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.
Implemented by the Center for Medicare and Medicaid Services (CMS), the Physician Quality Reporting System (PQRS) is the health care quality measurement program authorized under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) and designed by the Centers for Medicare & Medicaid Services (CMS) that applies to individual and groups of eligible providers (EPs). Broadly speaking, CMS has identified six (6) quality domains of patient care into which all quality measures fall (NQS Priorities). CMS has also established reporting thresholds with respect to specific cross-cutting measures and the overall numbers of measures that eligible providers must report. For more general information on the PQRS program, please click here. For a timeline on the PQRS program, click here.
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.
Beginning in 2015, CMS is required to transition PQRS to a mandatory pay-for-performance program that will apply 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
Guidance for Reporting under the 2015 PQRS
This guidance is intended for IDSA members who report as individual eligible providers via claims or registry for 2015 PQRS requirements that will affect payment in 2017. Specifically, this is guidance that will assist IDSA members to avoid a payment penalty in 2017 that will occur as a result of failing to correctly report under the PQRS program in 2015.
Guidance for Reporting 2015 PQRS (PDF)
Please reivew the 2015 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 2015 PQRS
For 2015, 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.
PQRS Measures Reportable by ID Physicians
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
Maintenance of Certification (MOC) Incentive Program
2014 PQRS Data Submission TimeframePhysician Quality Reporting System Updates and Overview
PQRS Overview Fact Sheet (PDF): Overview of the CMS PQRS program, including information about payments, reporting, and additional resources.
PQRS Updates 2014 (PDF): This factsheet includes important information about changes to the PQRS for 2014, as authorized by MIPPA.
PQRS 2015 Measures List and Implementation Guide (.zip): 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. 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.
PQRS Program: What Medicare Eligible Professionals Need to Know in 2014: This Medicare Learning Network (MLN) video discusses PQRS eligibility, 2014 PQRS updates that include new reporting requirements and data submission methods, incentives available for 2014 as well as potential 2016 payment adjustments, measures applicability process, Physician Compare website, and the Quality and Resources Use Report.
Value-Based Payment Modifier: What Medicare Eligible Professionals Need to Know in 2014: This Medicare Learning Network (MLN) video discusses the value modifier, applicable Medicare physicians and eligible professionals who can be assessed the value modifier, relation to PQRS and Meaningful Use Programs, quality and cost measures used to calculate value modifier, reporting options, quality tiering, and accessing participants Quality and Resources Use Report.
How to Avoid 2016 Negative Payment Adjustments for CMS Medicare (PDF): This Medicare Learning Network (MLN) presentation provides information on avoiding 2016 negative payment adjustments for the PQRS and the EHR Incentive Program as well as the Value-Based Payment Modifier. Additionally, information on reporting on 2015 quality measures available.
PQRS 2014-2016 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. 2015 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.2015 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. To select a qualified registry vendor, please refer to 2014 Participating Registry Vendors (PDF).2015 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.
2014 PQRS Qualified Registry (PDF): This presentation provides information about PQRS Qualified Registry measures for the 2014 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. 2014 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.2014 Clinical Quality Measures for EHR Incentive Program for EPs (PDF): This document provides a table of finalized clinical quality measures for the 2014 EHR Incentive Program.
EHR Incentive Program: What Medicare & Medicaid Providers Need to Know in 2014: This Medicare Learning Network (MLN) video discusses eligibility, incentives available in 2014 as well as potential payment adjustments for 2016, stages of meaningful use, certification and requirements for EHR systems in 2014, available clinical quality measures, audits and appeals, hardship exemptions, and meaningful use objectives.
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 2014 Qualified Clinical Data Registry (PDF). 2015 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. Please view the 2014 PQRS GPRO Requirements (PDF) for more details. 2014 PQRS GPRO Requirements (PDF): This document outlines how to determine group size, criteria for participation through the GPRO, registration information, and resources for additional information about the 2014 PQRS GPRO.2014 PQRS GPRO: GPRO Web Interface Reporting Made Simple (PDF): This document applies to group practices that have registered to take part in 2014 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. 2014 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.
Back to TopMOC Incentive Program
A physician or a group of physicians who have qualified for a 2014 PQRS incentive payment of 0.5% can earn an additional incentive of 0.5% by satisfactorily submitting data on PQRS CQMs to a Maintenance of Certification entity. Eligible physicians must submit data for a 12-month reporting period via any of the reporting methods. Additionally, participants who report more frequently than is required will qualify for or maintain board certification.2014 Qualified Maintenance of Certification Program Incentive Entities (PDF) 2014 PQRS MOC Program Incentive Made Simple (PDF): This factsheet provides steps for successful participation in the Maintenance of Certification Program Incentive. It also explains the role of the qualified Maintenance of Certification Program Incentive entity.
2014 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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