PQRS – It’s Time to Start

 In Articles, PQRS

You’ve heard of the PQRS or Physician Quality Reporting System for several years now, but likely have determined that it is too much work for too little gain.  This common understanding changes in 2013 when the program moves from an optional bonus program to mandated penalties for providers who are not successfully participating.  Failure to act in 2013 will result in an additional 1.5% reduction in Medicare reimbursement in 2015. 

What providers are impacted?  Virtually all providers who bill Medicare are impacted, including MD, DO, PA, NP, LCSW, Clinical Psychologists, PT, OT, Speech/Language, and Audiologists.  Providers who submit Medicare claims under two separate Tax ID numbers will need to participate under each organization.

What is the best source of information?  CMS recently published a Tip Sheet that provides an excellent overview of the program and how to avoid the penalties: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS-2015_PaymentAdjustmentTipSheet060313.pdf

If I am currently participating in the PQRS bonus program, do I need to do anything to avoid the penalty? No. If you have been submitting claims with quality codes to cover three PQRS measures or if you complete a Measures Group submission through a registry or directly through your EHR, you will not need to take any other action regarding the PQRS penalties.  Please note that submitting quality measures for the EHR Incentive program by attesting  under the  Meaningful Use program does not qualify for the PQRS bonus program.

What is the easiest way to avoid the penalty?  There are two approaches that require minimal effort:

1)   Register your selection to allow CMS to calculate quality measures based on claims data.  This approach requires you to first register in the IACS system, or extend your privileges if already registered.  Details on the registration process can be found here: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html. Once you have an IACS password, then you will need to elect the administrative claims option through the PV-PQRS option at https://portal.cms.gov. This selection must be completed between July 15 and October 15, 2013 however it may take 4-6 weeks to receive an IACS system login so you should start that process soon.  The downside of this approach is that you have no opportunity to review the resulting quality measures that the government will be using.  By 2015, it is likely that the quality measures will be made publicly available on the CMS website.

2)   Select one PQRS measure that applies to your practice and report the appropriate quality measure codes on at least one eligible claim to Medicare for each provider by December 31, 2013.  It is likely that in 2014, CMS will require all providers to report on 3 PQRS measures for at least 50% of the eligible Medicare claims.  This approach has the benefit of forcing you to become familiar with the available  PQRS measures and assist you in preparing for the more stringent requirements expected in future years.   Here are some tips to get you started with this process:

  • Download the 2013 PQRS Implementation Guide and review the list of PQRS measures for 2013.  You are limited to those that list Claims as an option in the right hand column.  Select 2-3 measures that fit your Medicare patient population. Some measures that you might examine which are applicable to all specialties include PQRS # 46, 47, 130, 131, and 226. Measure 226 (smoking assessment and counseling) is also a Core Quality Measure for Stage 1 EHR Incentives (Meaningful Use) Program.  Several other PQRS measures can also be found in the EHR Stage 1 and Stage 2 lists. Although you have to report the measures separately to PQRS on a claim with a qualified service  and for MU through the attestation process, you may be able to piggy-back onto your current process for capturing the required data.  Link to the Implementation Guide: http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_MeasuresList_ImplementationGuide_12192012.zip
  • Identify a process in your practice for adding the required quality measure codes (usually a Gxxxx or xxxF) code to a claim for at least one qualifying Medicare patient/service prior to claim submission.  See Sample Process below.
  • Monitor EOBs for claims to verify that the quality code is listed with the same claim number  as the qualifying service and has a remark code of N365. This indicates that CMS received the quality measure code and is processing it for PQRS.
  • If you are a billing client of MSOC, be sure to let your Client Analyst know what measure(s) you are submitting and we will monitor compliance to ensure you avoid the penalty.

Sample Process For Capturing and Reporting on Quality Measure 226 (Smoking Assessment & Intervention):

This measure applies to standard E&M office visit codes (99202-99205, 99212-99215) and all diagnosis codes.  You need to enter a second CPT code to the claim for the qualifying service:

1036F:  Patient does not currently use tobacco

4004F:  Patient uses tobacco and cessation intervention was completed

4004F with Modifier 8P:  Patient uses tobacco and no cessation intervention was provided.

Pick a day when the provider has several Medicare patients scheduled for office visits that typically receive a standard E&M code (initial consultations, follow-up visits, etc.).  Be sure to include only traditional Medicare beneficiaries and not those covered by Medicare Advantage plans:

  • If using paper chart/encounter form: Highlight or add a sticky note to the encounter sheet to indicate that smoking status should be recorded for this patient.   Have staff mark on the encounter form whether the patient uses tobacco and was provided an intervention.  During charge entry, add the appropriate Quality Measure code to the charge for this patient, using all the same diagnosis and physician data as the E&M charge.
  •  If using an EHR to capture charge data and pass to your PM system:  Prior to submitting claims for this day, review the medical record of each patient on your list and add the appropriate Quality measure code, using all the same diagnosis and physician data as the E&M charge.


Have other questions about PQRS?  Contact Jeanne Chamberlin, 919-442-2422 or j.chamberlin@msochealth.com.

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