Revenue Cycle Management Blog | GroupOne Health Source

Understanding PQRS: What It Is and What You Need to Know Now

Written by Jeff Jones, CPHP | April 12, 2016

You could say Meaningful Use stole the spotlight from PQRS over the past couple of years. This could be why so many providers still have questions about the Physician Quality Reporting System. With the Merit Based Incentive Payment System (MIPS) just around the corner, PQRS isn't quite in the spotlight but it does play an important role in physician reimbursement. Now is the time to begin understanding PQRS (if you don't already) and how it will contribute to MIPS.

What is PQRS?

The Physician Quality Reporting Systems (PQRS) is a quality reporting program for providers who participate in Medicare Part B. 

PQRS was implemented under the Tax Relief and Health Care Act of 2006 and originally called the Physician Quality Reporting Initiative (PQRI). PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time.

There is more to PQRS than just assessing the quality of care of patients. PQRS reporting gauges how well medical professionals do their jobs by reducing fraud, optimizing payments, and improving the quality of care.

From 2007 to 2014 incentive payments were available to providers who participated in the program.

However, in 2015 and beyond, in return for successfully reporting quality measures, CMS allowed clinicians to keep 100 percent of their charges included in the Medicare Part B Physician Fee Schedule. If medical professionals did not participate they were subject to a negative penalty adjustment. 

[Also: Should You Be Participating in PQRS? ]

PQRS and Quality of Care

PQRS was the first step in linking the payments of healthcare professionals who participate in Medicare to the quality of care they provide.

The program is a large effort in moving reimbursement away from volume and towards value. Thus, PQRS addresses two important aspects of healthcare goals:

  • Reducing costs
  • Improving outcomes

Overtime the number of measures for PQRS has increased to accommodate the needs of a broader number of providers. Thus, CMS is making a continual effort to change the program to include all the providers in the healthcare arena. The PQRS program is updated annually and allows for recommendations, revisions and elimination of rules.

2016 Reporting Period for PQRS

The reporting period for PQRS in 2016 is from January 1, 2016 through December 31, 2016. As of 2015, penalties are being assessed for non-participation in PQRS.

Eligible Professionals (EPs) who do not participate in 2016 (performance year) are subject to a -2% negative payment adjustment in 2018 (payment year). This payment adjustment is also amplified by an automatic penalty for the Value-based Modifier (VBM) because the VBM program relies on PQRS data. This modifier is -2% for groups of 1-9 EPs and -4% for groups of 10 or more.

Thus, the penalty for not participating in PQRS for the 2016 reporting year is -4% for groups of 1-9 EPs and -6% for groups of 10 or more, and will be reflected in the 2018 payment year.

[Also: What PQRS Payment Adjustments Could Mean for Your Practice ]

Successfully Reporting for PQRS

If an EP does successfully report PQRS data they will avoid the automatic -2% negative adjustment for not participating but they will then be subject to the VBM Quality tiering method which can provide negative, neutral, or positive payment adjustments. For more information on VBM, subscribe to instant blog updates. We'll be posting a series of articles on PQRS and the Value Based Modifier.