help align efforts and guide the healthcare industry towards high-quality, more
affordable care for individuals and the community, the Agency for Healthcare
Research and Quality (AHRQ), on behalf of the US Department of Health and Human
Services, developed the National Quality Strategy (NQS) in March of 2011. The
guiding principles of the NQS are comprised of three overarching aims with six
underlying priorities to help achieve the aims. The NQS priorities, also
referred to as domains, are utilized within the Physician Quality Reporting System
(PQRS) to help drive healthcare services towards achieving the aims.
The data submitted to PQRS will be displayed on the Physician Compare Website, which currently shows whether a particular physician participated in the PQRS, Electronic Prescribing (eRx) Incentive, and Electronic Health Record (EHR) programs. Ratings for physicians and other healthcare professionals will be added in the future to assist patients in choosing a physician based on cost and quality metrics.
In 2015, CMS was required to transition PQRS to a mandatory pay-for-performance program that applies a payment penalty (payment adjustment) to EPs who do not satisfactorily report data on PQRS CQMs for covered professional services. EPs who do not satisfactorily report will be subject to a 2.0% payment adjustment.
To satisfactorily report for PQRS, CMS has mandated that EPs submit data on at least 50 percent of the Medicare Part B FFS patients seen during a specified reporting period on at least nine PQRS clinical quality measures associated with at least three of the six NQS priorities (domains) to satisfy PQRS reporting requirements and avoid payment adjustments. Additionally, if an EP has a face-to-face encounter with a Medicare patient, the EP must report on one crossing-cutting measure. IDSA has provided comments advocating on behalf of the society’s members regarding the concerns over the expansion of PQRS reporting requirements specified in the CY2014 Physician Fee Schedule (PFS) Final Rule.
In cases where PQRS reporting requirements are not met, the Measure-Applicability Validation (MAV) process will be performed to determine whether the EP should have submitted additional measures or additional measures with additional NQS domains to be considered incentive or payment adjustment eligible.
The MAV process will be conducted in the following instances:- EP satisfactorily reports only 1-8 PQRS measures across one or more NQS domains OR - EP satisfactorily reports 9+ PQRS measures across less than 3 NQS domains OR - EP who do not submit any PQRS measures OR - EP who has a face-to-face encoutner with a Medicare patient and does not report one cross-cutting measure
For more information on the MAV process, please review the 2016 PQRS MAV Process for Claims-Based Reporting of Individual Measures (PDF) document.
Guidance for Reporting under the 2016 PQRS
This guidance is intended for IDSA members who report as individual eligible providers via claims or registry for 2016 PQRS requirements that will affect payment in 2018. Specifically, this is guidance that will assist IDSA members to avoid a payment penalty in 2018 that will occur as a result of failing to correctly report under the PQRS program in 2016.
Guidance for Reporting 2016 PQRS (PDF)
Please review the 2016 Physician Quality Reporting System (PQRS) Implementation Guide for further information on how to select measures to report, how your submitted data gets analyzed, reporting options, and when and how to report PQRS data.
Specific goals of 2016 PQRS
For 2016, CMS has set the goal that eligible providers should report at least 9 quality measures that fall into at least 3 of the 6 domains. It is important to remember that quality reporting applies to all face-to-face encounters under the Medicare Part B program, therefore Evaluation & Management codes for both inpatient and outpatient settings apply, (link to an excel file of codes that qualify as face-to-face encounters here). IDSA encourages all members to examine their Part B billing to identify the relevant codes and understand their volume of services that are relevant to PQRS reporting.
Physician Quality Reporting System (PQRS) Updates and Overview PQRS - Claims-Based Reporting PQRS - Registry Reporting PQRS - Electronic Health Record (EHR) Reporting PQRS - Qualified Clinical Data Registry (QCDR) Reporting PQRS - Group Practice Reporting Option (GPRO) & CMS-Certified Survey Vendor Electronic Prescribing (eRx) Incentive Program
2015 PQRS Data Submission TimeframePhysician Quality Reporting System Updates and Overview
2016 PQRS Beginner Reporter Toolkit (.zip): This beginner-level toolkit provides two documents to help EPs and PQRS group practices navigate through various PQRS decision points and the impact of quality reporting. (1) Quality Reporting Roadmap (2) Take a Moment & Participate Flowchart
PQRS 2016 Measures List: The Measures List identifies and describes the measures used in PQRS, including all available reporting methods/options, corresponding PQRS number and NQF number, NQS domains, plus measure developers and their contact information.
PQRS 2016 Measures Implementation Guide: The Implementation Guide provides guidance about how to select measures for reporting, how to read and understand a measure specification, and outlines the various reporting methods available for 2014 PQRS.
Understanding the 2018 Medicare Quality Program Payment Adjustments (PDF): This beginner-level document provides a general overview of the 2018 payment adjustments for CMS Medicare quality programs, including PQRS, Medicare Electronic Health Record (EHR) Program, and the Value-Based Payment Modifier (Value Modifier).
Value-Based Payment Modifier: The CMS Value-Based Payment Modifier webpage has multiple fact sheets regarding how the value modifier is applied to physicians.
PQRS 2015-2017 Milestones Timeline (PDF): Provides an overview of start and end dates for PQRS data submission and program registration as well as associated resources.
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PQRS Claims-Based Reporting
Under claims-based reporting, EPs may satisfactorily report to PQRS via paper or electronic Medicare Part B claims. An EP may report up to eight diagnoses by paper format and up to 12 diagnoses by electronic format. The Medicare Part B claims form (CMS-1500) is submitted to the Carrier or A/B Medicare Administrative Contractor (MAC), who processes and transfers the submitted PQRS data to the National Claims History (NCH) for PQRS analysis. Please be aware that PQRS data reported on claims denied for payment are not included in PQRS analysis. 2016 PQRS Claims Reporting Made Simple (PDF): This document describes claims-based reporting and outlines steps that eligible professionals or practices should take prior to participating. It also provides helpful reporting tips for eligible professionals and their billing staff.
2016 PQRS Claims-Based Coding and Reporting Principles (PDF): This document describes claims-based coding and reporting and outlines steps that eligible professionals or practices should take prior to participating in 2013 Physician Quality Reporting.
PQRS Registry Reporting
With the registry reporting option, an EP or group practice must submit CQM data to a qualified registry who in turn submits the data to CMS on behalf of the participants. EPs reporting via a qualified registry are allowed to report on individual measures or measure groups. 2016 PQRS Registry Reporting Made Simple (PDF): This document describes registry-based reporting and outlines steps that eligible professionals or practices should take in selecting a registry to work with for the 2014 program year.
2016 PQRS Qualified Registry (PDF): This presentation provides information about PQRS Qualified Registry measures for the 2016 program year.
PQRS EHR Reporting
Under the EHR reporting option, an EP or group practice must submit data on CQMs using a Certified EHR Technology (CEHRT) product recognized by the Office of the National Coordinator for Health Information (ONC). The PQRS EHR-based reporting option is aligned with the Medicare EHR Incentive Program (Meaningful Use Program), making available the same CQMs and requiring the same actions to satisfactorily report. 2016 PQRS EHR Reporting Made Simple (PDF): This document describes EHR-based reporting and outlines steps that eligible professionals should take in selecting an EHR to work with for the 2013 program year.
2016 PQRS Group Practice Reporting Option (GPRO) Guide for EHR Direct and EHR Data Submission Vendors (PDF): This intermediate-level fact sheet on 2016 GPRO reporting for vendors who use an EHR includes information about how EHR Direct and Data Submission Vendors should report 2016 PQRS for group practices participating in PQRS GPRO. EHR vendors wishing to participate in the 2016 PQRS and submit data for groups participating in PQRS GPRO should review this document.
Back to TopPQRS QCDR Reporting NOTE: A QCDR is different from a qualified registry in that it is not limited to measures within PQRS, please refer to the documents referenced below for more information. The Qualified Clinical Data Registry (QCDR) reporting option allows EPs to satisfy PQRS requirements by submitting clinical data to a CMS-approved entity for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. The data submitted to CMS via QCDR covers quality measures across multiple payers and is not limited to Medicare.To select a QCDR vendor, please refer to 2016 Qualified Clinical Data Registry (PDF). 2016 PQRS QCDR Reporting Made Simple (PDF): This document describes QCDR reporting and outlines steps that an individual EP should take in selecting a QCDR to work with for the 2014 PQRS program year.
Back to TopPQRS GPRO & CMS-Certified Survey Vendor
Group practices are able to satisfy PQRS reporting requirements via GPRO Web Interface, qualified registry, EHR, or CMS-certified survey vendor. Group practices must register to participant in PQRS are a group entity as well as signifying the method of reporting. Reporting requirements differ with group practice sizes, 25-99 EPs and 100+ EPs.
2016 PQRS GPRO Web Interface Reporting Made Simple (PDF): This document applies to group practices that have registered to take part in 2016 PQRS using the GPRO Web Interface. Group practices may also report via the CMS-Certified Survey Vendor method, which only partially fulfills PQRS reporting requirements. The CMS-Certified Survey Vendor reporting option is only considered equivalent to reporting on three PQRS CQMs and one NQS domain. Group practices utilizing this reporting option will have to report on at least 6 additional measures associated with at least two additional NQS domains via qualified registry or EHR reporting options.The CMS-Certified Survey reporting option uses the Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) survey module to collect data, which will subsequently be available to consumers on the Physician Compare website. 2016 CMS-Certified Survey Vendor Made Simple (PDF): This document outlines the necessary criteria for using CG CAHPS summary survey modules.
Back to TopeRx Incentive Program
NOTE: The eRx Incentive Program ended in 2013, but Electronic Prescribing continues under the Medicare and Medicaid EHR Incentive Programs. Electronic prescribing via certified EHR technology is still a requirement for eligible professionals in order to achieve meaningful use under the Medicare and Medicaid EHR Incentive Programs. Visit the CMS EHR Incentive Programs page for more information.
2015 PQRS Data Submission Timeframe
Please visit the Medicare website for more information about the PQRS. To alert IDSA to problems that should be raised with the Centers for Medicare and Medicaid Services, please e-mail IDSA staff.
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