What’s new in PQRS 2016? Changes in reporting requirements you need to know


For almost a decade, the Physician Quality Reporting System (PQRS) has been preparing physicians and other healthcare professionals for the shift from fee-for-service to pay for performance. Although many in the healthcare industry are looking ahead towards the bright and shiny new Merit-Based Incentive Payment System (MIPS) that was included in the 2015 MACRA legislation, there is still time left where physicians will need to ensure they are meeting PQRS requirements to avoid penalties down the road. With MIPS penalties set to start in CY 2019, the final year of payment adjustments under the Physician Quality Reporting System will come in CY 2018 and will be based on data reported during this year.

As in previous years, physicians who do not report PQRS will face multiple negative payment adjustments to their CY 2018 Medicare Part B reimbursements since the Value-Based Payment Modifier, another CMS quality-related incentive program, is based on PQRS reporting. However, there are some key changes to the PQRS program for its final year that physicians should be aware of:

  • The definition of a PQRS “EP” has changed. CMS updated the PQRS definition for “Eligible Professional” (EP) for 2016, which means that more non-physician providers in your physician group may also be subject to these penalties in CY 2018. CMS has posted an online list to help clarify which providers meet the definition of an EP for 2016.
  • Group practices can report PQRS via QCDR. Previously, only individual EPs could take advantage of reporting PQRS using a QCDR, which supports non-PQRS measures for PQRS reporting. Starting in 2016, group practices that self-nominate for GPRO have the option of reporting via QCDR.
  • New cross-cutting measures have been added. CMS has added some measures to the cross-cutting measures list for 2016. These include Unhealthy Alcohol Use: Screening & Brief Counseling, Breast Cancer Screening, Falls: Risk Assessment, and Falls: Plan of Care.
  • New measures groups have been added. CMS has added three measures groups in 2016, bringing the total to 25. The new measures groups are: Cardiovascular Prevent, Diabetic Retinopathy, and Multiple Chronic Conditions.
  • A few old measures groups have been changed. CMS has made modifications to the following measures groups: CABG, Dementia, Diabetes, Preventive Care and Rheumatoid Arthritis. If you reported any one of these measures groups in the past or are considering reporting them in 2016, pay close attention to which measures are included to make sure you are tracking and reporting accurately.
  • New measures have been added and measures were removed. As usual, CMS has added new measures to both the individual and group measures measure set and has removed measures from the existing PQRS measure set beginning in 2016.
  • PQRS reporting will now impact Value-Based Payment Modifier (VBPM) eligibility for some non-physician EPs. While non-physician EPs have been subject to PQRS penalties in the past, starting in 2016, PQRS reporting will now impact eligibility for an additional payment adjustment between -2.0% and +2.0% in CY 2018 for groups that consist of non-physician EPs and solo practitioners who are physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). Note that the VPBM will not be applied to therapists.

The table below outlines the updated payment adjustments that will be applied to group practices, physicians, and other EPs that do not meet PQRS requirements in 2016.

PQRS 2016 payment adjustments

One part of the PQRS program that did not change in 2016 is the vast number of reporting options and reporting requirements that exists. While this does give physicians a number of different ways to participate in the program, it also makes it harder to really understand the requirements for successfully participating. Stay tuned for more information in future posts about the 2016 PQRS reporting options.

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

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