What are the most important things to know about PQRS in 2015?


Whether you are hearing the acronym PQRS for the first time or catching up on this year’s changes, navigating the reporting system’s rules and options available to you can be daunting. With so much information out there, it may seem hard to figure out what is really important and what is not.

For those who are new, the Physician Quality Reporting System (PQRS) is a quality improvement program administered by the Centers for Medicare and Medicaid Services (CMS). The program offers eligible professionals financial incentives or penalties based on reporting quality measure data on an annual basis. PQRS is a complex program that applies to almost all Medicare providers, and due to regulatory changes each year, it is important to keep up with the requirements for the program and how they may impact your medical practice.

Here are the top five things you need to know about 2015 PQRS reporting:

1. Starting this year, there are no more PQRS incentives on the table—only penalties

Beginning in 2015, PQRS will no longer include a payment incentive for participating, only payment penalties. Lack of participation in PQRS in 2015 will result in a 2.0% negative payment adjustment in 2017 for all eligible physicians.If you were used to receiving an incentive payment for participating in PQRS, there are still opportunities to earn additional reimbursement based on the quality measures you report for PQRS as part of the Value-Based Payment Modifier (more on VBPM in #5).

2. PQRS still offers numerous reporting options

There are many different ways for a provider to satisfy PQRS requirements to report quality measure data to CMS. These include: claims-based reporting, registry reporting, qualified clinical data registry reporting, reporting through an EHR vendor, or choosing one of those mechanisms and reporting as a group via the Group Practice Reporting Option (GPRO). While it is great to have many options, not all the reporting mechanisms have the same requirements, and not all quality measures can be reported via every method. Therefore, it is important for practice administrators and eligible professionals to be familiar with each option in order to determine the most suitable approach.

3. Payment penalties will be applied in 2017

Determination of PQRS penalties is based on data collected two years prior. This means that your participation this year will result in either a full reimbursement amount or an adjusted amount in 2017. The adjustment that will come from 2015 participation in PQRS (which results in receiving 98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual eligible professional or group practice during 2017.

4. Cross-cutting measures add complexity to the measure selection process

Providers who see Medicare patients in face-to-face visits will be required to report at least one cross-cutting measure as part of PQRS reporting in 2015. Cross-cutting measures are non-disease-specific measures designed to encourage preventive care and care coordination for all Medicare beneficiaries. The cross cutting measures address topics such as: tobacco use, immunizations, preventive care, medication reconciliation, functional outcomes assessment, and pain assessment. Having to include a cross-cutting measure in your PQRS measure set means added complexity to ensure all measure selection requirements are met.

5. PQRS participation this year will impact how the Value-Based Payment Modifier is applied in 2017

PQRS participation in 2015 impacts how eligible professionals will be evaluated by CMS for the purposes of applying the Value-Based Payment Modifier (VBPM). VBPM is another quality improvement program that is administered by CMS, but the program differs from PQRS because both quality and cost metrics are evaluated, and overall performance against national benchmarks on both types of metrics will determine whether a negative, neutral, or positive payment adjustment will be applied to the provider’s Medicare reimbursement payments:

  • Solo practitioners and groups between 2 and 9 physicians are subject to a negative, neutral, or positive VBPM adjustment based on performance, ranging between -2.0% and 2.0% in 2017.
  • Groups of 10 or more physicians are also subject to performance-based adjustments ranging between -4.0% and 4.0% in 2017.

The good thing to remember is that providers and groups that satisfactorily participate in PQRS in 2015 will not be subject to any negative payment adjustments under the VBPM in 2017, which means a little more time to work on improving the performance of those measures before they directly impact your reimbursement totals.

Do you want to know more about PQRS, Value-Based Payment Modifier, or other quality programs? Submit your questions in the sidebar or via email to ask@ablehealth.co.

Further reading:
How using the MIPS 90-day reporting period will increase your 2017 Composite Score
Avoiding a penalty in 2018 MIPS: the nuts and bolts

Email Alerts

Stay informed with Able Health email alerts

Be the first to know about key PQRS and MACRA information, deadlines, and expert analysis