The Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) program provides incentive payments to eligible health care professionals who satisfactorily report specific data on quality measures to Medicare.
By reporting on PQRS quality measures, individual eligible professional (EPs) and group practices can also quantify how often they are meeting a particular quality metric. In 2015, the program began to apply a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment.
January 1, 2016: Reporting for the 2016 PQRS program year begins for both group practices and individuals (Note: 2016 program year data will determine the 2018 payment adjustment) First day to submit 2015 PQRS data using registry, EHR, or QCDR Payment adjustments begin for both group practices and individuals who did not satisfactorily report quality data to CMS in 2014.
January 18, 2016: 2015 GPRO Web Interface submission period begins.
February 26, 2016: Last day that 2015 claims will be process to be counted for PQRS reporting to determine the 2017 payment adjustment.
March 11, 2016: 2015 GPRO web interface submission period ends.
March 31, 2016: Last day for QCDRs (QCDR XML only) and registries to submit 2015 data.
April 30, 2016: QCDRs must post 2015 quality measure data as directed by the MPFS final rule.
December 31, 2016: Reporting for the 2016 PQRS program year ends for both groups and individuals. (2016 data will determine 2018 payment adjustments)
January 1, 2017: Reporting for the 2017 PQRS program year begins for both group practices and individuals (Note: 2017 program year data will determine the 2019 payment adjustment) Payment adjustments begin for both group practices and individuals who did not satisfactorily report quality data to CMS in 2015 First day to submit 2016 PQRS data using registry, EHR, or QCDR 2016 GPRO Web Interface submission will be in the first quarter; stay tuned for exact dates.
February 24, 2017: Last day that 2016 claims will be processed to be counted for PQRS reporting to determine the 2018 payment adjustment.
February 28, 2017: Last day to submit 2016 CQMs for dual participation in PQRS and the Medicare EHR Incentive Program Last day for QCDRs (QRDA) and EHRs to submit 2016 data.
March 31, 2017: Last day for 2016 QCDRs (XML only) and registries to submit 2016 data.
December 31, 2017: Reporting for the 2017 PQRS program year ends for both group practices and individuals (Note: 2017 program year data will determine the 2019 payment adjustment).
More information and educational materials can be found on the CMS PQRS site. Here are a few basic steps to help eligible professionals successfully participate in PQRS in 2016.
Step 1: Determine Eligibility
Under PQRS, eligible professionals include doctors, therapists, and other practitioners who provide covered PFS services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries, including Railroad Retirement Board and Medicare Secondary Payer. The following professional are PQRS eligible:
Note: Professionals who reassign benefits to a Critical Access Hospital (CAH) that bills professional services at a facility level, such as CAH Method II billing, can participate via all reporting mechanisms. To do so, the CAH must include the individual provider NPI on their Institutional (FI) claims.
Step 2: Determine if you participate as an Individual EP or as Part of a Group Practice
- Individual EPs are identified by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN)
- Group practice is defined as a single TIN with 2 or more individual EPs who have reassigned their billing rights to the TIN. Group practices can register to participate in PQRS via the group practice reporting option (GPRO) to be analyzed at the group TIN level.
Step 3: Choose Reporting Method
Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An individual EP may choose from the following methods:
- Qualified PQRS Registry
- Medicare Part B Claims
- Electronic Health Record (CEHRT)
- CEHRT via Data Submission Vendor
- Qualified Clinical Data Registry (QCDR)
Groups of two or more eligible professionals may choose from the following methods:
- Qualified PQRS Registry
- Web Interface (for groups of 25+ only)
- CEHRT via Data Submission Vendor
- CG CAHPS CMS-Certified Survey Vendor (for groups of 25+ only)
Step 4: Select Measures
The quality measures adopted under PQRS are developed by provider associations, quality groups, and CMS. Quality measures generally are used to assign a quantifiable score—based on a standard set by the developers—to the quality of care provided by the eligible professional or group practice.
The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method. When selecting measures for reporting, eligible professionals should consider factors such as their quality improvement goals and the types of care they frequently deliver.
To view the complete list of measures reportable in 2014 and 2015 in the nursing home setting click here.
To view a complete list of CMS Individual Measure Specifications please click here.
Step 5: Review Payment Adjustment Information
For 2016 (based on participation in 2014) and subsequent years, the negative payment adjustment is 2.0%. EPs and groups who do not satisfactorily report data on quality measures for covered professional services will be subject to a negative payment adjustment under PQRS beginning in 2015. The PQRS negative payment adjustment applies to all of the EP’s or group practice’s Part B covered professional services under the Medicare Physician Fee Schedule (MPFS). Review information on the CMS PQRS Payment Adjustment page for complete information on how to avoid future PQRS payment adjustments.
For more information about participating in PQRS, review the PQRS website: http://www.cms.gov/PQRS. For additional questions, eligible professionals should contact the QualityNet Help Desk via phone or email: