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Experience. Integrity. Advocacy.

Navigating the Medicare PQRS Program


The Centers for Medicare and Medicaid Services (CMS) is offering several tools to help eligible providers (EPs) navigate the increasingly complex guidelines of the Medicare Physician Quality Reporting System (PQRS). That program currently is in transition from a bonus program for successful participation to a penalty program for inadequate participation—2014 is the last year to earn an incentive. And for the second year in a row, providers are faced with a dual set of guidelines—one to avoid the penalty and another to earn the bonus.

Avoid PQRS Penalties

A National Provider call at 1:30 p.m. on Wednesday, September 17, will help providers review the requirements for avoiding a penalty—also called a negative payment adjustment. Registration for “PQRS: How to Avoid 2016 Negative Payment Adjustments for CMS Medicare Quality Reporting Programs” is now open and available on the following webpage: MLN Connects™ Upcoming Calls. Space is limited, and participants are urged to register early.

In addition to avoiding the PQRS payment adjustment, the National Provider Call also will review the guidelines for avoiding penalties in other CMS quality programs, including the clinical quality measure (CQM) component of the Electronic Health Records (EHR) Incentive Program and the automatic CY 2016 Value-Based Modifier (VM) downward payment adjustment.

Understanding MAV

Additionally, CMS also has announced the launch of a new Measure-Applicability Validation (MAV) course, which is now available on the Physician Quality Reporting System ( PQRS)website. MAV is an important provision of the PQRS program, particularly for providers attempting to avoid payment adjustments or earn incentive bonuses through the claims or registry reporting options but for whom there are not enough applicable measures to satisfy the reporting requirements.

The recently released course offers a high-level overview of the MAV process and how it applies for the 2014 PQRS reporting year. Organized in four modules, the course helps providers handle real-world MAV scenarios, earn the 2014 PQRS incentive, and avoid the 2016 PQRS payment adjustment.

2013 PQRS Incentive Payments

Meanwhile, Medicare Administrative Contractors (MACs) and Railroad Medicare have begun paying 2013 PQRS Incentive Bonuses. CIPROMS already has collected PQRS payments for most participating clients for 2013, and since the program’s inception in 2007, CIPROMS has successfully reported quality data codes resulting in more than half a million dollars for our clients.

Providers who were successful reporters in the 2013 PQRS program should watch for payment which will be issued by their MAC based on how their TIN is set up to receive Medicare payments—either electronically or via check. The incentive payment with the remittance advice will be issued by the MACs with an indicator of LE (“Levy”) in the PLB-03-1 segment of the 835 to indicate a federally mandated payment. Additionally, the FCN will end with a 4-digit code, PQ13, to indicate the type of incentive and reporting year.

2014 PQRS GPRO Registration

In other PQRS news, the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System is open until September 30, 2014, for authorized representatives of group practices to register to participate as a group in the PQRS Group Practice Reporting Option (GPRO) for CY 2014. If a group does not register to participate through the PQRS GPRO, CMS will calculate a group quality score for the 2016 value-based payment modifier program if at least 50 percent of the eligible professionals within the group report measures individually and meet the criteria to avoid the 2016 PQRS payment adjustment. The group does not have to register for this 50% threshold option.

Group practices of 10 or more EPs who don’t participate in PQRS in 2014, either as a group or by having at least 50% EPs reporting as individuals, will be subject to a -2% VM downward payment adjustment in 2016.

Authorized representatives can access the PV-PQRS Registration System at https://portal.cms.gov using a valid Individuals Authorized Access to the CMS Computer Services (IACS) User ID and password. For additional information regarding registration and obtaining or modifying an IACS account, please see the Quick Reference Guides in the “Downloads” section of the Self-Nomination/Registration page on the Physician Feedback/Value Modifier website.

2014 PQRS Interim Feedback Reports

Also, providers can now access their First Quarter 2014 PQRS Interim Feedback Reports available through CMS’s 2014 PQRS Interim Feedback Dashboard. These reports allow providers to monitor the status of their claims-based measures and measures group reporting to see if they are meeting the PQRS reporting requirements.

Providers can access the Dashboard through the Physician and Other Health Care Professionals Quality Reporting Portal using an IACS User ID and password. For help navigating the system, refer to the 2014 Interim Feedback Dashboard User Guide, and for providers who don’t already have an IACS, the IACS Quick Reference Guide provides step-by-step instructions for requesting an account.

The Dashboard does not provide final data analysis for full-year reporting, indication of incentive eligibility or subjectivity to payment adjustment/value modifier, data from other CMS programs, or data submitted via methods other than claims. Data submitted via other 2014 reporting methods will be available for review in the Fall 2015 through the final PQRS feedback report or the QRUR for 2014 PQRS GPROs.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by 401(k) 2012 via Flickr used with permission under the Creative Commons License.


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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