An Overview of the Physician QualityReporting System (PQRS)Presented by:Lindsey Wiley, MHA, CHTS-IM, CHTS-TSHIT Manager, OFMQ

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Mission of OFMQOFMQ is a not-for-profit, consulting companydedicated to advancing healthcare quality. Since1972, we’ve been a trusted resource throughcollaborative partnerships and hands-on supportto healthcare communities.

OFMQ Areas of Expertise Analytics Case Review Education IT Consulting Health Information Technology National Quality Measures Quality Improvement

HIT Service Lines Security Risk Assessment - Level 1, 2, and 3Meaningful Use AssistanceMeaningful Use Audit SupportRisk Management Consulting and DevelopmentStaff IT Security TrainingWebsite Development & Secure EmailIT Consulting

Lindsey Wiley, MHA, CHTS-IM, CHTS-TSLindsey works with healthcare providersand hospitals to advance the use ofelectronic health records (EHR) to improvepatient care and health outcomes. Sheconsults with physician practices andhospitals to successfully implement andmeaningfully use EHRs, includingassistance associated with vendorproducts, hardware, software and systemconfiguration and troubleshooting,staffing considerations, workflow analysis,EHR utilization, security and privacy, andquality data reporting from EHR systems.

Targeted AudiencePresentation focuses on eligible professionals who are: Billing Medicare Part B fee for service Utilizing EHR technology Submitting data for individual providers or a group ofproviders 25 or less Not participating in the Medicare Shared Savings Program,Comprehensive Primary Care Initiative, or PioneerAccountable Care Organizations

Objectives Overview of the Physician Quality ReportingProgram Review eligible providers Review reporting options Review reporting criteria Discuss payment adjustments Discuss PQRS vs CQM for Meaningful Use Relation of PQRS to Value-Based Care

History Original called PQRI Initial period was July-December 2007included a 1.5% incentive Incentive payments increased to 2% in 2009and 2010; initial phases of Physician Compare Registry reporting was added Approx. 15% participation across all specialties

History 2010 program became permanent and nowcalled PQRS Incentives were available through 2014 andpenalties began in 2015 Improved feedback to physicians CMS begins integrating CQM reporting inMU/PQRS

HistoryPQRS Program YearIncentive Payment Amount20071.5% subject to %20140.5% Last year to earn an incentive payment

Letter from CMS

What is PQRS? Started in 2007 by CMS as a voluntary program called PQRI- Physician’s QualityReporting Initiative Providers were paid an incentive for reporting on selected quality measuresbased on their Medicare fee for service claims In 2011 the initiative evolved into PQRS-Physicians Quality Reporting System 2014 was the last year to receive an incentive 2015 payment adjustments began (1.5% for performance year 2013) 2016 payment adjustments begin (2.0% for performance year 2014)Source: nt-Information.html

CMS Defines PQRSA quality reporting program that uses negative paymentadjustments to promote reporting of quality information byindividual eligible professionals (EPs) and group practices. Thosewho do not satisfactorily report data on quality measures forcovered Medicare Physician Fee Schedule (MPFS) servicesfurnished to Medicare Part B beneficiaries (including RailroadRetirement Board, Medicare Secondary Payer, and Critical AccessHospitals [CAH] method II) will be subject to a negative paymentadjustment under PQRS. Medicare Part C–Medicare Advantagebeneficiaries are not included.Source: tient-Assessment-Instruments/PQRS/Downloads/2015 PQRS ImplementationGuide.pdf

What Determines PQRSEligibility?Eligible ProfessionalsEligible Professionals are defined as all Medicare physicians,practitioners, and therapists providing covered professionalservices paid under or based on the Medicare Physician FeeSchedule (MPFS). Those services are eligible for PQRS negativepayment adjustments. Individual EPs, EPs in group practicesparticipating via GPRO (PQRS group practices), Accountable CareOrganizations (ACOs) reporting PQRS via the GPRO WebInterface, and Comprehensive Primary Care (CPC) practice sitesare eligible to participate in PQRS.Source: tient-Assessment-Instruments/PQRS/Downloads/2015 PQRS ImplementationGuide.pdf

Eligible and Able to Participate Medicare Physicians Doctor of Medicine Doctor of Osteopathy Doctor of PodiatricMedicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Therapists Physical Therapist Occupational Therapist Qualified Speech-LanguageTherapist Practitioners Physician AssistantNurse Practitioner*Clinical Nurse Specialist*Certified Registered NurseAnesthetist* (andAnesthesiologist Assistant) Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists*Includes Advanced PracticeRegistered Nurse-APRNSource: tient-Assessment-Instruments/PQRS/Downloads/2015 PQRS List of Eligible Professionals.pdf

CAH Professionals(Critical Access Hospital)EPs who reassign benefits to a Critical Access Hospital that bills professionalservices at a facility level such as CAH Method II billing are eligible toparticipate in all methods of reporting including claims based via the CMS1450 form or electronic equivalent

Reporting Options12 month reporting periodJanuary to DecemberReporters may choose from the following reporting options tosubmit their quality data: Reporting electronically using a certified electronic health record (EHR)Qualified RegistryQualified Clinical Data Registry (QCDR)PQRS group practice via GPRO Web InterfaceCMS-Certified Survey Vendor (CAHPS)Claims“All EPs who do not meet the criteria for satisfactory reporting orparticipating for 2015 PQRS will be subject to the 2017 negative paymentadjustment with no exceptions” (CMS, 2015).Source: tient-Assessment-Instruments/PQRS/Downloads/2015 PQRS ImplementationGuide.pdf

Common Clinical Quality Measures CMS165 NQF 0018 Controlling High Blood Pressure (effective clinical care) CMS138 NQF 0028 Tobacco Use: Screening and Cessation Intervention(Community/Population Health) CMS69 NQF 0421 Body Mass Index (BMI) Screening and Follow-Up(Community/Population Health) CMS 130 NQF 0034 Colorectal Cancer Screening (effective clinical care) CMS 147 NQF 0041 Preventive Care and Screening Influenza Immunization(Community/Population Health) CMS 127 NQF 0043 Pneumonia Vaccination Status for Older Adults(Community/Population Health) CMS 68 NQF 0419 Documentation of Current Meds in the Medical Record(Patient Safety) (cross cutting measure) CMS 122 NQF 0059 Diabetes Hemoglobin A1c Poor Control (effective clinical care) CMS 123 NQF 0056 Diabetes Foot Exam (effective clinical care)Each measure is categorized in a NQS domain

Participate in 2015 to Avoid the 2017PQRS Payment AdjustmentEPs that do not satisfactorily report in 2017 will have a -2% PQRS adjustmentin 2017 for Medicare Part B payments Individual Measures Report 9 measures (1 cross cutting) across 3 NQS domains via EHRor Registry on 50% of Medicare patients seen in a face to faceencounter in 2015 Measure Group Report on 20 patients with at least 11 patient being Medicare PartB FFS List of measure groups on next slideSource: nt-Information.htmlSource: -To-Do-In-2015-For-The-2017-VM-03-24-15.pdf

Measures Groups

Specialty Measure Sets CMS is collaborating with specialty societies to ensure that the measuresrepresented within Specialty Measure Sets accurately illustrate measuresassociates within a particular clinical area (suggested, NOT required); the followingwere established in 2015: MedicineGastroenterologyGeneral Practice/FamilyInternal MedicineMultiple Chronic thalmologyPathologySurgery CMS is adding the following specialty measure sets in 2016:1. Dermatology4. Hospitalist2. Physical Therapy/ Occupational Therapy 5. Urology3. Mental Health

PQRS Updates for 2016 281 measures in the PQRS measures set and 18 measures inthe GPRO Web Interface; 23 cross-cutting measures Added the Qualified Clinic Data Registry (QCDR) reportingoption for groups They added 3 new measures groups (only for registryreporting):– Multiple Chronic Conditions– Cardiovascular Prevention (Million Hearts)– Diabetic Retinopathy 2018 PQRS payment adjustments is the last adjustment thatwill be issued under PQRS– Starting in 2019, adjustments to pay for quality reporting will be made under theMerit-Based Incentive Payment System (MIPS)

What if I Can’t Meet 9 Measures? You must report You are subject to Measure-ApplicabilityValidation (MAV) process which will be usedto determine if EP could have reported 9measures covering at least 3 domains

In AdditionThe Value Based Modifier (VBM) program will assess the PQRS quality dataand Medicare cost data to calculate a provider’s overall VBM score and applyan upward, downward or neutral payment adjustment that will reflectpayments in 2017. Solo EPs and physician groups of 2 to 9 EPs: exempt for 2017 (2018 -2%penalties phase in) Group practices with 10 or more EPs: up to a -4% adjustment in 2017 VBM program is considered budget neutral- incentives are rewarded tothe “high quality/low cost” practices that are funded by the “lowquality/high cost” practices

Penalties for EPs that Do NotParticipate in PQRS & VBM(for groups of 1-9 EPs)VBM adjustment is phased in- 2018PerformanceYearPenaltyapplied inPQRSPenaltyVBMPenaltyTotal 201620182%2%4%201720192%2%4%

Penalties for Groups that Do NotParticipate in PQRS & VBM(groups of 10 EPs)PerformanceYearPenaltyapplied inPQRSPenaltyVBMPenaltyTotal %201620182%4%6%201720192%4%6%

Adjustments for EPs & Groupsthat Do Participate in PQRSPhysician ReportingGroupYearSizePenaltyYearProviders/Groups that DO Successfully tral (0%)Upward (up to 2%)10 20152017NoPenaltyNegative (up to -4%)Neutral (0%) orUpward (up to 4%)(Depends on calculated qualityscore- quality tieringSource:

2016 Incentive Payments & 2018Payment Adjustments

2016 Incentive Payments & 2018Payment Adjustments

2016 Incentive Payments & 2018Payment Adjustments

2015-2017 PQRS Timeline2015December 31, 2015Reporting for the 2015PQRS program year endsfor both group practicesand individuals2016March 11, 2016Last day to submit2015CQMs for PQRSIs it too late to start for 2015?

First Steps Determine eligibility Choose Reporting option Report as an individual provider via - EHR or Registry Choose measures Depends on provider specialty, reporting methods, and vendormeasure availabilitySuggest Diabetes Measure Group for Family Practice and InternalMedicine (report 6 measures on 20 patients via registry)– Diabetes Hemoglobin A1c Poor Control– Diabetes attention to Nephropathy– Diabetes Eye Exam– Diabetes Foot Exam– Tobacco Use: Screening and Cessation Intervention– Preventive Care and Screening Influenza Immunization

Contact the QualityNet Help Desk for help with: General CMS PQRS information PQRS Portal password issues PQRS feedback report availability and access PQRS-EIDM registration questions PQRS-EIDM login issuesMonday – Friday; 7:00 a.m.–7:00 p.m. CSTPhone: 1-866-288-8912TTY: 1-877-715-6222Email: [email protected] informed about he latest PQRS news by subscribing to the PQRS listservat: ubscriber/new?topic id USCMS 520

Physician CompareAs outlined in the 2015 MPFS final rule, CMS will publicly reportthe individual EP and PQRS group practice quality measure datacollected via all reporting mechanisms. This information istargeted for publication on Physician Compare in 2016.Source: tient-Assessment-Instruments/PQRS/Downloads/2015 PQRS ImplementationGuide.pdf


PQRS and CQM Clinical Quality Measures (CQM) help measure and track the quality ofhealth care services provided by eligible professionals and eligiblehospitals. The purpose of reporting CQMs help to ensure our health care system isdelivering effective, safe, efficient, patient-centered, equitable, and timelycare. CQMs are required to be reported if participating in the Medicare andMedicaid Electronic Health Record (EHR) Incentive Programs CQM data must be exported electronically from certified EHR technology If you are participating in PQRS then you do not have to report CQM datafor meaningful use (MU), however if you are just doing MU and reportingCQMs then that will NOT count for your PQRS requirement.

CQM Eligible Professionals will need to report 9 CQM’s and eligible hospitalsand CAH’s will need to report 16 CQM’s CQM’s must cover at least 3 of the 6 available National Quality Strategydomains which represent the Department of Health and Human Services’priorities for healthcare quality improvement and include the following: Patient and Family Engagement Patient Safety Care Coord