PQRS reporting in 2016 and what the College is doing to help

The Centers for Medicare & Medicaid Services (CMS) recently released revised guidelines for 2016 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. This article addresses concerns surgeons may have regarding PQRS, including penalties for nonparticipation and changes in reporting requirements for 2016 PQRS, and directs readers to American College of Surgeons (ACS) resources designed to help surgeons successfully participate in the program.

Program penalties in 2018

Eligible professionals (EPs) who do not participate in PQRS in 2016 may be subject to a –6 percent payment adjustment in 2018. This reduction is the total penalty resulting from payment adjustments for nonparticipation in PQRS and the effects on the value-based payment modifier (VM), which, in part, hinges on PQRS participation. Following are the breakdowns of potential penalties for each program.

PQRS

PQRS is a pay-for-reporting program. As required under the Affordable Care Act, individual providers and groups that fall short of meeting the PQRS requirements in 2016 will be penalized in 2018. The penalty in 2018 for unsatisfactory participation in PQRS is –2 percent of the total allowed charges for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period.

VM

The VM program provides either bonus payments, penalties, or a neutral adjustment to a physician’s Medicare fee-for-service (FFS) payments based on their performance on a composite of cost and quality measures. To avoid an automatic 2018 VM penalty, surgeons must satisfactorily participate in PQRS in 2016. Failure to successfully participate in the 2016 PQRS program may result in a penalty of up to –4 percent under the VM, in addition to the –2 percent penalty associated with the PQRS. However, even with successful participation in PQRS, surgeons may face the –4 percent penalty based on their cost and quality measures.

PQRS changes from 2015 to 2016

CMS released the Medicare physician fee schedule (MPFS) final rule for calendar year (CY) 2016 on October 30, 2015. This rule makes minimal changes to the PQRS program; however, CMS did finalize one noteworthy change. Groups registered to participate using the group practice reporting option (GPRO) now have the ability to report using a qualified clinical data registry (QCDR).

2016 PQRS reporting options

Surgeons may report as either an individual or as part of a group. In 2016, five reporting options are available to individual surgeons, which are listed in Table 1.* Group practices that register to participate in PQRS using the GPRO may report using one of five options listed in Table 2.*

 

Table 1. Individual reporting requirements for 2018 PQRS payment adjustment

Reporting period Measure type Reporting mechanism Satisfactory reporting/
satisfactory participation criteria
12-month (January 1– December 31 Individual measures Claims Report at least 9 measures covering at least 3 of the NQS domains and report each measure for at least 50 percent of the EP’s Medicare Part B fee-for-service (FFS) patients seen during the reporting period to which the measure applies. Of the measures reported, if the EP sees at least 1 Medicare patient in a face-to-face encounter, the EP will report on at least 1 measure contained in the PQRS cross-cutting measure set. If fewer than 9 measures apply to the EP, the EP would report on each measure that is applicable, and report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.
12-month (January 1–
December 31)
Individual measures Qualified registry Report at least 9 measures covering at least 3 of the NQS domains and report each measure for at least 50 percent of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Of the measures reported, if the EP sees at least 1 Medicare patient in a face-to-face encounter, the EP will report on at least 1 measure contained in the PQRS cross-cutting measure set. If fewer than 9 measures apply to the EP, the EP would report on each measure that is applicable, and report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.
12-month (January 1– December 31) Individual measures Direct electronic health record (EHR) product or EHR submission vendor product Report 9 measures covering at least 3 of the NQS domains. If an EP’s direct EHR product or EHR data submission vendor product does not contain patient data for at least 9 measures covering at least 3 domains, then the EP would be required to report all of the measures for which there is Medicare patient data. An EP would be required to report on at least 1 measure for which there is Medicare patient data.
12-month (January 1– December 31) Measures groups Qualified registry Report at least 1 measures group and report each measures group for at least 20 patients, the majority (11) of which are required to be Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent performance rate will not be counted.
12-month (January 1– December 31) Individual PQRS measures and/or non-PQRS measures reportable via a QCDR QCDR Report at least 9 measures available for reporting under a QCDR covering at least 3 of the NQS domains, and report each measure for at least 50 percent of the EP’s patients. Of these measures, the EP would report on at least 2 outcome measures, or, if 2 outcomes measures are not available, report on at least 1 outcome measures and at least 1 of the following types of measures: resource use, patient experience of care, efficiency/appropriate use, or patient safety.

Note: Individual reporting criteria for the satisfactory reporting of quality measures data via claims, qualified registry, EHRs, and satisfactory participation criterion in QCDRs.

 

Table 2. Group practice reporting requirements for 2018 PQRS payment adjustment

Reporting period Group practice size Measure
type
Reporting mechanism Satisfactory reporting/
satisfactory participation criteria
12-month
(January 1–December 31)
25–99 EPs that elect Consumer Assessment for Healthcare Providers and Systems (CAHPS) for PQRS; 100+ EPs (if CAHPS for PQRS applies) Individual GPRO measures in the Web Interface + CAHPS for PQRS Web Interface + CMS-certified survey vendor The group practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified survey vendor. In addition, the group practice must report on all measures included in the Web Interface and populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order that they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is fewer than 248, then the group practice must report on 100 percent of assigned beneficiaries. A group practice will be required to report on at least 1 measure for which Medicare patient data are available. If the CAHPS for PQRS survey is applicable to a group practice that reports quality measures via the Web Interface, the group practice must administer the CAHPS for PQRS survey in addition to reporting the Web Interface measures.
12-month
(January 1– December 31)
2–99 EPs; 100+ EPs (if CAHPS for PQRS does not apply) Individual measures Qualified registry Report at least 9 measures, covering at least 3 NQS domains. Of these measures, if a group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice would report on at least 1 measure in the PQRS cross-cutting measure set. If fewer than 9 measures covering at least 3 NQS domains apply to the group practice, the group practice would report on each measure that is applicable to the group practice and report each measure for at least 50 percent of the group’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.
12-month
(January 1– December 31)
2–99 EPs that elect CAHPS for PQRS; 100+ EPs (if CAHPS for PQRS applies) Individual measures + CAHPS for PQRS Qualified registry + CMS-certified survey vendor The group practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified survey vendor, and report at least 6 additional measures, outside of the CAHPS for PQRS survey, covering at least 2 of the NQS domains using the qualified registry. If fewer than 6 measures apply to the group practice, the group practice must report on each measure that is applicable. Of the additional measures that must be reported in conjunction with reporting the CAHPS for PQRS survey measures, if any EP in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group must report on at least 1 measure in the PQRS cross-cutting measure set.
12-month
(January 1– December 31)
2–99 EPs; 100+ EPs (if CAHPS for PQRS does not apply) Individual measures Direct EHR product or EHR data submission vendor product Report 9 measures covering at least 3 domains. If the group practice’s direct EHR product or EHR data submission vendor product does not contain patient data for at least 9 measures covering at least 3 domains, then the group practice must report all of the measures for which Medicare patient data are available. A group practice must report on at least 1 measure that includes Medicare patient data.
12-month (January 1– December 31) 2–99 EPs that elect CAHPS for PQRS; 100+ EPs (if CAHPS for PQRS applies) Individual measures + CAHPS for PQRS Direct EHR product or EHR data submission vendor product + CMS-certified survey vendor The group practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified survey vendor and report at least 6 additional measures, outside of CAHPS for PQRS, covering at least 2 of the NQS domains using the direct EHR product or EHR data submission vendor product. If fewer than 6 measures apply to the group practice, it must report all of the measures for which Medicare patient data are available. Of the additional 6 measures that must be reported in conjunction with reporting the CAHPS for PQRS survey measures, a group practice would be required to report on at least 1 measure for which Medicare patient data are available.
12-month
(January 1–
December 31)
2+ EPs Individual PQRS measures and/or non-PQRS measures reportable via a QCDR QCDR Report at least 9 measures available for reporting under a QCDR covering at least 3 NQS domains and report each measure for at least 50 percent of the group practice’s patients. Of these measures, the group practice would report on at least two outcome measures or, if 2 outcomes measures are not available, report on at least 1 outcomes measure and at least 1 of the following types of measures—resource use, patient experience of care, efficiency/appropriate use, or patient safety.

Note: Group practice reporting criteria for satisfactory reporting of quality measures data via the GPRO.

 

Surgeons can use the 2016 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures to identify measures that are applicable for routine professional services. They should select the measures based upon prevalence and volume in their practice.

The ACS encourages individual surgeons to report General Surgery Measures Group data. This requires reporting on a minimum of 20 patients, at least 11 of whom should be Medicare Part B beneficiaries. Surgeons who choose this option must report on all seven measures listed in Table 3.

 

Table 3. Measures included in the 2016 General Surgery Measures Group

Measure number 2016 PQRS General Surgery Measures Group NQS domain

130

Documentation of current medications in the medical record II. Patient safety

226

Preventive care and screening: Tobacco use: Screening and intervention IV. Community/population health

354

Anastomotic leak II. Patient safety

355

Unplanned reoperation within the 30-day postoperative period II. Patient safety

356

Unplanned hospital readmission within 30 days of principal procedure VI. Effective clinical care

357

Surgical site infection VI. Effective clinical care

358

Patient-centered surgical risk assessment and communication I. Person and caregiver-centered experience and outcomes

 

ACS resources for PQRS reporting

The ACS has two registries that can be used for PQRS reporting. The ACS Surgeon Specific Registry (SSR) can be used to comply with regulatory requirements, including participation in PQRS. The SSR was approved by CMS as a registry for 2015 PQRS, and is pending approval for 2016.

The SSR allows individual surgeons to report on the following:

  • The PQRS General Surgery Measures Group
  • 2016 PQRS individual measures
  • 2016 SSR QCDR: Trauma Measures Option

Surgeons will have until January 31, 2017, to submit CY 2016 patient information in the SSR, which will then submit the PQRS data to CMS.

CMS also has approved the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as a QCDR for PQRS 2015; approval for 2016 was pending at press time. MBSAQIP participants will have the opportunity to voluntarily elect that their MBSAQIP QCDR quality measures results be submitted to CMS for PQRS participation.

MAV process

In addition, the PQRS Measure-Applicability Validation (MAV) process, instituted in 2014, takes effect when surgeons who participate in the individual claims or traditional registry-based measures reporting options report on fewer than nine measures, fewer than three National Quality Strategy (NQS) domains, or fail to report on a cross-cutting measure. This process does not apply to measures groups; surgeons who choose to report on the measures group are expected to report on all seven measures in the group for at least 20 patients.

The MAV process uses a clinical relation/domain test to determine whether a surgeon should have reported on additional measures or domains. The clinical relation/domain test is rooted in the concept that if one measure in a cluster of measures related to a particular clinical topic or service is applicable to a surgeon’s practice, then other clinically related measures within the clinical cluster may also be applicable. For example, a surgeon who reported on one measure in a clinical cluster of three measures would be expected to report on the other two measures in the cluster for 50 percent of applicable patients to avoid a penalty. Only measures found within a clinical cluster will trigger a MAV analysis, and not all measures are associated with a cluster.

If CMS determines that a surgeon could not have reported additional measures, the surgeon will be able to avoid the 2018 payment adjustment. If, however, CMS determines that a surgeon should have submitted additional measures or domains, a penalty will be applied in 2018.

Additional background information and PQRS resources are available on the ACS website. If you have questions regarding PQRS, contact Molly Peltzman, Quality Associate, ACS Division of Advocacy and Health Policy, at mpeltzman@facs.org.


*Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the Physician Fee Schedule and other revisions to Part B for CY 2016. Federal Register. Available at: www.federalregister.gov/articles/2015/11/16/2015-28005/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Accessed February 16, 2016.

Centers for Medicare & Medicaid Services. 2016 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process for Registry-Based Reporting of Individual Measures. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2016_PQRS_MAV_ProcessforRegistryBasedReporting_121815.pdf. Accessed February 29, 2016.

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