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Experience. Integrity. Advocacy.

CMS Raises the Bar for Earning PQRS Incentives, Avoiding Penalties for 2014

The Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) is a program designed to encourage physicians and other eligible professionals to perform industry recognized quality measures and report them to CMS. Through the 2012 reporting year, PQRS was an incentive-only program for successful participation. Continuing in 2013, successful participants could earn a .5% incentive, but non- or unsuccessful participants face a 1.5% payment adjustment for 2015 Part B Medicare claims. 2014 is the last year for eligible professionals to earn incentives (.5%), and non- or unsuccessful participants face a 2.0% payment adjustment for 2016 Part B Medicare claims.

To participate in PQRS in 2014, eligible professionals must decide the following:

  1. whether they will participate as an individual or group; then
  2. which reporting option they will use. Options for individual reporting are Claims, Qualified Registry, EHR, or the new Qualified Clinical Data Registry. Options for group reporting are Qualified Registry and EHR for groups of 2 or more eligible professionals; the new Certified Survey Vendor and the Web Interface for groups of 25 or more eligible professionals; and groups of 100 or more eligible professionals also are required to report all CG CAHPS Survey Measures via Certified Survey Vendor; and finally
  3. which measures they will report. (Different specialties have various measures available depending on their chosen reporting option.)

To earn the .5% incentive for 2014, eligible professionals must successfully report quality data for nine measures across three (of six available) National Quality Strategy Domains (NQSD) for at least 50% of eligible Medicare patients for most reporting options. (The EHR, GPRO Certified Survey Vendor, and Web Interface options for groups of 25 or more eligible professionals have different guidelines.) Measures with 0% performance will not be counted.

To avoid a 2% payment adjustment for 2016 Medicare Part B claims, eligible providers must either meet the 2014 requirements to earn an incentive, or successfully report quality data for three measures covering at least 1 NQSC for at least 50% of eligible Medicare patients via Claims, Qualified Registry, or Qualified Clinical Data Registry. Measures with 0% performance will not be counted.

If fewer than 9 measures are submitted or 9 or more measures covering fewer than 3 NQSD for the claims and qualified registry reporting options, the Measure Applicability Validation(MAV) process will be utilized to determine successful reporting to earn an incentive . The MAV process is basically two steps and requires providers to successfully report 1-8 measures or 9 or more measures in only 1 or 2 NQSD. Step one will determine if measures that were submitted fall within a clinically-related cluster. If so, if the cluster contains measures that weren’t submitted or measures in domains that weren’t submitted, CMS will consider those as possible measures that should have been reported. For registry reporting, that means the provider should have reported those measures and will not earn a bonus. For claims reporting, step two of MAV establishes whether there were 15 or more eligible instances (patients or encounters identified in the denominator) for the possible measures. If yes, then the provider should have reported those measures and will not earn a bonus. The process is followed in a similar manner for avoiding the payment adjustment, though the number of measures reported changes from fewer than nine to fewer than three. For more information about MAV and a look at the clinically-related clusters, visit CMS online at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html.

Eligible professionals also can earn an additional .5% incentive for 2014 by participating in a qualified Maintenance of Certification Program. For more information, visit CMS online at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Maintenance_of_Certification_Program_Incentive.html.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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