Gulf Coast Regional Extension Center

PQRS

What is PQRS?

The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. 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.

In 2018, the Value Modifier will apply to payments under the Medicare Physician Fee Schedule (MPFS) for physician and non-physician solo practitioners and physicians and non-physicians in group practices of 2 or more EPs. Calendar year 2016 is the performance period for the Value Modifier that will be applied in 2018.

Includes:

  • Physicians
  • Physician assistants (PAs)
  • Nurse practitioners (NPs)
  • Clinical nurse specialists (CNSs)
  • Certified registered nurse anesthetists (CRNAs)

Individual EPs: To participate in 2016 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measures groups using the following mechanisms:

  1. Medicare Part B claims
  2. Qualified PQRS registry
  3. Direct electronic health record (EHR) using certified EHR technology (CEHRT)
  4. CEHRT via data submission vendor
  5. Qualified clinical data registry (QCDR).

Group Practices: A group practice may also avoid the PQRS negative payment adjustment by meeting the criteria for satisfactory reporting specified by CMS. To participate in the 2016 PQRS via the GPRO, group practices must register to take part in PQRS GPRO by June 30, 2016. Registration must be completed online through the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System. During registration, group practices must indicate their reporting method as well as CAHPS for PQRS participation. They may choose to report information on PQRS quality measures using the following:

  1. Qualified PQRS registry
  2. Web Interface (for groups of 25+ only)
  3. Direct EHR using CEHRT
  4. CEHRT via data submission vendor
  5. CAHPS for PQRS via CMS-certified survey vendor (for group practices of 2+)

PQRS/Value Modifier (VM) Penalty

Individual EPs and group practices who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms listed above for MPFS services furnished during the 2016 reporting period will avoid the 2018 negative PQRS payment adjustment (-2%) for covered professional services furnished during that same reporting period.

Note: Program participation during a calendar year will affect payments after two years (i.e. 2015 program participation will affect 2017 payments).

  • Physician and physicians and non- physicians in groups with 2-9 EPs: Upward neutral, or downward VM adjustment only based on quality-tiering (-2.0% to +2.0x of MPFS)
  • Physicians and non-physicians in groups with 10 or more EPs: Upward, neutral, or downward VM adjustment based on quality-tiering (-4.0% to +4.0x of MPFS)

Beginning in 2017, the VM will apply to EPs participating in a Shared Savings Program ACO.

In 2017 and 2018, the application of the Value Modifier is waived for groups and solo practitioners, as identified by their taxpayer identification number (TIN), if at least one EP who billed for MPFS items and services under the TIN during the applicable Value Modifier performance period participated in the following:

  • Pioneer ACO Model
  • CPC initiative
  • Or, other similar Innovation Center models (e.g., the Next Generation ACO Model, Oncology Care Model, Comprehensive ESRD Care Initiative)