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Avoiding Medicare Penalties in 2015

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Physician Quality Reporting System PQRS 2013

 Harold Ingram


CMS (The Centers for Medicare and Medicaid Services) created several quality initiatives intended to provide quality of care information for a variety of providers, in a number of different settings.  The rationale offered is that this information will be beneficial in empowering patients and will support new payment models that include quality of care measures in determining reimbursement.

The Tax Relief and Health Care Act of 2006 initiated this process by implementing the Physician Quality Reporting Initiative PQRI, which is now referred to as the Physician Quality Reporting System or PQRS.  As with some earlier health care related legislation, the passage of the Affordable Care Act (ACA) modified the PQRS program.  For the past several years, CMS has encouraged physicians to participate by offering incentives, the carrot.  However, beginning this year, 2013, CMS is bringing out the stick.  If physicians fail to participate in PQRS by reporting on services provided in 2013, a payment adjustment of -1.5% will be applied to all Medicare payments in 2015.  However, successful participation in the program will avoid the penalty. As an additional benefit, successful participation will also give the provider a .5% incentive payment or bonus for 2013.

If CMS determines that  a physician or group did not successfully participate through a qualified reporting option for 2013, Medicare payments for 2015 will be 98.5% of the Medicare allowable for the services provided.  As specified in the 2012 Medicare Fee Schedule, there are multiple ways to report PQRS activity.  These include (1) Claims-Based Reporting, (2) Registry-Based Reporting, (3) EHR-Based Reporting, and (4) Group Practice Reporting.  Information on the reporting methods are available on the CMS website.

At this point, the easiest way for a physician to report is through a qualified Registry.  A Registry is an organization that has met CMS requirements allowing it to report PQRS information on behalf of a provider.  If registry reporting is the selected reporting method, there are two options. One is through Individual Measures. The other is through measures groups.

Individual Measures registry reporting requires the physician to select at least 3 individual measures from a list of CMS approved measures.  For 2013, 138 individual measures were approved.  If this method is selected, the provider must report on at least 80% of the Medicare Part B fee for service patients seen in 2013.

Measures Groups registry reporting is probably going to be the easiest way to report.  It provides for two reporting periods, January 1, 2013 through December 31, 2013 or July 1, 2013 through December 31, 2013.  It will require the selection of at least one measures group.  And, the physician will have to report on at least 20 patients.  A minimum of 11 of these patients will have to be Medicare Part B patients.

To obtain additional information on PQRS, the reporting requirements, and the measures that may be selected, go to the CMS website and search for PQRS measures.  Twenty-two (22) measures groups were approved for 2013.  One frequently selected is the Diabetes Measures Group.

To get an idea of what is required to report on a measures group, MDinteractive has a brief tutorial for its registry at that demonstrates the information needed for reporting purposes.  The cost for using a registry is generally between $200 and $300.

There are a number of organizations authorized to submit information on the behalf of physicians.  These Registries will provide guidance and assistance in collecting, qualifying, and reporting PQRS data.  Many specialty groups or societies offer this service to their members.  Some Registry websites that you may wish to visit for further reporting information are:





This type of reporting is just a pre-cursor to the requirements physicians will face for future reimbursement.  PQRS reporting is currently a Medicare requirement that provides a limited assessment of the quality of care provided.  However, as payment models change, there will be more emphasis on measuring quality, like PQRS, as well as measuring the expense associated with treating patients.  Expect these new models to apply to all insurance carriers, Medicare, Medicaid and commercial.






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