- What is the bonus payment available for 2011?
- What will the rate be for future incentive payments? And when will CMS switch from incentives to penalties?
- What are the key changes in the PQRS program for 2011?
- How many measures are there for 2011? How many measures and patients do I need to report on?
- What are the measure groups for 2011?
- Do all the patients have to be traditional Medicare Part B Fee-For-Service?
- What are the different ways in which I can participate in PQRS for 2011?
- Is the 2011 PQRS incentive based on reporting rates or performance rates?
- What if none of the measures groups or measures within the measures group applies to us (i.e., 0% Participation Rate)?
- How and when will CMS determine the PQRS bonus payment for participating providers?
- Does CMS allow multiple submissions? How many incentive payments can I receive?
- Can I participate in the ARRA Meaningful Use program as well as the PQRS program?
- How is PQRS connected to the overall effort of improving the quality of patient care?
- How does the Registry-based reporting process for PQRS work?
- Who qualifies as an Eligible Professional for PQRS?
What is the bonus payment available for 2011?
For 2011, the Physician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative (PQRI) provides a 1% bonus on total allowed Medicare Part B Fee-For-Service (FFS) charges for reporting on a minimum of three Quality Measures or for one of 14 Measure Groups.
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What will the rate be for future incentive payments? And when will CMS switch from incentives to penalties?
Participation in PQRS is currently voluntary, but beginning in 2015 all providers eligible for incentive payments will be subject to penalties for failing to participate.
- 2011 = 1.0% incentive
- 2012-2014 = 0.5% incentive
- 2015 = 1.5% reduction in Medicare reimbursement for those who do not submit PQRS measures
- 2016 and beyond = 2.0% reduction in reimbursement
What are the key changes in the PQRS program for 2011?
- Program name changed from PQRI (Physician Quality Reporting Initiative) to PQRS (Physician Quality Reporting System)
- For Registry-based measure group submissions, all 30 patients reported on must be Medicare Part B Fee-for-Service patients
- 30 individual PQRI measures added
- Group practice provision for reporting
- Eligible providers receiving incentive payment for 2010 will be posted to CMS website
How many measures are there for 2011? How many measures and patients do I need to report on?
There are 194 individual PQRS quality measures available for 2011. Of these, 56 measures can be reported only through a Registry. An eligible provider can choose to report on a minimum of three individual measures or on a minimum of one of the 14 Measure Groups. An eligible professional (EP) may report on as many measure groups or individual measures as are applicable to their medical practice.
The threshold for successful PQRS participation is reporting on at least 30 eligible patient encounters for Measure Group reporting or on 80% of all eligible Medicare Part B FFS patients. For 2011, ALL patients must be Medicare Part B FFS for Measure Group reporting.
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What are the measure groups for 2011?
A measure group is composed of 4-10 individual measures. CMS has approved the following groups for 2011:
- Asthma (new for 2011)
- Back Pain
- CABG (Coronary Artery Bypass Graft)
- CAD (Coronary Artery Disease)
- CAP (Community-Acquired Pneumonia)
- CKD (Chronic Kidney Disease)
- Diabetes
- Hepatitis C
- Failure
- HIV/AIDS
- IVD (Ischemic Vascular Disease)
- Perioperative Care
- Preventive Care
- RA (Rheumatoid Arthritis)
Do all the patients have to be traditional Medicare Part B Fee-For-Service?
Yes. For 2011 Registry-based, measure group-based reporting, all 30 patients must be Medicare Part B FFS. This is a new requirement for 2011 and a significant change from previous years.
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What are the different ways in which I can participate in PQRS for 2011?
There are several ways to report data for PQRS:
- Claims-Based – quality data codes associated with individual measures are reported and submitted directly to CMS along with claims
- EHR-Based – eligible professionals report a small number of quality measures using a qualified EHR
- Registry-Based – eligible professionals report data for measures or measures groups through a CMS-qualified registry like WellCentive’s
Is the 2011 PQRS incentive based on reporting rates or performance rates?
PQRS is currently a pay-for-reporting program. CMS will determine eligibility for incentive payment based on reporting rates, not performance rates on clinical measures, provided the performance rates are non-zero.
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What if none of the measures groups or measures within the measures group applies to us (i.e., 0% Participation Rate)?
This is a new rule for 2011. Eligible professionals reporting via a registry for a measures group need to report all of the measures in the group (that are applicable to the population that is reported) for 30 unique Medicare Part B FFS patients AND a performance rate >0% for each applicable measure during a specified reporting period to be considered incentive eligible. In cases where a measure within a measures group is not applicable to a patient, the patient would not be counted in the performance denominator for that measure, so those patients should not be affected (e.g., Preventive Care Measures Group – Measure #39: Screening or Therapy for Osteoporosis for Women would not be applicable to male patients according to the patient sample criteria).
An answer of “Not Done/Unknown” for all 30 patients for a given measure within the measures group will result in a performance rate of 0% for that measure, and the provider will not be eligible for the Physician Quality Reporting incentive.
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How and when will CMS determine the PQRS bonus payment for participating providers?
Only CMS can determine if a PQRS submission is qualified for the incentive payment. CMS generally makes the determinations sometime during the summer of the year following the submission (e.g., 2011 PQRS submissions will be determined during summer 2012). As long as the reporting requirements are met, a PQRS submission should be qualified for the incentive payment. WellCentive’s PQRS solution helps ensure payment by checking all data against the reporting criteria and identifying any gaps that need to be addressed prior to submission.
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Does CMS allow multiple submissions? How many incentive payments can I receive?
CMS does allow multiple submissions; however, CMS will make only one incentive payment. If all criteria are met for one or more submissions, CMS will use the longest reporting period (most complete data set) submitted to calculate the 1% bonus. For example, if a physician submits a claims-based submission for a 12-month period and also a WellCentive Registry-based submission for 3 individual measures for six months, and both submissions are qualified for the incentive payment, CMS will use the 12-month submission to calculate the incentive payment.
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Can I participate in the ARRA Meaningful Use program as well as the PQRS program?
Yes. Providers can receive incentives from both programs concurrently, and you don’t need to be participating in Meaningful Use in order to participate in PQRS.
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How is PQRS connected to the overall effort of improving the quality of patient care?
PQRS is designed to encourage providers to discuss quality care oriented questions during an office visit, as well as to encourage appropriate documentation of data in the patient’s chart for follow-up or reference. PQRS reporting promotes awareness by providers and practices of what data may or may not be fully or appropriately documented with their current processes.
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How does the Registry-based reporting process for PQRS work?
To registry report PQRS, an eligible professional can choose from five reporting methods, which are split into two reporting periods:
For a Full-Year Bonus
The first reporting period is the Full-Year period (January 1 – December 31, 2011). The bonus is based on the total allowed Medicare Part B FFS charges filed during the entire 2011 reporting period. There are three reporting methods in this period:
1. Measure Group Reporting – 30 Eligible Patient Encounters
- Choose one or more of 14 PQRS Measures Groups
- Report on a minimum of 30 eligible patients
- All patients MUST be Medicare Part B FFS patients
2. Measure Group Reporting – 80% Reporting Method
- Choose one or more of 14 PQRS Measures Groups
- Report on at least 80% of eligible patients, with a minimum of 15 patients
- All patients MUST be Medicare Part B FFS patients
3. Individual Quality Measures Reporting – 80% Reporting Method
- Choose 3 or more of 194 PQRS Individual Quality Measures
- Report on at least 80% of eligible patients
- All patients MUST be Medicare Part B FFS patients
For a Half-Year Bonus
The second reporting period is the Half-Year period (July 1 – December 31, 2011). The bonus is based on the total allowed Medicare Part B charges filed during the July 1 -December 31, 2011 reporting period.
There are two reporting methods in this period:
1. Measure Group Reporting – 80% Reporting Method
- Choose 1 or more of 14 PQRS Measures Groups
- Report on at least 80% of eligible patients, with a minimum of eight patients
- All patients MUST be Medicare Part B FFS patients
2. Individual Quality Measures Reporting – 80% Reporting Method
- Choose 3 or more of 190 PQRS Individual Quality Measures
- Report on at least 80% of eligible patients
- All patients MUST be Medicare Part B FFS patients
Who qualifies as an Eligible Professional for PQRS?
Under PQRS, covered professional services are those paid under or based on the Medicare Physician Fee Schedule (PFS). Eligible professionals are those who are providing services which get paid under or based on the PFS. Eligible professionals include:
1. Medicare Physicians
- Doctor of Medicine
- Doctor of Osteopathy
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Doctor of Oral Surgery
- Doctor of Dental Medicine
- Doctor of Chiropractic
2. Medicare Practitioners
- Physician Assistant
- Nurse Practitioner
- Clinical Nurse Specialist
- Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
- Certified Nurse Midwife
- Clinical Social Worker
- Clinical Psychologist
- Registered Dietician
- Nutrition Professional
- Audiologist
3. Medicare Therapists
- Physical Therapist
- Occupational Therapist
- Qualified Speech-Language Therapist