Revenue Cycle Management Blog | GroupOne Health Source

Should You Be Participating In PQRS?

Written by Jeff Jones, CPHP | March 29, 2016


For the first few years of PQRS, practices were eligible for incentive payments for PQRS reporting. In 2015, however, EPs that did not report on specific quality measures are facing downward adjustments to Medicare payments in 2017. Here's how you know whether you should be participating in PQRS (if you aren't already).
 

What is PQRS?

The Physician Quality Reporting System (PQRS) was implemented under the Tax Relief and Health Care Act of 2006 and originally called the Physician Quality Reporting Initiative (PQRI). The program attempts to decrease costs and improve quality by linking physician payments to performance.

As of 2015, penalties are being assessed for non-participation in PQRS. EPs who do not participate in 2016 (performance year) are subject to an automatic -2% negative payment adjustment in 2018 (payment year). These EPs will also automatically fail the Value-based Modifier program because VBM is based on PQRS data. This results in either a -2% or -4% penalty (depending on group size). This means the penalty for non-participation in PQRS is -4% to -6%, depending on group size.

If an EP does submit PQRS data then they will avoid the automatic -2% penalty for non-participation but they will then be subject to the Value-Based Modifier program which provides positive, neutral, or negative payments based upon the quality of care furnished compared to cost during a performance period. Stay tuned for more about the VBM program by subscribing to our blog, as we will be releasing blog posts dedicated to that soon.

Who’s Eligible for PQRS?

To be eligible for PQRS the provider must have a National Provider Identifier number (NPI) and a Tax Identification Number (TIN). Under PQRS, an eligible professional (EP) is defined as one of the following types of professionals:

  • Medicare physicians
    • Doctor of Medicine
    • Doctor of Osteopathy
    • Doctor of Podiatric Medicine
    • Doctor of Optometry
    • Doctor of Oral Surgery
    • Doctor of Dental Medicine
    • Doctor of Chiropractic
  • Practitioners
    • Physician Assistant
    • Nurse Practitioner*
    • Clinical Nurse Specialist *
    • Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant)
    • Certified Nurse Midwife*
    • Clinical Social Worker
    • Clinical Psychologist
    • Registered Dietician
    • Nutrition Professional
    • Audiologists

*Includes Advanced Practice Registered Nurse (APRN)

  • Therapists
    • Physical Therapist
    • Occupational Therapist
    • Qualified Speech-Language Therapist

[Also: View the 2015-2017 PQRS Timeline with Milestone Dates]

Eligible and Able for PQRS

Even if an EP is eligible they may not be able to participate. Eligible and able participants are those EPs that render services based on the Medicare Physician Fee Schedule (MPFS).

Eligible but Not Able for PQRS

“EPs who bill Medicare Part B services, but do not fall into the denominator for any measures are not able to report PQRS. Additionally, some EPs may not be able to participate due to their billing methodologies” (CMS PQRS List of EPs 2016).

Here are some examples of eligible but not able EPs:

  • If the EP does not bill services payable under the MPFS. This would mean the EP renders services under an organization that is registered as a federally qualified health center (FQHC) and only bills professional services that are payable under the FQHC methodology.
  • If the EP does not submit individual rendering National Provider Identifier (NPI). This means that the EP is not billing Medicare at an individual NPI level, where the rendering provider’s NPI is entered on the professional or institutional form associated with specific line-item services.

-Organizations that fall into this category are Independent Diagnostic Testing Facilities (IDTF) and Independent Laboratories (IL) and as such, would not be subject to the PQRS payment adjustment

  • The EP provides Part B services but bills Medicare at a facility or institutional (Medicare Part A) level
  • The EP reassigns benefits to a Critical Access Hospital (CAH) that bills outpatient services at a facility level
  • Any services that are payable under fee schedules or methodologies other than the PFS are not included in PQRS

If you need assistance determining whether or not you render services under Part B MPFS via the CMS-1500 or 1450 claim form, or the electronic equivalent, contact your Medicare Administrative Contractor (MAC). For MAC contact information, see the Review Contractor Directory.

Not Sure if you are eligible and able?

If you need assistance determining whether or not you render services under Part B MPFS via the CMS-1500 or 1450 claim form, or the electronic equivalent, contact your Medicare Administrative Contractor (MAC). For MAC contact information, see the Review Contractor Directory.

How to Start Participating

Submitting claims-based reporting data with your clinical billing and/or submitting PQRS participation data through a certified registry automatically indicates a provider is participating.

There is a registration process for those who intend to participate through the Group Practice Reporting Option (GPRO). To learn more about GPRO registration, please visit the CMS GPRO resources page.