The Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) is a result of the Tax Relief and Health Care Act of 2006, which authorized a financial incentive for eligible professionals to participate in a voluntary reporting program. The Patient Protection and Affordable Care Act requires a penalty, beginning in 2015, for eligible professionals who do not satisfactorily report. 

2013 PQRS Measures

There is time to report: There is still time to submit 2013 Medicare quality data via the AGA Digestive Health Recognition Program™ (DHRP) for the IBD or hepatitis C measures group.

Updates to PQRS: CMS finalized additional changes to PQRS in the 2013 Medicare Physician Fee Schedule Final Rule

Incentives

For 2013 and 2014, eligible professionals who satisfactorily report in the 2013 PQRS program can qualify for an incentive equal to 0.5 percent of the total estimated part B allowed charges for all covered professional services furnished by the eligible professional during the applicable reporting period. In the case of a group practice participating in the group practice report option (GPRO), that incentive is based on the total estimated part B allowed charges for all covered professional services furnished by the group practice.

Penalties

Upcoming CMS Penalties for Non-participation in Quality Programs:

Year

eRx

EMR

PQRS

Total Penalty

2013

-1.5%

No penalty

No penalty

-1.5%

2014

-2.0%

No penalty

No penalty

-2.0%

2015

No penalty

-1.0%

-1.5%

-2.5%

2016

No penalty

-2.0%

-2.0%

-4.0%

2017

No penalty

-3.0%

-2.0%

-5.0%

Eligible professionals who do not satisfactorily report quality data under PQRS 2013 are subject to a 1.5 percent payment reduction in 2015. For PQRS 2014, penalties will increase to two percent in 2016 and subsequent years.

To avoid the 2015 PQRS payment adjustment, professionals and group practices have three options for reporting:

  • Meet the criteria for the 2013 PQRS incentive.
  • Report one applicable measure or, for individual professionals only, one measures group.
  • Elect to be analyzed under the administrative claims-based reporting mechanism.

Reporting Periods

For 2013 PQRS a 12-month (Jan. 1, 2013 through Dec. 31, 2013) and a 6-month (July 1, 2013 through Dec. 31, 2013) reporting periods are available depending upon the 2013 reporting option the eligible professional selects for submitting PQRS quality data. The 6-month period would apply only to individual eligible professionals reporting measures groups via registry.

Regarding adjustments, both the 6- and 12-month reporting periods occurring 2 years prior to the 2015 and 2016 PQRS payment will impact adjustments (e.g., Jan. 1, 2014–Dec. 31, 2014 or July 1, 2014–Dec. 31, 2014 for the 2016 adjustment). For 2017 and beyond, CMS finalized a 12-month reporting period for payment adjustments, eliminating the 6-month reporting period.

For the PQRS EHR reporting periods in 2013, the CQM reporting requirements in place for professionals for 2011 and 2012 in the EHR Incentive Program – Stage 1 final rule will continue. Additional details are provided in the CMS Alternative Reporting Mechanisms documents.

Definition of Group

CMS has changed its definition of group practice from 25 or more to 2 or more. The revised definition is a single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN. This will allow more practices to participate in the PQRS Group Practice Reporting Option (GPRO).  

In addition to offering the GPRO Web Interface, CMS finalized new criteria that allow group practices participating in the GPRO to use registry and EHR-based reporting mechanisms.

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2013 PQRS Measures

CMS finalized the 307 individual measures and 22 measures groups for 2013 PQRS reporting. There are 12 reporting mechanism options as well. The six-month reporting option is only available for reporting measures groups via registries. 

Individual 2013 PQRS measures related to gastroenterology include: 

  • Measure 320: Endoscopy and Polyp Surveillance. Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients. Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
  • Measure 321: Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality. Participation in a systematic qualified clinical database registry involves: a. Physician or other clinician submits standardized data elements to registry. b. Data elements are applicable to consensus endorsed quality measures. c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry's clinical topic(s) and report on all patients eligible for the selected measures. d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians. e. Registry must receive data from more than 5 separate practices and may not be located (warehoused) at an individual group’s practice. Participation in a national or state-wide registry is encouraged for this measure. f. Registry may provide feedback directly to the provider’s local registry if one exists.
  • Measure 185: endoscopy & polyp surveillance: colonoscopy interval for patients with a history of adenomatous polyps — avoidance of inappropriate use. Percentage of patients aged 18 years and older receiving a surveillance colonoscopy with a history of colonic polyp(s) in a previous colonoscopy, who had a follow-up interval of three or more years since their last colonoscopy documented in the colonoscopy report.
  • Measure 128: preventive care and screening: body mass index (BMI) screening and follow-up. Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented.
    • Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18-64 years BMI ≥ 18.5 and < 25.
  • Measure 226: preventive care and screening: tobacco use: screening and cessation intervention. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.

Hepatitis C Measures are also available to be reported as individual measures. These are PQRS measures 83, 84, 85, 86, 87, 89, 90, 183 and 184. 

Reporting Measure Groups

The minimum patient count for reporting measures groups has been lowered from 30 to 20 for individuals reporting measures groups via claims and registry for the 2013 and 2014 PQRS incentives.

Reporting instructions and specifications for 22 measures groups, including those related to gastroenterology, can be found in the 2013 PQRS Measure Groups Specifications, Release Notes, Getting Started with 2013 PQRS Measures Groups, 2013 Quality-Data Code Categories, and 2013 PQRS Measures Groups Single Source Code Master.

The Hepatitis C (chronic) Measures Group is comprised of the following measures:

  • Measure 84: RNA testing before initiating treatment
  • Measure 85: HCV genotype prior to treatment
  • Measure 86: Antiviral treatment prescribed
  • Measure 87: HCV RNA testing at week 12 of treatment
  • Measure 89: Counseling regarding risk of alcohol consumption
  • Measure 90: counseling regarding use of contraception prior to anti-viral therapy
  • Measure 183: hepatitis A vaccination in patients with HCV
  • Measure 184: hepatitis B vaccination in patients with HCV

The hepatitis C measures group may be reported via claims or registry.

The Inflammatory Bowel Disease (IBD) Measures Group is comprised of the following measures: 

  • Measure 269: Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented
  • Measure 270: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
  • Measure 271: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment
  • Measure 272: Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization
  • Measure 273: Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization
  • Measure 274: Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor)Therapy
  • Measure 275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
  • Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

The IBD measures can only be reported as a group via the registry reporting mechanism.

The Preventive Care Measures Group is comprised of the following measures: 

  • Measure 39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
  • Measure 48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
  • Measure 110: Preventive Care and Screening: Influenza Immunization
  • Measure 111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 years and Older
  • Measure 112: Preventive Care and Screening: Breast Cancer Screening
  • Measure 113: Preventive Care and Screening: Colorectal Cancer Screening
  • Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
  • Measure 173: Preventive Care and Screening: Unhealthy Alcohol Use – Screening
  • Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

The preventive care measures group may be reported via claims or registry.

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PQRS Measure Specification

PQRS measure specification are updated and posted prior to the beginning of each program year; therefore, eligible professionals need to use the specification for the current/applicable year for which they are reporting. It is most prudent to access those materials directly from the CMS PQRS Web page to be sure you are using the most current versions. 

In the measures codes section, you will find the 2013 PQRS measure list and implementation guide as well as documents with detailed reporting specification and instructions for each measure and reporting method. 

The 2013 Physician Quality Reporting System (PQRS): Implementation Guide – Claims-Based Reporting for Incentive provides an overview of the reporting system including decision trees to help your practice understand how of the various reporting options might be applied to your specific circumstances.  

2013 PQRS Measures Group Specifications

Once you have selected the measures (at least three), carefully review the following documents:

2013 PQRS Measure Groups Specifications

New Administrative Claims Reporting Option to avoid the 2015 Penalty

A new administrative claims reporting option, which can be used by providers to avoid the 2015 payment adjustment is available.  This option will not be used for the 2013 or 2014 PQRS incentives. 

CMS will analyze each professional’s or group practice’s patient’s Medicare claims to determine whether the individual or practice has performed the clinical quality actions indicated in a designated set of PQRS quality measures over a specified reporting period. A professional or group practice would not be required to submit quality data codes (QDCs) on claims to CMS for analysis. Physicians will have until Oct.15, 2013 to elect (via web) to use the administrative claims based reporting mechanism. 

There are 17 measures, comprised of 14 process and 3 outcome measures, for inclusion in the PQRS administrative claims-based measure set for reporting for the 2015 PQRS payment adjustment only. These measures are listed in Tables 123 and 124.

To avoid the 2015 payment adjustment, a professional or group practice using the administrative claims reporting mechanism for the 12-month reporting period must report ALL measures in Tables 123 and 124 of the final rule for 100 percent of the cases in which the measures apply. 

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Participation and Getting Help

See the CMS website for step by step guidance on how to get started on reporting individual measures and measures groups for 2013 PQRS.

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