A discussion with Jackie Coult, CHBC regarding the Physician Quality Reporting System (PQRS) and avoiding potential reimbursement penalties in 2015.

1. Jackie Coult, CHBC

2. CPT® Disclaimer
2
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3. Overview
3
Physician Quality Reporting System (PQRS) formerly known as the
Physician Quality Reporting Initiative (PQRI) is a reporting program
that uses a combination of incentive payments and payment adjustments
to promote reporting of quality information by eligible professionals
(EPs).
Incentive Payment or Penalties are tracked by practices EP’s individual
National Provider Identifier [NPI] and Tax Identification Number
[TIN]). EPs satisfactorily report data on clinical quality measures (CQM)
for covered Physician Fee Schedule (PFS) services furnished to
Medicare Part B Fee-for-Service (FFS) beneficiaries (including
Railroad Retirement Board and Medicare Secondary Payer).

4. PQRS Payment & Penalty
4
Year
Incentive Payment
2013
2014
Payment Adjustment
2015
2016
2017
Year Data Collected
to Inform
Payment/Penalty
Bonus/Adjustment
2013
2014
+ 0.5%
+ 0.5%
2013
2014
2015
- 1.5%
- 2.0%
- 2.0%

5. Incentive Eligibility by Reporting Options
5
Reference: United States Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS); 2011 Reporting
Experience Including Trends (2008-2012). CMS, 26 Mar. 2013. Web. 11 Apr 2013. (www.cms.gov/pqrs)

6. PQRS - How To Get Started
6
 STEP 1: Determine if you are eligible to participate or group participate
 STEP 2: Determine which PQRS reporting method best fits your
practice.




Claims-based, or
Registry-based, or
Qualified Electronic Health Record (EHR), or
Group Practice Reporting Option (GPRO)
 STEP 3: Review the specific criteria for the chosen reporting option in
order to satisfactorily report.
 STEP 4: Individual Measures or Measures Group
 STEP 5:Review information on the PQRS Payment Adjustment

7. PQRS - Who’s Eligible?
7
Providers payable under Medicare Physician Fee Schedule
are Eligible to Participate “EP’s” in the PQRS program:
Medicare Physicians
Practitioners
Therapists
Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric
Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental
Medicine
Doctor of Chiropractic
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse
Anesthetist (and
Anesthesiologist Assistant)
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Physical Therapist
Occupational Therapist
Qualified Speech-Language
Therapist

8. PQRS Program - Who’s NOT Eligible?
8
Services not payable under Physician Fee Schedules are not
included in Physician Quality Reporting Requirements.
•Federally Qualified Health Centers (FQHCs)
•Independent Diagnostic Testing Facilities (IDTF)
•Independent Laboratories
•Hospitals (including critical access hospitals)
•Rural Health Clinics
•Ambulance Providers
•Ambulatory Surgical Centers

9. How to Report PQRS Measures
9

10. 2013 PQRS Reporting Options for Incentive Payment
(Dates of Service 1/1/2013-12/31/2013)
10
Reporting
Mechanism
Group Practice Size
Registry
All Group Practices
GPRO Web
Interface
25-99 EPs only
GPRO Web
Interface
100+ EPs only
2013 Registered Group (PQRS GPRO) Reporting Options for Incentive Payment
Report at least 3 measures, AND
Report each measure for at least 80% of the group practice’s Medicare Part B FFS
patients seen during the reporting period to which the measure applies.
Measures with a 0% performance rate will not be counted.
Report on all measures included in the Web Interface; AND
Populate data fields for the first 218 consecutively ranked and assigned
beneficiaries in the order in which they appear in the group’s sample (with an
over-sample of 283) for each module or preventive care measure. If the pool of
eligible assigned beneficiaries is less than 218, then report on 100% of assigned
beneficiaries.
Report on all measures included in the Web Interface; AND
Populate data fields for the first 411 consecutively ranked and assigned
beneficiaries in the order in which they appear in the group’s sample (with an
over-sample of 534) for each module or preventive care measure. If the pool of
eligible assigned beneficiaries is less than 411, then report on 100% of assigned
beneficiaries.
 Claims Submission: For the 2015 PQRS payment adjustment only.

Report: 1 Medicare PT, 1 Measure, on 1 Claim, 1 time before 12/31/2013

11. NEW 2013 Group Reporting Definition
11
A “group practice” under 2013 Physician Quality
Reporting consists of a physician group practice, as
defined by a single TIN, with 2 or more individual
eligible professionals (as identified by individual NPIs)
who have reassigned their billing rights to the TIN.
This definition of group practice is different from the
definition of group practice that was applicable for the
2012 Physician Quality Reporting System, which defined
a group practice as 25 or more eligible professionals.

12. Factors to Consider
12
At a minimum, EPs should consider the following factors
when selecting measures for reporting:
•Clinical conditions commonly treated
•Types of care delivered frequently - e.g., preventive, chronic,
acute
•Settings where care is often delivered - e.g., office,
emergency department (ED), surgical suite

13. 22 Measures Groups
13

14. 247 Individual Groups
14
Sample of Individual Measures
PQRS
Number
NQF
Number
Measure Title & Description
Diabetes Mellitus: Hemoglobin A1c Poor Control
1
0059
2
0064
3
0061
*5
*5
0081
0081
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control
Diabetes Mellitus: High Blood Pressure Control
Individual Measures
Reporting: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor
or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
Measures Group Reporting:
Heart Failure: Angiotensin- Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic
Dysfunction (LVSD)

15. Payment Incentives
15
PQRI/PQRS WAS DEVELOPED BY CMS IN 2007
VOLUNTARY PAY-FOR-REPORTING PROGRAM

16. Reporting Periods
16
There are 2 reporting periods available for eligible
professionals to report 2013 PQRS measures groups:
12- month reporting period from January 1 through
December 31, 2013,
OR
a 6-month reporting period from July 1 through
December 31, 2013 (available only via Registry).
Registry Closed on October 18th, 2013.

The 6-month reporting period allows those eligible
professionals who may have decided to participate later in the
year to begin reporting.

17. Claims Reporting
17

18. Claims-Based Reporting
18
 Claims-based reporting of individual measures on 50% of Medicare
patients (within 12 months period)

138 individual quality measures eligible for claims-based reporting
 Claims-based reporting of at least one measures group for 20
unique Medicare Part B FFS patients (12 months)

12 measures groups eligible for claims-based reporting
 Measures groups containing a measure with a 0% performance rate
will not be counted as satisfactorily reporting the measures group.
 EPs may choose to submit Quality Data Codes (QDC) either on a
current claim or on a claim representing a subsequent visit,
particularly if the quality action has changed. For example, a new
laboratory value may be available at a subsequent visit.

19. Group Measures Reported via Claims & Registry
19
G-codes – intended to report the following Groups:
G8485: Diabetes Mellitus (DM) Measures Group
G8487: Chronic Kidney Disease (CKD) Measures Group
G8486: Preventive Care Measures Group
G8490: Rheumatoid Arthritis Measures Group
G8492: Perioperative Care Measures Group
G8493: Back Pain Measures Group
G8545: Hepatitis C Measures Group
G8547: Ischemic Vascular Disease (IVD) Measures Group
G8645: Asthma Measures Group
G8898: Chronic Obstructive Pulmonary Disease (COPD) Measures Group
G8902: Dementia Measures Group
G8905: Cardiovascular Prevention Measures Group

20. Individual Measures
20
PQRS
Number
Measure Title & Description
Meets
Medical
Performance Performance
Exclusion
Patient
Performance
Exclusion
System
Other
Performance
Performance Performance
Not Met
Exclusion
Exclusion
Perioperative Care: Meets all measures
20, 21, 22, 23
G8510
Perioperative Care: Timing of
Prophylactic Parenteral Antibiotic –
Ordering Physician
Perioperative Care: Selection of
Prophylactic Antibiotic – First OR
Second Generation Cephalosporin
G8629 G8630 N/A
N/A
N/A
G8631
No Report
G8632
4041F
4041F-1P
N/A
N/A
No Report
4041F-8P
Perioperative Care: Discontinuation of
Prophylactic Parenteral Antibiotics
(Non- Cardiac Procedures)
4049F &
4046F
4049F-1P &
4046F
N/A
N/A
22
4042F
No Report
4049F-8P &
4046F
4044F
4044F-1P
N/A
N/A
No Report
4044F-8P
23
Perioperative Care: Venous
Thromboembolism (VTE) Prophylaxis
(When Indicated in ALL Patients)
5015F-1P
5015F-2P
N/A
No Report
5015F-8P
24
Osteoporosis: Communication with the 5015F
Physician Managing On-going Care
Post-Fracture of Hip, Spine or Distal
Radius for Men and Women Aged 50
Years and Older
20
21

21. Measures Reported via Claims
21

22. Registry Based Reporting
22
Registration Closed
10/18/2013

23. Registry Based Reporting
23
At least 3 individual PQRS measures for 80% or
more of applicable Medicare Part B FFS patients
of each eligible professional (12 months)
At least one measures group for 20 patients, the
majority of which must be Medicare Part B FFS
patients (12 months)
At least one measures group for 20 patients, the
majority of which must be Medicare Part B FFS
patients (6 months)

24. Group Measures Reported via Registry ONLY
24
G-codes – intended to report the following Groups:
 G8544: Coronary Artery Bypass Graft (CABG) Measures Group
G8548: Heart Failure (HF) Measures Group
G8489: Coronary Artery Disease (CAD) Measures Group
G8491: HIV/AIDS Measures Group
G8899: Inflammatory Bowel Disease (IBD) Measures Group
G8900: Sleep Apnea Measures Group
 G8903: Parkinson’s Disease Measures Group
 G8904: Hypertension (HTN) Measures Group
 G8906: Cataracts Measures Group
 G8977: Oncology Measures Group

25. Payment Adjustment (Only)
25
EP’S FROM 1-99 CAN AVOID THE -1.5%
PAYMENT A ADJUSTMENT IN 2015
DATE OF SERVICE: JANUARY 1ST-DECEMBER 31ST, 2013
CLAIM MUST PROCESS BY: FEBRUARY 28TH, 2014

26. How to avoid 2015
PQRS Payment Adjustment - Individuals EPs
26
EPs can avoid the 2015 payment adjustment (-1.5%) by
meeting one of the following criteria during the 2013
PQRS program year:
1.EP reports at least:
1.
2.
One valid individual measure via claims, or
through a qualified Electronic Health Record
(EHR), OR
One valid group measure via claims

27. How to avoid 2015
PQRS Payment Adjustment - Group
27
Group practices (2-99 EP’s) can avoid 2015 payment adjustments of (-1.5%) by meeting one of the following
criteria during the 2013 PQRS program year.
NOTE: If you have NOT registered through the registry, GPRO or PV-PQRS (closed October 18, 2013), see option 4:
1.Group meets the following requirements, outlined in the 2013 PQRS measure specification for satisfactorily
reporting:

Reports specific ACO/GPRO measures through the Web Interface based on a pre-populated patient sample (only available to group
practices of 25 or more EPs) OR

Reports at least 3 registry measures (for 80% of the group’s eligible patients for each measure) for the GPRO outlined in the 2013
PQRS Measure Specification for Claims/Registry Reporting of Individual Measures (available to all group practices of 2 or more EPs)
Group reports at least one valid measure through:
1.
2.
Web Interface (only available to group practices of 25 or more EPs) OR
Participating Registry (available to all GPRO participants)
a)Group elects to participate as a GPRO in the administrative claims-based reporting mechanism by October 18,
2013.
b)EP reports at least:


One valid individual measure via claims, or through a qualified Electronic Health Record (EHR), OR
One valid group measure via claims

28. Conclusion
28
Avoid -1.5% Payment Penalty in 2015:
Report on: 1 Medicare PT, 1 Measure, on 1 Claim, 1 time before 12/31/2013.
Note: Claim must be processed by no later than 2/28/2014
Obtain +.5% Incentive Payment in 2013:
Report on: 50% Medicare PT’s, 1-3 Measures, on all Claims or reporting
option selected (the applicable 50%), for 6 months, before 12/31/2013.
Although, CMS proposal for PQRS in 2014, to avoid 2% Penalty in 2016 is:
Report on: 50% Medicare PT, 3 Measures, on all Claims, for 1 yr.

29. Proposed Changes for 2014 Physician
Quality Programs and The Value Based
Payment Modifier
29
ON JULY 8, 2013, THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) ISSUED A
PROPOSED RULE THAT WOULD UPDATE PAYMENT POLICIES AND PAYMENT RATES FOR
SERVICES FURNISHED UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) ON OR
AFTER JAN. 1, 2014.
THE PROPOSED RULE ALSO PROPOSES CHANGES TO SEVERAL OF THE QUALITY
REPORTING INITIATIVES THAT ARE ASSOCIATED WITH PFS PAYMENTS, INCLUDING THE
PHYSICIAN QUALITY REPORTING SYSTEM (PQRS), AS WELL AS CHANGES TO THE
PHYSICIAN COMPARE TOOL ON THE MEDICARE.GOV WEBSITE.
FINALLY, THE PROPOSED RULE INCLUDES PROPOSALS FOR IMPLEMENTING THE VALUEBASED PAYMENT MODIFIER (VALUE MODIFIER) REQUIRED BY THE AFFORDABLE CARE
ACT THAT WOULD AFFECT PAYMENT RATES TO CERTAIN GROUPS BASED ON THE
QUALITY AND COST OF CARE THEY FURNISH TO BENEFICIARIES ENROLLED IN THE
TRADITIONAL MEDICARE FEE-FOR-SERVICE PROGRAM.

30. PQRS – What’s to come in 2014?
30
In an effort to consolidate, CMS will begin to incorporate PQRS Measures into
Meaningful Use Stage 2 by reducing claims-based reporting.
Add and Delete Measures
 47 new individual Measures
 3 Measure groups
 Retire a number of claims-based measures (encourage reporting via registry & EHR-based
mechanisms)
Individual EPs
 Increase the number of measures that must be reported from 3-9 (for both claims & registry)
 Reduce a reporting threshold via registry from 80% to 50% for all applicable patients on
individual measures
 Eliminate the reporting option to report on claims-based measure groups
PQRS reporting utilizing the Clinical Data Registries
 Report at least 9 measures to the registry covering 3 of the National Quality Strategy domains
 Report at least 50% of the applicable patients Individual EPs

31. E-Prescribe & Meaningful Use
2013/2014
31
MEANINGFUL USE IS THE SET OF STANDARDS DEFINED BY
THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
INCENTIVE PROGRAMS THAT GOVERNS THE USE OF
ELECTRONIC HEALTH RECORDS AND ALLOWS ELIGIBLE
PROVIDERS AND HOSPITALS TO EARN INCENTIVE
PAYMENTS BY MEETING SPECIFIC CRITERIA.

32. Electronic Prescribing Incentive Program
32
For years 2012 through 2014, eligible professionals
who are not successful electronic prescribers will
receive a payment adjustment under the eRx Incentive
Program are as follows:
Utilizing e-Prescribing
Not Utilizing e-Prescribing
+1.0% in 2012
+0.5% in 2013
-1.0 % in 2012
-1.5 % in 2013
-2.0 % in 2014

33. Meaningful Use Incentive
33
For the most part, EPs may participate in more than one incentive program at the same time. However, there are some
limitations. This table outlines the programs that EPs may participate in at the same time:
Table 1: Maximum EHR Incentive Payments by Program Based on the First Calendar Year (CY) for Which
the EP Receives Payment
CY
CY 2011
Medicare
Medicaid
2011
$18,000
Medicare
Medicaid
$12,000
$8,500
$18,000
2013
$8,500
$12,000
2014
$4,000
$8,500
2015
$2,000
Medicaid
$8,500
$15,000
$8,000
$8,500
$12,000
$8,500
$4,000
$8,500
$2,000
$8,500
CY 2015
CY 2016
Medicare Medicaid
Medicare Medicaid
$21,250
$8,500
Medicaid
$8,500
$12,000
$21,250
$8,000
$8,500
$8,000
$8,500
$21,250
$4,000
$8,500
$4,000
$8,500
$8,500
$21,250
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
$8,500
2017
Medicare
$8,500
2016
Medicare
CY 2014
$21,250
$8,000
CY 2013
$21,250
2012
CY 2012
$8,500
$8,500
2018
2019
2020
2021
$8,500
Total (if EP
does not
switch
programs)
$44,000
$63,750
$44,000
$63,750
$39,000
$63,750
$24,000
$63,750
$0
$63,750
$0
$63,750
NOTE: Medicare EPs may not receive EHR incentive payments under both Medicare and Medicaid.
NOTE: The amount of the annual EHR incentive payment limit for each payment year will be increased by 10 percent for EPs who predominantly furnish services in an area that is
designated as an HPSA.

34. Summary of Proposed Stage 2 Rule of Meaningful Use
34
To avoid penalties starting in 2015, EPs need to:
 Attest to meaningful use in 2013; or
 Have achieved and attested to the first year of meaningful use
by October 1, 2014
The requirement as to when different stages of
meaningful use need to be met was officially relaxed.

Those that attest to meaningful use in 2011 must meet Stage 2
criteria in 2014 and Stage 3 in 2016
Quality measures are still not final.
The proposed rule generally makes Stage 1 optional
(menu) items required (core) in Stage 2

35. Multiple Incentive Programs at the Same Time
35
Payments Based on the First Year Calendar Year (CY) for Which an EP Receives an EHR Incentive Payment*
This table identifies the maximum incentive payments available by year depending on whether the EP chooses to participate in either the Medicare or Medicaid EHR
Incentive Program. It also shows payment adjustments for not meeting these criteria.

36. Need Medicare Assistance
36
Contact the Quality Net Help Desk for help with:
• General CMS PQRS & eRx information
• PQRS Portal password issues
• PQRS/eRx feedback report availability and access
• PQRS-IACS registration questions
• PQRS-IACS login issues
PQRS Registry website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Registry-Reporting.html
PQRS EHR: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Electronic-Health-Record-Reporting.html
PQRS GPRO website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html
Monday – Friday; 7:00 a.m.–7:00 p.m. CST
Phone: 1-866-288-8912
TTY: 1-877-715-6222
Email: qnetsupport@sdps.org

37. Q&A
37

38. Jackie Coult, CHBC
801-550-5058
Jgc.coult@comcast.net
P.O. Box 171004
Holladay, UT 84117-1004