to physician payment. The Affordable Care Act states that eligible professionals (EPs) who successfully participate in the program through 2014 may receive incentive payments. This column addresses concerns surgeons may have regarding PQRS and offers resources for successful participation.

What are the penalties for failure to comply with the PQRS program’s participation requirements?

The incentive payment for the 2014 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. EPs who fall short of meeting the PQRS requirements in 2014 will be penalized in 2016. Table 1 summarizes the payments during these years.

Table 1. PQRS payment incentives and penalties

Calendar year Incentive Penalty*
2014 0.50%
2015 1.50% (based on 2013 performance)
2016 and beyond 2.00% (based on 2014 performance)
*Penalties are applied based on an EP’s performance two years prior to the calendar year.

Did the requirements for PQRS participation change significantly from 2013 to 2014?

CMS released the Medicare physician fee schedule (MPFS) final rule for calendar year (CY) 2014 on November 27, 2013. In the final rule, CMS finalized several significant changes to the PQRS for 2014, which can be found in Table 2.

Table 2. 2014 PQRS changes

2013 PQRS 2014 PQRS
Group practices choosing to participate in the PQRS group practice reporting option (GPRO) were required to submit a self-nomination statement to CMS by October 15, 2013. CMS changed the deadline to submit self-nomination statements for groups choosing to participate in the PQRS GPRO option to September 30, 2014.
To earn the 2013 PQRS incentive, EPs reporting through one of the individual quality measures reporting options must report on three measures for at least 80 percent of the applicable Medicare Part B fee-for-service (FFS) patients. To earn the 2014 PQRS incentive, EPs reporting through one of the individual quality measures reporting options must report on nine measures covering at least three National Quality Strategy (NQS) domains for at least 50 percent of the applicable Medicare Part B FFS patients.
GPROs of 25 or more EPs could report either through the GPRO Web interface or a PQRS-qualified registry. GPROs of 25 or more EPs may report via the registry, Electronic Health Record (EHR), GPRO Web interface, or the new “certified survey vendor” reporting options.
EPs reporting on measure groups could report via the claims or registry reporting option. Surgeons commonly reported on the perioperative measures group in 2013. EPs can only report on a measures group via the registry reporting option. In addition to the perioperative measures group, CMS has also created a new “general surgery” measures group.
EPs had the option of reporting to PQRS through the claims, EHR, or the registry reporting methods. EPs now have the option of reporting through claims, EHR, registry, or the new “qualified clinical data registry” reporting method.

Also of significance, the 2014 PQRS includes 285 quality measures (individual measures) and 25 measures groups. Note that 2013 PQRS quality measures may be continued in the 2014 PQRS, and that measure specifications may have been updated for the new program year. Surgeons who reported PQRS in 2013 should use the following link to review the 2014 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures, which has updates and changes.1 Visit the American College of Surgeons (ACS) PQRS Web page  for more information on the program.

How do I use the measure specifications manual?

Use the 2014 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures to identify measures applicable for professional services that a practice routinely provides. 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.2

How do I report PQRS measures?

There are several ways to report. Table 3 lists the six PQRS 2014 reporting options.3-5 Group practices that are approved by CMS to participate in PQRS as a GPRO can report using one of the five options listed in Table 4.6

Table 3. Summary of requirements for the 2014 PQRS incentive
Individual reporting criteria for satisfactory reporting of individual quality measures via claims, qualified registries, and EHRs and satisfactory participation criterion in qualified clinical data registries3

Reportingperiod Measure type Reporting mechanism Satisfactory reporting criteria/satisfactory participation criterion
12-month(January 1–December 31) Individualmeasures Claims Report at least 9 measures covering at least 3 NQS domains, or, if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains, and report each measure for at least 50% of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate would not be counted.*For an EP who reports fewer than 9 measures covering 3 NQS domains via the claims-based reporting mechanism, the EP will be subject to the claims Measures Applicability Validation (MAV) process, which would allow [CMS] to determine whether an EP should have reported quality data codes for additional measures and/or covering additional NQS domains.4
12-month(January 1–December 31) Individualmeasures Qualifiedregistry Report at least 9 measures covering at least 3 of the NQS domains or, if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains for which there is Medicare patient data, and report each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate would not be counted.*For an EP who reports fewer than 9 measures covering 3 NQS domains via the registry-based reporting mechanism, the EP will be subject to the registry MAV process, which would allow [CMS] to determine whether an EP should have reported on additional measures and/or measures covering additional NQS domains.5
12-month(January 1–December 31) Individualmeasures Direct EHRproduct and data submission vendor Report 9 measures covering at least 3 of the NQS domains. If an EP’s certified EHR technology does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data.An EP must report on at least 1 measure for which there is Medicare patient data.
12-month(January 1–December 31) Measures groups Qualifiedregistry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of which must be Medicare Part B FFS patients.
6-month (July 1–December 31) Measures groups Qualifiedregistry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of which must be Medicare Part B FFS patients.
12-month(January 1–December 31) Measuresselected by qualified clinical data registry Qualifiedclinical dataregistry Report at least 9 measures covering at least 3 NQS domains and report each measure for at least 50% of the EP’s applicable patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate would not be counted. Of the measures reported via a qualified clinical data registry, the EP must report on at least 1 outcome measure.
*Subject to the MAV process for claims-based or registry-based reporting.4,5
Finalized in the CY 2013 PFS final rule (see Table 91 at 77 FR 69194).

Table 4. Summary of final requirements for the 2014 PQRS Incentive
Criteria for satisfactory reporting of data on PQRS quality measures via the GPRO6

Reportingperiod Reporting mechanism Group practice size Proposed reporting criterion
12-month(January 1–December 31) GPRO Web interface 25–99 EPs Report on all measures included in the Web interface, andpopulate data fields for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100% of assigned beneficiaries.
12-month(January 1–December 31) GPRO Web interface 100+ EPs Report on all measures included in the Web interface, and populate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries.In addition, the group practice must report all Clinician and Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) survey measures via certified survey vendor.
12-month (January 1–December 31) Qualifiedregistry 2+ EPs Report at least 9 measures covering at least 3 of the NQS domains, or, if less than 9 measures covering at least 3 NQS domains apply to the group practice, report 1 to 8 measures covering 1 to 3 NQS domains for which there is Medicare patient data. Report each measure for at least 50% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate would not be counted.*For a group practice that reports fewer than 9 measures covering at least 3 NQS domains via the registry-based reporting mechanism, the group practice will be subject to the MAV process, which would allow [CMS] to determine whether a group practice should have reported on additional measures and/or measures covering additional NQS domains.
12-month(January 1–December 31) Direct EHR product that is CEHRTEHR data submission vendor that is CEHRT 2+ EPs Report 9 measures covering at least 3 of the NQS domains. If a group practice’s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the group practice must report the measures for which Medicare patient data are available.A group practice must report on at least 1 measure for which Medicare patient data are available.
12-month (January 1–December 31 CMS-certifiedsurvey vendor+ qualified registry, direct EHR product, EHR data submission vendor, or GPRO Web interface 25+ EPs Report all CG CAHPS survey measures via a CMS-certified survey vendor, and report at least 6 measures covering at least 2 of the NQS domains using a qualified registry, direct EHR product, EHR data submission vendor, or GPRO Web interface.
*Subject to the MAV process for registry-based reporting5
Criteria finalized in the CY 2013 PFS final rule (77 FR 69200).

Additional background information and PQRS resources are available at www.facs.org/ahp/pqrs/. If you have questions regarding PQRS, contact Sana Gokak in the ACS Division of Advocacy and Health Policy at sgokak@facs.org.


References

  1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System measures specifications. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_IndClaimsRegistry_MeasureSpecs_SupportingDocs_12132013.zip. Accessed January 6, 2014.
  2. Centers for Medicare & Medicaid Services. Patient assessment instruments measures codes. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html. Accessed January 6, 2014.
  3. Centers for Medicare & Medicaid Services. Revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Page 802. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014-Physician-Fee-Schedule-Final-Rule_CMS-1600-FC.pdf. Accessed January 6, 2014.
  4. Centers for Medicare & Medicaid Services. Patient assessment instruments claims measure applicability validation. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013.zip. Accessed January 6, 2014.
  5. Centers for Medicare & Medicaid Services. Patient assessment instruments registry-based measure applicability validation. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_12132013.zip. Accessed January 6, 2014.
  6. Centers for Medicare & Medicaid Services. Revisions to payment policies under the physician fee schedule clinical laboratory fee schedule & other revisions to Part B for CY 2014. Page 821. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014-Physician-Fee-Schedule-Final-Rule_CMS-1600-FC. Accessed January 6, 2014.

Tagged as: , , , , , ,

Contact

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