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 March 2013 Issue

PQRS: Physician Quality Reporting System

By Anne Miller, MD
Beginning in 2006, the federal government passed legislation for the Physician Quality Reporting Initiative (PQRI), which was renamed the PQRS in 2010. Initially a voluntary system, the initiative provided for payments to qualified providers as an incentive for reporting on quality measures on their Medicare Part B fee for service patients. With the implementation of the Affordable Care Act by 2015, the incentives will be diminished and will be replaced by fines for those providers who choose not to participate. This program is federally mandated and is administered through CMS.
Regardless of your politics or your opinion about linking payment to quality, these financial penalties will be imposed on those who choose not to participate in the PQRS. In fact, eligible providers must report by October 2013 in order to avoid the expected penalties in 2015. The penalties are harsh; for example, an individual physician who does not report PQRS measures in 2013 will have their 2015 allowable fees reduced by 1.5%. In a group practice with more than 100 eligible professionals, there will be an additional 1% fee reduction.
Who is eligible to participate?
All professionals who provide services to patients through the Medicare fee schedule are eligible. This includes physician assistants, nurse practitioners, physical therapists and occupational therapists.
When did PQRS begin?
The program has been in effect for several years. It was first part of PL 109-432 the Tax Relief and Health Care Act of 2006 (TRHCA) which was signed on December 20, 2006.  If you have not participated in the past, you will not be penalized, but you have not taken advantage of incentive payments previously available. If you report on at least one measure during 2013 you will not be penalized in 2015. However, if you want to receive the incentive payment for 2013, and avoid the penalty for 2015, then you must report on 3 measures before October of this year.
Do I need to register?
No. Registration is not needed. A particular physician or group can choose 3 measures that apply to their patient population and then track these. If the physician is a participant in Medicare, then the reporting can begin at any time. The information is sent to CMS via specified quality codes on claims sent to Medicare.
What are the quality measures?
CMS, with the input of some specialty societies, has developed a list of quality measures. There are 153 quality measures and 7 measures groups in the 2013 PQRS Program. The complete list is attached (Attachment A). A physician or group may decide on any of the available quality measures for tracking purposes. Many do not apply to the practice of hand surgery. However other measures are easier to apply to our patients. For example, screening for osteoporosis, smoking, pain, and functional issues from osteoarthritis are included as possibilities. Please see the attached document (Attachment B) for a list of measures that can be utilized by hand surgeons. In addition to the individual measures, there are groups that can be reported on in a different manner. However, most of the groups do not apply to the practice of hand surgery. For example, one of the groups refers to rheumatoid arthritis. However, the parameters that need to be reported refer to the medical management of the disease in addition to function and deformity. If one decides to use the group measures, then fewer patients can be utilized for the report, but each patient in the reported cohort needs to be evaluated on all measures within the group. Therefore, even if one has a practice with a large number of rheumatoid patients, the group reporting may not apply to our members. Information on group reporting can be found in the attached (Attachment C).
Do I have to report on all Medicare patients?
No.  The reporting physician needs to report on at least 50% of eligible patients. The numerator is the number of patients for whom 3 quality measures have been reported. The denominator includes all Medicare patients for whom an evaluation and management code has been generated. This includes both new and follow-up patients. At present, the commercial insurance carriers are not participating in this program. As previously stated, the 2015 penalty can be avoided if at least one measure is reported for 2013.
Do you have to report the same 3 quality measures for all your eligible patients?
Yes. It is most straightforward if an individual provider or group chooses 3 measures and then tries to capture as many patients as possible. If the physician or group chooses to report on a larger list of quality measures, then the percentages may not reach the required 50%.
How is the report made?
The most straightforward PQRS reporting method for hand surgeons is claims-based. CPT Category II codes (or temporary G-codes where CPT II codes are not available) will be used for reporting quality measure data. Quality codes, which supply the measure numerator, must be reported on the same claim as the payment codes, which supply the measure denominator. In other words, at least 50% of the Medicare Part B patients for whom you send a claim for E and M services need to be reported on for the three chosen quality measures. Alternatively, there are some codes that can be reported on through a registry. These codes however are based more on underlying disease such as hypertension or cardiovascular problems. These registry-based codes are included in the complete list in Attachment A.
How does this program interact with an electronic health record?
Most EHR vendors utilized by our members are qualified to deal with PQRS. A complete list of vendors is listed in Attachment D. Speak to your provider to get the details. As a subspecialist however, the system can become more streamlined with less hassle to the provider if it is set up properly with physician assistance. Most of the systems can be programmed so that a pop up window can appear with your chosen quality measures for any eligible Medicare part B patients. When the claim is sent to Medicare, the appropriate data can then be forwarded. Alternatively, the physician may choose to report through their vendor utilizing the EHR programs. If this is done, then it is required that the physician choose 3 core measures for reporting. These include:
  • PQRS #128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
  • PQRS #237 (NQF 0013): Hypertension (HTN): Blood Pressure Measurement
  • PQRS #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.
Although not directly related to hand surgery, if you can remember to screen for these core measures in your Medicare patients, then the reports can be made directly via your EHR vendor and you can avoid the impact on your billing staff. Further information regarding the electronic health record option can be found in Attachment E.
How is the bonus calculated?
The bonus is calculated based on total claims billed by the provider under the Physician Fee Schedule during the reporting period. The bonus for 2013 and 2014 is 0.5%. As previously stated there will be no bonus in 2015. The penalty for not reporting will be 2015 and will increase to 2016.
What will CMS do with the collected data?
This question has not really been answered. One purported benefit to participation in the system is that the government will report back to the provider with a confidential summary of their data. There is no indication at this time that data from this system will be utilized in pay for performance. However, it should be noted that quality data would be publicly reported by CMS in the following year.
What other resources are available?
CMS is available to help with reporting for 2013 only. To sign up, you must be utilizing the claims reporting option. Then you must go onto the CMS web site and affirmatively elect to use this option for 2013. The data needed will be the providers name, practice name, tax identification number and national provider identifier. If a group is making use of this option, the data need will be the business name, group tax identification number, and contact information for a responsible individual within the group, or in most cases the practice administrator. The information needs to be given to CMS by October 15 of this year via the online website. Alternatively, a letter can be sent to: Centers for Medicare and Medicaid Services, Center of Clinical Standards and Quality, Quality Measurement and Heath Assessment Group, 7500 Security Blvd., Mail Stop S3-02-01, Baltimore, Md, 21244-1850.
The CMS website has a large area devoted to the specifics at  In addition, a decision tree put out by CMS that can be very useful in making a decision on how to report can be found in Attachment F.