The Physician Quality Reporting System (PQRS) originated in 2007 as a voluntary program. It was the first Centers for Medicare & Medicaid Services (CMS) initiative to link the reporting of quality data to physician payment. Calendar year (CY) 2014 was the last year that eligible professionals (EPs) and group practices could receive incentive payments for participating in the program. Beginning in 2015, the PQRS program has moved into a penalty-only phase. EPs who do not participate in the program in CY 2015 will face a 2 percent payment reduction that will be applied to their Medicare Part B fee-for-service (FFS) payments in CY 2017. The penalty will continue at 2 percent in future years.
In addition to the PQRS penalty for nonparticipation, EPs and group practices will be subject to an additional 2 percent or 4 percent penalty, depending on their group size, due to the value-based payment modifier (VM). The VM provides for differential payment to a physician or group of physicians under the Medicare physician fee schedule based on the quality of care furnished compared with cost during a performance period.* Thus, the VM program hinges on successful PQRS participation. Table 1 shows the future penalties for the PQRS and VM programs.
Table 1. PQRS and VM Future Penalties*
This article discusses the changes to the PQRS program in 2015, as well as options available for surgeons who are seeking to avoid the PQRS and VM penalties.
2015 PQRS reporting options
There are several ways that surgeons can participate in the PQRS program. Surgeons, whether they are individual practitioners or part of a group practice, may report individually and choose one of the methods from the “EP Reporting Options” listed in the figure below. EPs can participate individually in the PQRS program through one of four methods: claims-based reporting, traditional registry-based reporting, qualified clinical data registry (QCDR)-based reporting, or electronic health records (EHR)-based reporting. A detailed description of each option is provided in the next section.
2015 PQRS for individual EPs
Surgeons who are part of a group should note that group practices also may collectively report PQRS data by selecting a reporting method from the group practice reporting option (GPRO) listed in the document available on the CMS website.† Groups interested in using the GPRO must send a request to CMS by June 30, 2015. Groups must receive CMS approval to report to PQRS via the GPRO. Surgeons who are part of a group practice but would like to report individually should call the CMS QualityNet Help Desk at 1-866-288-8912 to ensure that their institution has not already enrolled them for the GPRO.
Note that this column focuses on the individual EP reporting options. Successful compliance with any of the appropriate reporting options will allow EPs and GPROs to avoid the 2015 PQRS penalty of 2 percent and to potentially avoid the VM penalties of 2 percent or 4 percent.
PQRS options for individuals
Claims-based reporting option
The claims-based reporting option for 2015 requires EPs to report nine PQRS measures covering a minimum of three National Quality Strategy (NQS) domains for at least 50 percent of the Medicare Part B FFS patients to whom they provided care from January 1 to December 31, 2015. Of these nine measures, one must be from a list of what CMS defines as cross-cutting measures. These are broadly applicable measures that apply to many specialties.
Three individual claims-based measures are directly relevant to surgery:
- #21 Perioperative Care: Selection of Prophylactic Antibiotic—First or Second Generation Cephalosporin
- #22 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac procedures)
- #23 Perioperative Care: Venous Thromboembolism Prophylaxis (when indicated in all patients)
Reporting on these three measures will satisfy three of the nine measures required for claims-based reporting and will cross only one NQS domain—patient safety. Therefore, EPs will need to report on six additional PQRS measures that cross two additional NQS domains and include one cross-cutting measure to satisfy the claims-based reporting option.
Traditional registry-based reporting option
To use the traditional registry-based reporting option for PQRS reporting, EPs must participate through a CMS-approved registry. CMS typically publishes a list of approved registries in the spring. The American College of Surgeons (ACS) Surgeon Specific Registry (SSR) has been an approved PQRS registry in previous years and is awaiting CMS approval for PQRS reporting in 2015. The ACS will inform Fellows of the SSR’s approval status via ACS NewsScope and the SSR website.
EPs can report through the registry-based reporting option in one of two ways. One way is to report on individual measures, and the other is to report on measures groups. Note that reporting on either individual measures or measures groups simply refers to the way a provider or group decides to report measures for PQRS, and this terminology should not be confused with reporting measures as an individual EP or as group practice reporting via the GPRO.
EPs reporting through the individual measures reporting option are required to report on nine PQRS measures covering at least three NQS domains for at least 50 percent of their Medicare Part B FFS patients seen January 1 through December 31, 2015. Of these nine measures, one must be from the cross-cutting measures list referenced earlier. Although the requirement for reporting individual measures through a registry is similar to that of the claims-based reporting option, unlike claims-based reporting where cases must be submitted actively on claims, in a registry EPs can retroactively enter PQRS information on qualifying cases.
EPs who report through the measures group reporting option are required to select one measures group and report on 20 cases—at least 11 cases of which must be Medicare patients. EPs should review the list of allowed procedures for the measures group that they select and identify 20 patients. For surgeons, there is one relevant measures group for 2015: the General Surgery Measures Group. In previous years, the Perioperative Care Measures Group was also available for surgeons to report on, but this group has been removed from PQRS 2015. However, some of the measures (noted earlier) from the Perioperative Care Measures Group can be reported individually through claims or the registry-based individual reporting option.
For CY 2015, the General Surgery Measures Group consists of seven measures, shown in Table 2 with the PQRS measure numbers.
Table 2. 2015 PQRS General Surgery Measures Group
*New for 2015
Two new measures, #130 and #226, have been added to the group for 2015. Table 3 below has a list of the 2015 PQRS procedures approved for the General Surgery Measures Group. Surgeons must carefully read the specification for measures #354, #355, #356, #357, #358, #130, and #226 to ensure that they can report on the applicable PQRS measures within the group on each of the 20 (majority Medicare) patients from January 1 through December 31, 2015. It is particularly important to note the specifications for measure #354, as it should only be reported if a patient has a procedure performed specific to gastric bypass surgery or colectomy. The measure specifications for the General Surgery Measures Group can be found on pages 337–354 of the CMS Measure Group Manual.‡
Table 3. 2015 procedures allowed for General Surgery Measures Group*
*Centers for Medicare & Medicaid Services. 2015 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual. Available at: www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_MeasuresGroupsSpecs_SupportingDocs_111214.zip. Accessed January 22, 2015.
EHR-based reporting option
In order to participate via the EHR-based reporting option, EPs need to submit nine measures covering at least three NQS domains. EPs should work with their EHR vendor to make sure that the EHR system can submit data on the PQRS-approved electronic measures for CY 2015.
QCDR reporting option
The qualified clinical data registry (QCDR) is a CMS-approved entity that collects clinical data for the purpose of patient and disease tracking to improve quality of care provided to patients with specific health care conditions. The QCDR reporting option allows entities approved as a QCDR to determine their own quality measures; therefore, EPs who participate in the QCDR are not required to report on traditional PQRS measures. In comparison with traditional PQRS measures, QCDR measures are intended to be more relevant, clinically appropriate, and actionable for EPs who are participating in a clinical data registry.
Similar to traditional registries, QCDRs must also receive CMS approval. CMS will publish a list of approved QCDRs, likely in the spring. The ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was approved as a QCDR in CY 2014 and, at press time, was awaiting CMS approval for CY 2015.
EPs interested in participating in PQRS through a CMS-approved QCDR must report at least nine individual measures, including at least two outcome measures (or, in lieu of two outcome measures, at least one outcome measure and one of the following other types of measures—resource use, patient experience of care, efficiency/appropriate use, or safety), covering at least three NQS domains, and report each measure for at least 50 percent of their applicable patients (Medicare and non-Medicare) January 1 through December 31, 2015.
The VM’s effect on surgeons
For 2015, surgeons may be subject to an additional penalty under VM, which will also be applied to their Medicare Part B FFS payments in CY 2017. The VM program provides incentives or penalties based on CMS’ analysis of a provider’s cost and quality. PQRS reporting satisfies part of the quality component of the VM determination.
Essentially, payment penalty amounts differ based on group size, successful or unsuccessful PQRS participation, and performance. For example, in 2015, solo practitioners and groups of up to nine providers who unsuccessfully report to the PQRS will be subject to a 2 percent penalty under the PQRS program and an additional 2 percent penalty under the VM. Penalties will be applied to these providers in CY 2017. If a surgeon belongs to a group practice of 10 or more practitioners in 2015, and that group does not participate in one of the PQRS GPRO mechanisms referenced previously, or if 50 percent of that group does not participate in PQRS via one of the individual reporting options listed in the figure above, this surgeon will receive a 2 percent penalty under the PQRS program and an additional 4 percent penalty under the VM in CY 2017. Hence, participating in the PQRS program in CY 2015 is imperative to avoid significant payment penalties.
Resources for surgeons
As reporting requirements and penalties for the CMS quality programs increase, the ACS continues to create tools and resources to assist surgeons in their efforts to comply with program requirements. Pending CMS approval, the ACS will have two registries that support 2015 PQRS reporting—the ACS SSR and the MBSAQIP.
Additionally, Fellows are encouraged to use CMS feedback tools to improve their participation in quality programs. CMS publishes annual Quality and Resource Use Reports (QRURs) that contain quality data based on PQRS reporting plus information on resource use by applying the measures and benchmarks that CMS has selected for the VM. QRURs are available as a resource to assist EPs and group practices to improve their performance on quality and resource-use measures.
*Centers for Medicare & Medicaid Services. Summary of 2015 physician value-based payment modifier policies. Available at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf. Accessed February 10, 2015.
†Centers for Medicare & Medicaid Services. Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) 2015 Criteria January 2015. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_GPRO_Criteria.pdf. Accessed February 10, 2015.
‡Centers for Medicare & Medicaid Services. License for use of Current Procedural Terminology, Fourth Edition. Available at: www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_MeasuresGroupsSpecs_SupportingDocs_111214.zip. Accessed February 10, 2015.