Revenue Cycle Management Blog | GroupOne Health Source

Avoiding 2015 PQRS Payment Adjustments

Written by Kaitlyn Houseman | March 29, 2013

Purpose

This article provides information on the 2015 PQRS payment adjustment and guidance on how individual eligible professionals and group practices can avoid the 2015 PQRS payment adjustment. Information provided in this article is based on the 2013 Medicare PFS Final Rule.
This article focuses on the PQRS payment adjustment and does not provide guidance for Value-Based Payment Modifier upward adjustment or payment adjustments from other Medicare sponsored programs. See the Additional Information section below for links to the CMS Value-Based Payment Modifier website, and the Medicare and Medicaid EHR Incentive Program website.

Background

Section 1848(a)(8) of the Social Security Act, requires the Centers for Medicare & Medicaid Services (CMS) to subject eligible professionals and group practices who do not report data on Physician Quality Reporting System (PQRS) quality measures for covered professional services during the 2013 program year for a payment adjustment beginning in 2015. Eligible professionals and group practices receiving a PQRS payment adjustment in 2015 will be paid 1.5% less than the PFS amount for services rendered January 1-December 31, 2015.
The applicable percent for payment adjustments under PQRS are as follows:

  • 1.5% adjustment in 2015 (eligible professional will receive 98.5% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services)
  • 2.0% adjustment in 2016 and subsequent years (eligible professional will receive 98% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services)

2015 PQRS Payment Adjustment Eligibility

Those providers considered eligible and able to participate in PQRS as outlined on the CMS PQRS website could be subject to the 2015 PQRS payment adjustment. Eligible professionals working for more than one organization need to meet the reporting criteria for each tax identification number (TIN) under which (s)he works during the 2013 PQRS program year to avoid the 2015 PQRS payment adjustment for each TIN. Those groups who self-nominate or register to participate in PQRS as a group through the group practice reporting option (GPRO) or participate as an ACO GPRO will be analyzed at the TIN level; therefore, all providers under that TIN who bill Medicare Part B PFS will be included in analysis for purposes of the 2015 PQRS payment adjustment.

Exclusion Criteria for Individual Eligible Professionals

Individual eligible professionals (regardless of participation in other CMS incentive programs) will avoid the 2015 PQRS payment adjustment if one of the payment adjustment criteria (listed in Table 1) is met during the 2013 PQRS program year, January 1-December 31, 2013.

Individual Eligible Professionals

Meet the requirements for satisfactorily reporting for incentive eligibility as defined in the 2013 PQRS Measure Specifications (same criteria as 2013 PQRS incentive eligibility as shown in Appendix 2)
Report at least one valid measure via claims, registry, or qualified Electronic Health Record (EHR, including data submission vendors and direct EHRs)
OR
Report at least one valid measures group via claims or registry
Elect to participate in the administrative claims-based reporting mechanism by October 15, 2013
Details on how to choose this option will be made available in 2013

Note: CMS will determine whether an individual eligible professional (defined by individual rendering National Provider Identifier, or NPI) is subject to the 2015 PQRS payment adjustment for each TIN. The PQRS 0% performance rule only applies to satisfactorily reporting for incentive eligibility.

Exclusion Criteria for Registered Groups (ACO/PQRS GPRO)

Group practices participating in GPRO (regardless of participation in other CMS incentive programs) will avoid the 2015 PQRS payment adjustment if one of the payment adjustment criteria (listed in Table 2) is met during the 2013 PQRS program year, January 1-December 31, 2013.

Table 2: 2013 Registered Groups - Criteria for Avoiding the 2015 PQRS Payment Adjustment

Registered Groups

Meet the requirements for satisfactorily reporting for incentive eligibility as defined in the applicable 2013 measure specification (same criteria as 2013 PQRS incentive eligibility as shown in Appendix 2):
  • Report specific ACO/PQRS GPRO measures through the Web Interface based on a pre-populated patient sample, reference the 2013 ACO or PQRS GPRO Web Interface Specification (only available to group practices of 25 or more eligible professionals), OR
  • Report at least 3 registry measures for the PQRS GPRO, reference the 2013 PQRS Measure Specification for Claims/Registry Reporting of Individual Measures (available to all group practices participating in PQRS GPRO, not available to ACO GPRO)

Report at least one valid measure via:

  • Web Interface (only available to group practices of 25 or more eligible professionals), OR
  • Registry (available to all PQRS GPRO group practices; not availble ACO GPRO)
Elect to participate as a group in the administrative claims-based reporting mechanism by October 15, 2013 (not available to ACO GPRO)
  • Details on how to choose this option will be made available in 2013

Note: CMS will determine whether the group practice (defined by TIN) is subject to the 2015 PQRS payment adjustment. The PQRS 0% performance rule only applies to satisfactorily reporting for incentive eligibility. PQRS GPROs are analyzed at the TIN level under the TIN submitted at the time of final self-nomination/registration; therefore, if an organization or eligible professional changes TINs, the participation under the old TIN does not carry over to the new TIN, nor is it combined for final analysis.