Physician Quality Reporting System (PQRS)

Background

The PQRS is one of several long-term quality initiatives developed by the Centers for Medicare and Medicaid Services (CMS). It is intended to, among other things; obtain information on the quality of care across the healthcare system.  Specifically, the program collects data submitted by Eligible Professionals (EP), on quality measures for covered services provided to Medicare part B fee for service (FFS) beneficiaries.

Why Participate?

Participating in the PQRS is not mandatory, it is voluntary.  However, the program uses a combination of incentive payments and payment adjustments to promote reporting of quality information by EPs.  Those who participate and successfully meet the measure reporting criteria of the program receive incentive payments (bonus).  EPs that decide not to report measures, or do not meet the programs’ reporting criteria, are subject to payment adjustments (penalty).  The table below describes the incentive/adjustment payment schedule.  Based on program year 2013 participation, EPs will receive their incentive payment in 2014 or receive a payment adjustment in 2015.

Program Year

Incentive Payment

Payment Adjustment

2013

0.5% in 2014

-1.5% in 2015

2014

0.5% in 2015

-1.5% in 2016

2015

0.0% in 2016

-2.0% in 2017

2016

0.0% in 2017

-2.0% in 2018


Eligibility

EPs are physicians and non-physicians providing services that are paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services which get paid under or based on the PFS, those services are eligible for PQRS incentive payments and/or payment adjustments. EPs include Medicare physicians (Doctors of Medicine), Practitioners (Nurse Practitioners), and Therapists (Physical Therapists).

A list of, and more details on, EPs can be found at CMS’s website.

PQRS 2013: Mechanisms and Criteria for Satisfactory Reporting (Individual EPs)

The most common method the Nuclear Medicine community has for reporting measures is individual measures reporting. The three mechanisms that can be used to report these measures are described below:

Claims-based reporting: Report at least 3 PQRS measures.  Each measure must be reported for at least 50% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Registry-based reporting: Report at least 3 PQRS measures. Each measure must be reported for at least 80% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

EHR-based reporting: Report at least 3 measures. Each measure must be reported for at least 80% of an EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

What if fewer than three measures are applicable?

If fewer than three reportable measures are applicable to an EP, he/she can still qualify for incentive payments.  When this occurs, the only CMS-approved mechanism for reporting is claims-based reporting.  Claims-based reporting must be completed using a 50 percent sample of applicable Medicare Part B fee for service patients. CMS will then conduct a measure-applicability validation (MAV) process on the reports.  The MAV process verifies that no other measures could have been reported based on an EP’s billing claims (there are intentional overlaps among PQRS measures). During this validation process, CMS confirms that each case fits the description of the patient population for the measure (denominator eligibility) based on ICD-9 and/or CPT codes. If CMS finds an additional measure could have been reported, the EP will not qualify for an incentive payment.

How to Avoid a Payment Adjustment

EPs can avoid payment adjustments in 2015 by reporting one valid measure, on one patient, one time in 2013. This must be done using the claims-based reporting mechanism.

Measures to Consider

The table below is a composite of measures that several SNMMI members have identified as applicable to the nuclear medicine community.

Measures Applicable to EPs

130

Documentation of Current Medications in the Medical Record

147

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

194

Oncology: Cancer Stage Documented

322

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patient

323

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI

324

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

Other Measures: 20, 21, 22, 23, 24, 39, 40, 71, 76, 102, 104, 146, 156, 195, 225, 265