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

PQRS for Pain Physicians


For pain physicians, participating in the Physician Quality Reporting System (PQRS) will be a little different than for their colleagues performing only anesthesia services since there are many measures that may apply to their pain practice.

Generally, to avoid the 2 percent payment adjustment in 2017, eligible providers must report 9 measures across 3 National Quality Strategy Domains (NQSD) for at least 50 percent of the denominator-eligible encounters in the 2015 reporting year. In addition, for the claims and registry reporting options, providers who have at least one face-to-face encounter with a Medicare patient must report at least 1 cross-cutting measure of the 9 measures reported.

Pain physicians will find that there are more than 9 measures covering more than 3 NQSDs that may apply to their practice in both the claims and registry reporting. As well, many of those measures also are on the list of 18 cross-cutting measures. Since nearly all pain specialists will have at least one face-to-face encounter, being able to easily report at least one of the cross-cutting measures will help pain physicians be successful reporters.

Among many available, the following measures for both claims and registry may be applicable to pain physicians (starred items also are on the list of cross-cutting measures):

  • Measure #1 – Diabetes: Hemoglobin A1c Poor Control – Effective Clinical Care Domain
  • *Measure #41 – Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older – Effective Clinical Care Domain
  • Measure #47 – Care Plan – Communication and Care Coordination Domain
  • Measure #109 – Function and Pain Assessment – Person and Caregiver-Centered Experience and Outcomes Domain
  • *Measure #128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan – Community/Population Health Domain
  • *Measure #130 – Documentation of Current Medications in the Medical Record – Patient Safety Domain
  • *Measure #131 – Pain Assessment and Follow-Up – Community/Population Health Domain
  • Measure #134 – Preventive Care: Screening for Clinical Depression – Community/Population Health Domain
  • Measure #145 – Radiology: Exposure Time Reported for Procedures Using Fluoroscopy – Patient Safety Domain
  • Measure #154 – Falls: Risk Assessment – Patient Safety Domain
  • Measure #155 – Falls: Plan of Care – Communication and Care Coordination Domain
  • Measure #204 – Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic – Effective Clinical Care Domain
  • *Measure #226 – Prevent Care and Screening: Tobacco Use: Screening and Cessation Intervention – Community/Population Health Domain
  • *Measure #317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documents – Community/Population Health Domain
  • Measure #326 – Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy – Effective Clinical Care Domain

For providers participating in the claims or registry options, measure applicability validation (MAV) is the process the Centers for Medicare and Medicaid Services (CMS) uses to determine if providers can still avoid the payment adjustment penalties even if they report fewer than the required measures or domains.

If 1 cross-cutting measure is not successfully reported, MAV will be applied to determine if the provider had at least one face-to-face encounter and at least 15 or more eligible instances in the denominator of any cross-cutting measures. If so, the provider should have reported a cross-cutting measure and will be subject to the 2 percent payment adjustment.

Keep in mind that though ASA procedure codes are not considered face-to-face encounters, many other services provided by pain physicians and anesthesiologists, including initial inpatient visit codes (99221-99223), subsequent hospital visit codes (99231-99233), the critical care code (99291), and outpatient visit codes (99201-99204, 99211-99214), are included on the face-to-face encounter list and in the denominator of some cross-cutting measures. Any provider who bills for face-to-face services should plan to report at least one cross-cutting measure.

If the cross-cutting measure requirement is met through either submission or MAV, then the remainder of the MAV process follows two steps and requires providers to have successfully reported 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 percent 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 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 percent payment adjustment.

An anesthesia cluster is available for both claims and registry reporting and includes the following 2 measures: Measure 76 Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections and Measure 193 Perioperative Temperature Management. Both are in the Patient Safety NQSD. According to CMS instructions, reporting Measure 76 alone does not require anesthesiologists to report Measure 193, but reporting Measure 193 alone would obligate providers to report Measure 76 if the minimum threshold of denominator-eligible encounters is met.

While there is no general pain care cluster, many measures applicable to pain management may fall within other clusters. When that is the case, providers should carefully evaluate the denominator criteria of the other measures to see if they would be held accountable for those measures. Also keep in mind that not all measures are included in a cluster in either the claims or registry options.

Pain physicians may also be interested in reporting via the Qualified Clinical Data Registry (QCDR) offered by the American Society of Anesthesiologists (ASA), through its affiliate, Anesthesia Quality Institute (AQI). This reporting option is available to providers who participate individually in the PQRS program and is free for ASA members.

The following resources will provide additional information about MAV, cross-cutting measures, and the PQRS program in general:

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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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