Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Answers to Your PQRS Questions


When we talk to physicians and practice managers about Medicare’s Physician Quality Reporting System (PQRS), we hear a lot of confusion and concern. A lot of the comments revolve around the time it takes to participate in the program: “We don’t have time to document for nine measures,” or “We would need another employee to do all the work,” or “We will be staying until 8 p.m. every night.” We also hear that even after doing the work to understand and participate in the program, it feels like there are no guarantees of success. Do these complaints sound familiar?

Today, we address some of your questions about the PQRS program.

QUESTION 1: I haven’t participated in PQRS before. Where do I even start?

If you are just getting started with PQRS, here are a few basics you should know.

1. Start by reviewing our 2015 PQRS Overview Fact Sheet and then look over the 2015 PQRS Flowchart to see which reporting options are available and what the guidelines are for successful reporting or participation. For more detailed information, download the Centers for Medicare and Medicaid Services (CMS)  2015Physician Quality Reporting System (PQRS) Implementation Guide.

2. Using the information from these resources, decide whether you will report as an individual provider or group, and then choose your reporting method.

3. During this process, you will also need to select which measures you will report. Here are a few resources to help you choose:

4. Review the documentation and reporting specifications for each measure you will report.

5. Familiarize yourself with the requirements of your reporting option:

6. Look over the Negative Payment Adjustment Information page to understand more about what penalties are at stake and how they are determined.

QUESTION 2: Is the two percent penalty really worth the effort to avoid it?

Each provider will need to determine whether the effort of PQRS is worth the penalties incurred. But keep in mind that it’s not just two percent of your 2017 Medicare FFS payments that is at stake.

If you do not participate in PQRS, you also will be automatically subject to the Value-Based Payment Modifier penalty. For 2017, that’s an additional two percent for individual practitioners and groups of two to nine eligible providers and an additional four percent for groups of 10 or more eligible providers. That means an automatic reduction of Medicare payments by either four or six percent in 2017!

Don’t forget to add that to the two percent sequestration reduction that is ongoing. And, if you haven’t attested as an EHR meaningful user, there are additional penalties. Check out our 2015 Value-Based Medicare Penalties Overview Fact Sheet for a look at the upcoming penalties in aggregate.

Also remember that PQRS and other quality information will eventually be made public through the Physician Compare Website in the future. Non-participation in PQRS will eventually be reflected in your record.

QUESTION 3: Can’t CIPROMS (or my consultant, billing company, accountant, lawyer, professional organizations) just do what needs to be done (or tell us what to do) for PQRS?

While outside entities can certainly help you know which reporting options and measures are most suitable for your practice, as well as report quality data codes and other information to CMS on your behalf, you and your staff must take ownership and responsibility for the program.

At its inception, PQRS was a pay-for-reporting program, which meant that even if you did nothing related to your chosen measures, a coder or billing representative could note the lack of activity and still report quality data codes for a particular measure using an -8P modifier. Now, even if measures are reported, zero percent performance, or reporting only that the physician did nothing, doesn’t count.

To successfully report or participate in PQRS, you will need to choose measures that fit with your practice and specialty then perform and document the clinical activities specified so that you, a member of our staff, or an outside organization can extrapolate and submit the data to the CMS.

QUESTION 4: I can’t find at least 9 measures across 3 National Quality Strategy (NQS) domains in my reporting option and/or specialty. Do I still have to participate?

The short answer is yes. You still must participate or face the growing penalties.

For claims and registry reporting, if you do not have at least 9 measures across 3 NQS domains, CMS has a measure applicability validation (MAV) process to ensure you can still meet the criteria for successful reporting and avoid the two percent penalty.

The MAV process is basically two steps and requires providers to successfully report 1 cross-cutting measure along with 1-8 total measures or 9 or more measures in only 1 or 2 NQSD.

Step one of MAV determines if measures that were successfully 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 receive the 2.0% payment adjustment.

For claims reporting, step two of MAV establishes whether there were 15 or more eligible encounters identified in the denominator for the possible measures. If yes, then the provider should have reported those measures and will receive the 2.0 percent payment adjustment.

If there were no additional measures or domains that could have been reported or if additional measures had fewer than 15 denominator-eligible encounters, then the provider will be considered a successful PQRS reporter and will be spared the 2.0 percent payment adjustment.

To learn more about MAV, review these resources:

MAV is not available for other reporting options, so review the CMS guidelines and available measures carefully as you choose.

QUESTION 5: What is the cross-cutting measure I keep hearing about?

The cross-cutting measure requirement is new for the 2015 reporting year and applies only to the claims and registry reporting options. Generally, if a provider sees at least one patient in a face-to-face encounter, then that provider must report one of the 18 cross-cutting measures.

For more information about this new requirement, review these resources:

QUESTION 6: None of the cross-cutting measures really fit our practice. What should I do?

Regardless of whether or not any of the cross cutting measures reflects your current clinical routines, if you bill Medicare for one of the codes on the face-to-face encounter list, at least one of the measures you submit must be a cross-cutting measure.

Providers who do not bill a cross-cutting measure will be subject to the MAV process. As part of that process, providers who did not have a face-to-face encounter will be exempt from the requirement. As well, providers who did have a face-to-face encounter but who had fewer than 15 eligible instances in the denominator of any cross-cutting measures will also be exempt from the requirement.

Have other questions? We are here to help. Contact us today with additional questions.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


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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