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

PQRS for Method II Critical Access Hospitals


Critical Access Hospitals (CAHs) billing for provider services under Method II are responsible for reporting quality data to Medicare under the Physician Quality Reporting System (PQRS). The requirement began with the 2014 reporting year and continues with the 2015 reporting year. For 2015, all reporting methods, including claims reporting, is available for CAH Method II.

But Wait, We Don’t Use the CMS-1500?

Because CAH Method II requires CAHs to bill professional services on the institutional claim form (CMS-1450 or electronic equivalent), there was confusion about whether or not Method II providers were required or just “allowed” to participate in PQRS. Recently, however, CMS has updated their PQRS documentation to clearly indicate that even though CAH Method II billing takes place on CMS-1450 rather than CMS-1500 claim forms (or electronic equivalent), those claims are paid as a percentage of the Medicare Physician Fee Schedule and will be evaluated under PQRS for potential payment adjustments. (See the 2015 Physician Quality Reporting System (PQRS) List of Eligible Professionals and 2015 Physician Quality Reporting System (PQRS) Claims Reporting Made Simple for specific details.)

As well, the instructions on the PQRS List of Eligible Professionals seems to leave open the possibility that if the CAH Method II providers included their NPI on the CMS-1450 they were required to participate in PQRS but if they simply omitted their NPI on the CMS-1450, they could avoid PQRS. However, billing instructions for CAH Method II require that the rendering or attending provider’s NPI is included on the claim or the claim will be denied. (See MLN Matters® Number: SE1505 Physicians and Non-Physician Practitioners Reported on Part A Critical Access Hospital (CAH) Claims.)

In April 2015, CMS published a 2015 CAH-II Reporting PQRS toolkit that clears up much of the previous confusion and reiterates the need for CAH Method II hospitals and the providers they bill for to participate in the PQRS program.

Now what?

If you are a CAH or a CAH provider paid under Method II and you haven’t begun participating in PQRS, take action today to begin your participation.

To participate in PQRS in 2015, eligible professionals must decide the following:

1.) whether they will participate as an individual or group; then

2.) which reporting option they will use:

  1. Options for individual reporting are Claims, Qualified Registry, EHR, or Qualified Clinical Data Registry.
  2. Options for group reporting are Qualified Registry,  Qualified Registry plus CMS Certified Survey Vendor, EHR, EHR plus CMS Certified Survey Vendor, Web Interface, or Web Interface plus CMS Certified Survey Vendor; and finally

3.) which measures they will report. (Different specialties have various measures available depending on their chosen reporting option. For a complete list of measures and descriptions, visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html.)

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.

To report as a group, providers must register with the Physician Value-Physician Quality Reporting System (PV-PQRS) and elect their group reporting option by June 30, 2015. For groups electing the GPRO web interface mechanism, the sample size is now 248 regardless of the number of eligible providers in the group. Groups of 100 or more eligible professionals utilizing any of the GPRO reporting options must have all CAHPS for PQRS survey measures reported on their behalf via a CMS Certified Survey Vendor. CAHPS for PQRS is optional for groups of 2-99 eligible professionals.

For more information about choosing your reporting option, review the CIPROMS 2015 PQRS Flowchart. Still have questions about where to start? Contact CIPROMS today.

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