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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

2014 Physician Quality Reporting System (PQRS)

February 18th, 2014

Overview

Medicare’s Physician Quality Reporting System (PQRS) is a voluntary reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals through the use of PQRS measures and their correlating Quality Data Codes (QDC).  Incentive payments for successful reporting will be made one year after a reporting period while payment adjustments for those who fail to report successfully will be made two years after a reporting calendar year. 

There are quality measures that are applicable to the specialty of oral and maxillofacial surgery.  Whether one may earn an incentive depends on the number of Medicare covered services provided.  This paper summarizes what is needed to earn the incentive and what can be done to avoid the payment adjustment.  Complete details on the PQRS program can be found on the CMS PQRS website

Who is eligible

Doctors of Oral Surgery (DDS) and Doctors of Dental Medicine who render services in which PQRS measures exist (see list of measures applicable to OMSs) are eligible to report those measures. An Eligible professional (EP) can choose to report individually, or as a group practice.

An individual OMS may choose from the following methods to submit data to CMS:

  • Medicare Part B claims,
  • Qualified registry,
  • Qualified Electronic Health Record (EHR),
  • Qualified PQRS data submission vendor (new for 2014),
  • Qualified Clinical Data Registry (new for 2014), or
  • The Group Practice Reporting Option (GPRO). 

Group Practice Reporting Option (GPRO): GPRO consists of a physician group practice, using a single Tax Identification Number (TIN), with 2 or more individual eligible professionals (each identified by a different NPI) who have reassigned their billing rights to the group TIN. Group practices reporting via GPRO must register for their selected reporting method by September 30, 2014.   For information on how to become a selected group practice, refer to the downloads on the Group Practice Reporting Option section available from the navigation bar on the left side of the CMS PQRS website.

An OMS GPRO may choose from the following methods to submit data to CMS:

  • GPRO Web Interface
  • Qualified PQRS Registry
  • EHR Direct Product that is Certified EHR Technology (CEHRT)
  • EHR data submission vendor that is CEHRT
  • CMS- certified survey vendor

Note: If the eligible professional or the GPRO changes TIN, the participation does not carry over to the new TIN.

What are the PQRS Measures?

As mentioned above, quality measures help quantify healthcare processes, patient outcomes and/or perceptions as well as address various aspects of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination.  OMS’ and/or group practices may report either individual measures or measure groups. 

Individual Measures:  There are 285 individual PQRS measures for claims or registry-based reporting, 18 of which are applicable to OMS (see list of measures applicable to OMSs) To earn the incentive or avoid the payment adjustment, an applicable measure is to be reported each time a procedure is performed during the reporting period. For complete list of the individual measures and the instructions on the use and reporting of the measures visit the Measure List Implementation Guidelines found on the CMS website.

For example, when the physician reports a mandibular fracture repair code (i.e. 21461-21462) - and documents the order for prophylactic parenteral antibiotics prior to the fracture repair within the patient’s record- PQRS measure #20: Perioperative Care: Timing of Antibiotic Prophylaxis-Ordering Physician can be reported.  This measure is to be reported each time a procedure is performed during the reporting period.

Measure Groups: Measures groups, on the other hand, include reporting on a group of clinically-related measures identified by CMS for use in PQRS. Measures Groups are a subset of four or more measures that have a particular clinical condition or focus in common.  For a provider to report a particular measures group, all individual measures included within that group must be reported. 25 measures groups have been established for 2014 Physician Quality Reporting System, but at this time there are no measure groups applicable for an OMS to report.   

PQRS Incentive Schedule

The PQRS program provides incentive payments which are based on the OMS’ total allowable Medicare charges for the reporting year, not just the charges associated with reporting the measures. The Affordable Care Act (ACA) authorized the incentive payment available until 2014 to all EP’s who successfully report PQRS measures for the prior calendar year.  However, in 2015, EP’s will no longer have an opportunity for an incentive payment and would be penalized for not successfully reporting in 2013. 

For example, an OMS participating in the 2014 PQRS program can either:

  • Successfully participate and earn the 0.5% incentive payment for all 2014 Medicare charges and avoid the 2016 payment adjustment, or
  • Report at least one applicable measure to avoid the payment adjustment, however wouldn’t be eligible for the incentive, or
  • Receive the 2016 payment adjustment of 2.0% on all Medicare charges made within the 2014 calendar year for failing to participate. 

The payment adjustment will be made two years after the reporting calendar year.  (I.E. If an OMS fails to participate in the 2014 PQRS program, their Medicare payment in 2016 will reflect a 2% deduction.)

  • 2010 = 2% incentive payments
  • 2011 = 1% incentive payments
  • 2012-2014 = .5% incentive payment
  • 2015 = 1.5% reduction in Medicare reimbursement for those who do not submit PQRS measures
  • 2016 and Beyond = the penalty will be increased to 2% in subsequent years

Reporting Options

Individual EP’s may report individual PQRS quality measures by submitting the PQRS data via:

  • Claims-based Reporting: Professionals who choose to participate by reporting quality measures data through claims can simply report the appropriate quality-data codes on service lines of a Medicare Part B Physician Fee Schedule (PFS) claim form.  See CMS’ example.
    • To be eligible for the 2014 incentive payment an individual must report at least 9 measures, covering at least 3 of the National Quality Strategy (NQS) domains, AND report each measure for at least 50% of the EP’s Medicare Part B patients seen within the 2014 reporting period
    • To avoid the 2016 payment adjustment and individual EP must Report at least 3 individual measures covering at least 1 NQS domain for at least 50% of Medicare Part B patients seen within the reporting period, OR report 1-2 individual measures covering at least 1 NQS domain for at least 50% of Medicare Part B patient seen within the reporting period. 
  • Qualified Clinical Data Registry (QCDR):  New for 2014, the QCDR is a CMS approved program which will collect an EP’s medical and/or clinical data for patient and disease tracking, and is submitted to CMS.  The data submitted to CMS is not limited to Medicare.  A list of CMS approved QCDR’s will be available on the CMS website in the fall.
    • To be eligible for 2014 incentive payment an individual must report on a minimum of 9 measures covering 3 NQS domains for at least 50% of Medicare Part B patients seen during the 2014 reporting period
    • To avoid the 2016 payment adjustment an individual must report at least 9 measures covering at least 3 NQS domains for at least 50% of Medicare Part B patients seen during the 2014 reporting period, OR report at least 3 measures covering at least 1 NQS domain  for at least 50% of Medicare Part B patients seen during the 2014 reporting period

A GPRO may report individual PQRS quality measures by submitting the PQRS data via:

  • GPRO Web Interface: Successful completion of the 22 Web Interface measures for the required number of patients will determine PQRS incentive eligibility and performance rates for the measures. To earn a 2014 PQRS incentive payment and avoid the 2016 PQRS payment adjustment, group practices taking part in PQRS GPRO via the Web Interface must meet the requirements for satisfactory reporting. 

 

  • 25-99 eligible professionals: To both earn the 2014 incentive payment AND avoid the 2016 payment adjustment a GPRO must report on all 22 measures included in the Web Interface; AND

Populate data fields for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100 percent of assigned beneficiaries.

  • 100+ eligible professionals: To both earn the 2014 incentive payment AND avoid the 2016 payment adjustment a GPRO must report on all measures included in the Web Interface; AND Populate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100 percent of assigned beneficiaries.
  • CMS- Certified Survey Vendor: New for 2014, a CMS-certified survey vendor is available to group practices of 25 or more EPs who would like to report the 12 Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) summary survey modules. CAHPS are patient experience surveys that ask respondents to evaluate their experience with providers.
    • The CG CAHPS summary survey modules will be considered the equivalent of 3 individual measures and 1 NQS domain. Therefore, group practices that register for this method of reporting will need to report on at least 6 additional measures covering at least 2 additional NQS domains via qualified registry, direct EHR product, or EHR data submission vendor. Group practices of 25 or more eligible professionals that select to have the CG CHAPS summary survey modules reported on their behalf will need to complete 6 measures covering at least 2 NQS domains using a qualified registry, direct EHR product, EHR data submission vendor, or GPRO Web Interface.

Both an Individual EP and a GPRO may report individual PQRS quality measures by submitting the PQRS data via:

  • Qualified Registry-based Reporting:  Eligible professionals must select a qualified PQRS registry for reporting from the list of registries that can be found on the CMS website.   The AAOMS has partnered with CECity to offer the PQRSwizard to members and their staff to assist them in accurately participating within the PQRS program.  CECity’s PQRSwizard is an online portal customized for the OMS Specialty, which will allow members and their staff to submit the eligible quality measures directly to CMS.  In doing so, OMS’ will report using eligible measures and will avoid the payment reductions from their Medicare Part B reimbursement.  The PQRS Wizard is available in so that OMSs may submit eligible measures for the 2013 reporting year by March 2014 in order to avoid payment reductions in 2015

 

Individual EP

GPRO

Receive Incentive

Report on at least 9 measures covering 3 NQS domains for at least 50% of the EP’s Medicare Part B patients, OR

report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B patients seen within the reporting period

 

Report on at least 9 measures covering 3 NQS domains for at least 50 % of the group’s Medicare Part B patients seen within the reporting period

 

Avoid

Payment Adjustment

Report at least 3 measures covering 1 NQS domain for at least 50 % of the EP’s Medicare Part B patients seen within the reporting period

 

Report at least 3 measures covering one NQS domain for at least 50 percent of the group’s Medicare Part B patients seen within the reporting period

  • Qualified EHR-based Reporting:  Eligible professionals will submit their PQRS data through an EHR product that is Certified EHR Technology (CEHRT) or through an EHR data submission vendor what is CEHRT.    A list of qualified EHR vendors that are CEHRT and their products are available on the CMS website.

 

 

Individual EP

GPRO

Receive Incentive

Report on at least 9 individual measures covering 3 NQS domains.  If the EP’s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. 

 

Report on at least 9 individual measures covering 3 NQS domains. 

 

Avoid

Payment Adjustment

Report on at least 9 individual measures covering 3 NQS domains.  If the EP’s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. 

 

Report on at least 9 individual measures covering 3 NQS domains. 

PQRS Measure Applicability Validation (MAV)

The MAV process is for those EPs who submit two or less PQRS measures across at least 1 NQS domain for at least 50 percent of their patients or encounters eligible for each measure and who do not submit any other measure. Once the EP submits less than 3 PQRS measures, the Centers for Medicare and Medicaid Services (CMS) will begin the MAV process.   The MAV process will determine whether they should have submitted additional measures.  Those who fail the validation process will not earn the PQRS incentive payment for 2014. However, eligible professionals who fail MAV may still avoid the 2016 Payment Adjustment if they had reported at least one valid measure if that 1 measure is all that would apply to the EP.  For more information on the MAV process, visit the Analysis and Payment page of the CMS website.