Physician Quality Reporting System
& Value Based Payment Modifier Don Gettinger, Quality Data
Reporting Manager
QSource
Medicare - Pay for Performance
CMS is seeking to promote higher quality of care and
more efficient health for all Medicare beneficiaries.
CMS is doing this by implementing an increasing
number of quality measures, value based payment and
quality reporting programs.
Measures are based on high priorities and assess
clinical quality, care coordination, patient safety,
population health, patient and care giver experience.
Medicare Quality Reporting
Existing programs are being aligned/consolidated to
develop quality-tiering which will result in upward,
neutral or downward payment adjustments.
Medicare Quality Reporting (cont.)
Examples:
Hospital Value Based Payment (VBP)
• Inpatient Quality Reporting (IQR)
• Outpatient Quality Reporting (OQR)
• Readmission Reduction Program
• Meaningful Use (EHR incentive)
Physician Value Based Payment Modifier (VBPM)
Physician Quality Reporting System (PQRS)
Meaningful Use (EHR incentive)
Physician Quality Reporting System
(PQRS)
PQRS has been voluntary Medicare incentive payments
from 2005 – 2012
CY 2013
“Required to avoid a penalty”
PQRS History/Background
Reporting Year Incentive Year Incentive Payment Penalty Year Penalty Reduction
2005 2007 + 1.5%
2006 2008 + 1.5%
2007 2009 + 2.0 %
2008 2010 + 2.0%
2009 2011 + 1.0%
2010 2012 + 1.0%
2011 2013 + 0.5%
2012 2014 + 0.5%
2013 2015 - 1.5%
2014 2016 - 2.0%
2015 2017 - 2.0%
Adjustments are a percentage of all Medicare allowable FFS
charges.
There is a two year lag
between the reporting
year & the payment
impact year!
Failed to report - 2013
Over 7,000 professionals in Indiana received a penalty letter
in November 2014.
The penalties are based on TIN + NPI
If you believe this letter is in error – ask for an “informal
review” before Feb. 28, 2015.
All informal review requests must be submitted via a web-
based tool, the Quality Reporting Communication Support
Page (Communication Support Page), during the informal
review period, Jan. 1, 2015 through Feb. 28, 2015.
How are the penalties applied?
A negative 1.5% payment reduction will be applied to
all Medicare Part B MPFS covered allowable charges
in 2015.
The negative payment reduction will occur for those
TIN/NPI combinations that did NOT report in 2013.
Only 2015 bills with the TIN/NPI combination will
result in a payment reduction.
CY 2014
Failure to report in 2014 will result in a negative 2%
PQRS payment reduction in 2016.
Only limited options remaining:
Deadlines for reporting 2014 data:
February 28, 2015 (Direct EHR methods)
March 31, 2015 (Registry methods)
Qualified registries are listed online:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Registry-Reporting.html
PQRS Eligibility
Critical Access Hospitals (CAHs)
New Note: Beginning in 2014, professionals who reassign
benefits to a Critical Access Hospital (CAH) that bills
professional services at a facility level, such as CAH Method II
billing, can now participate (in all reporting methods except for
claims-based).
To do so, the CAH must include the individual provider NPI on
their institutional (FI) claims.
PQRS Eligibility
Cannot Participate
Providers who do not bill Medicare at an individual NPI
level, where the rendering provider’s individual NPI is not
entered on the CMS-1500 paper or electronic claim
• FQHCs
• RHCs
• Ambulatory Surgery Centers
• Independent Labs (including “81” place of service)
CY 2015
Start Planning NOW!
Deadlines impact your options
Claims based reporting
G codes must be submitted with each claim
throughout the year.
Group practice options
Groups must register in PV-PQRS between
April 1 – June 30, 2015.
Penalties consolidated and increased over time
CY 2015
CMS is consolidating PQRS and VBPM in 2015
Groups sized 1 – 9 EPs
Failure to report in 2015 results in a negative 4%
payment reduction in 2017.
◉ 2% for not PQRS reporting
◉ 2% for value based purchasing
Groups sized 10+ EPs
Failure to report in 2015 results in a negative 6%
payment reduction in 2017.
◉ 2% for not PQRS reporting
◉ 4% for value based purchasing
PQRS Eligibility All billing for covered Part B services under MPFS – TIN/NPI on 1500 claim
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
Practitioners & Therapists
Physician
Assistant
Nurse
Practitioner
Clinical Nurse
Specialist
Anesthetist Certified
Nurse Midwife
Clinical Social
Worker
Clinical
Psychologist
Registered
Dietician
Nutrition
Professional
Audiologist Physical
Therapist
Occupational
Therapist
Qualified
Speech-
Language
Therapists
2015 PQRS Reporting Methods
Individual EP Reporting Options Group Practice Reporting Options
(GPRO)
Claims GPRO Web-Interface
Direct EHR (CEHRT) Direct EHR (CEHRT)
EHR Data Submission Vendor (DSV) CEHRT EHR Data Submission Vendor (DSV) CEHRT
Qualified Registry Qualified Registry
Qualified Clinical Data Registry (measures are
selected by the QCDR)
Qualified Clinical Data Registry (measures are
selected by the QCDR)
CMS Certified Survey Vendor for (CG-CAHPS)
Individual EP
Reporting Options
Considerations
Claims Clinic collects data and submits quality codes on each 1500
claim as billed.
Direct EHR (CEHRT) EHR vendor must support direct reporting and EPs must be
using the system. Clinic must have an IACS account and
keep passwords up to date. Must submit data yourself via
portal before Feb 28, 2016.
EHR Data Submission Vendor
(DSV) CEHRT
EHR must support DSV reporting and EPs must be using the
system. Vendor extracts data from system, arranges IACS
account & submits data by Feb 28, 2016.
Qualified Registry Contract relationship with vendor, some extract from EHR and
some allow direct entry. Vendor arranges IACS account &
submits data by March 31, 2016.
Qualified Clinical Data Registry
(measures are selected by the
QCDR)
Contract relationship with vendor, often specialty, EHR or
health system related. Vendor arranges IACS account &
submits data by Feb or March 2016 depending on type of files
submitted.
2015 PQRS Reporting Methods
GROUP Reporting Considerations
Update group information in PECOS Register group in PV-PQRS by April – June 2015
Select reporting option & measures Measures: Entire group must report same set of measures
Reporting Options Available based on size group
GPRO Web Interface Only available to groups 25+ EPs: Enter data on 250
patients randomly selected from your claims data – answer
all applicable measures
Direct CEHRT EHR All group sizes: EHR must support direct reporting and all
EPs must be using the system.
EHR Data Submission Vendor (DSV)
CEHRT
All group sizes: EHR must support DSV reporting and
all EPs must be using the system
Qualified Registry All group sizes: Contract relationship with registry and have
a method to collect measures during the year.
Qualified Clinical Data Registry
(measures are selected by the QCDR)
All group sizes: Contract relationship with registry and have
a method to collect measures.
2015 PQRS Reporting Methods
2015 Reporting Requirements
High Level Overview
9 measures across 3 National Quality Strategy
Domains
One cross-cutting measure (face-to-face visits)
Groups 25+ begin reporting CAHPS
(patient satisfaction surveys)
National Quality Strategy (NQS)
NQS Domains
Patient Safety
Person & Caregiver-Centered Experience & Outcomes
Communication & Care Coordination
Effective Clinical Care
Community/Population Health
Efficiency & Cost Reduction
Same domains used for MU Clinical Quality Measures
2015 Reporting Links
2015 PQRS Implementation Guide:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf
2015 Measures List:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip
2015 Cross-cutting Measure List
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2015_PQRS_CrosscuttingMeasures_12172014.pdf
2015 Individual Claims/Registry Measures Specifications
http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_IndividualMeasureSpecs_Su
pportingDocs_111214.zip
2015 Measures Group Specifications
http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_MeasuresGroupsSpecs_Sup
portingDocs_111214.zip
Value Based Payment Modifier (VBM)
Cost and Quality
“Quality tiering” methodology based on quality
and cost metrics in comparison to national averages
A per-claim adjustment under the MPFS
Positive, negative, or no adjustment
This is in addition to any PQRS negative
adjustment
VBPM (cont.)
Applied to the Medicare paid at the TIN level to
physicians billing under the TIN
Aligned with and based on PQRS participation
2013/2015
100+ Physicians
2014/2016
10-99 Physicians
2015/2017
ALL Eligible Providers
VBPM (cont.)
Reports Based on TIN
Your Value-Based Payment Modifier
The highlighted payment adjustment will be applied to your
Medicare Physician Fee Schedule reimbursements in CY 2015.
Low Quality
Average Quality High Quality
Low Cost
+0.0%
+ 1.0 x AF + 2.0 X AF
Average Cost
-0.5%
+0.0%
+ 1.0 X AF
High Cost
-1.0%
-0.5%
+0.0%
Note: The displayed payment adjustment includes the high-risk bonus adjustment, if applicable. The precise size of the reward for higher-performing groups will vary from year to year, based on an adjustment factor (AF) derived from actuarial estimates of projected billings. The AF for 2015 will be posted athttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html.
Impacts Groups by Size
Size based on eligible professionals billing to your TIN that did not
participate in the Medicare Shared Savings Program (MSSP), the
Pioneer ACO Model, or the Comprehensive Primary Care (CPC)
initiative.
Value Based Modifier
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
Performance Year 2014 Benchmarks
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/PY2014-Prior-Year-
Benchmarks.PDF
Practice Size Performance Year Impact Year
100+ EPs 2013 2015
10 + EPs 2014 2016
1 + EPs 2015 2017
Quality & Resource Use Reports (QRUR)
All TINs (groups and solo practitioners) nationwide that meet the
following two criteria will receive a 2013 QRUR:
• At least one physician billed under the TIN in 2013, AND
• The TIN had at least one eligible case for at least one of the
quality or cost measures included in the QRUR.
TINs with one or more physicians that participated in the Medicare
Shared Savings Program, the Pioneer ACO Model, or the
Comprehensive Primary Care Initiative in 2013 will not receive a 2013
QRUR.
What Information is Contained in the QRUR?
1. Your Quality Composite Score
2. Your Cost Composite Score
3. Your Quality Tiering Performance
What Information is Contained in the
QRUR? (Cont’d)
Quality Composite Score Elements
PQRS Reported Data
For 2013 QRURs, only GPRO data is included
CMS Calculated Data Elements
CMS-1 Acute Conditions Composite
Bacterial Pneumonia, Urinary Tract Infection, Dehydration
CMS-2 Chronic Conditions Composite
Diabetes, Chronic Obstructive Pulmonary Disease (COPD)
or Asthma, Heart Failure
CMS-3 All-Cause Hospital Readmission
Cost Composite Score Elements
Per Capita Cost for All Attributed Beneficiaries
Per Capita Costs for Beneficiaries with Specific
Conditions
Diabetes, Heart Failure, COPD, Coronary Artery Disease
How to Use the QRUR Reports
Determine your payment adjustment for 2015 (Groups
of 100+ eligible providers only)
Review past performance to prepare for the 2016
payment adjustment based on 2014 reporting year
(Groups of 10+ eligible providers)
Identify opportunities to improve the quality and
efficiency of care delivered
How to Access QRUR Reports
Authorized representatives of groups and solo practitioners can
access the QRURs at https://portal.cms.gov using an Individuals
Authorized Access to the CMS Computer Services (IACS) account
with one of the following Physician Value (PV)-PQRS System roles:
For groups with 2 or more EPs (TIN with 2+ NPIs):
• PV-PQRS Group Security Official (primary or back-up)
• PV-PQRS Group Representative
For solo practitioners (TIN with 1 NPI):
• PV-PQRS Individual (primary or back-up)
• PV-PQRS Individual Representative
How to Access QRUR Reports
A quick reference guide, which provides step by step instructions for
accessing the2013 QRUR, is available at :
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeedbackProgram/Downloads/Quick-Reference-
Guide-for-Accessing-2013-QRURs.pdf
IACS Account Required
Obtaining An IACS Account is Required
To access the Registration System in order to register for a 2015 PQRS
GPRO or obtain a QRUR report, an authorized representative of the group
must have an IACS account.
If the group does not yet have an authorized representative with an IACS
account, then one person representing the group must sign up for an IACS
account with the primary “PV-PQRS Group Security Official” role.
If the group has a representative with an existing IACS account, but not one
with the primary “PV-PQRS Group Security Official” role, then please
check with the QualityNet Help Desk that the account is still active and add
this role to that person’s existing IACS account.
IACS Account Required (cont.)
Obtaining An IACS Account is Required
Group representatives can sign up for a new IACS account or
modify an existing account at https://applications.cms.hhs.gov.
Please complete this step NOW to avoid any last minute delays in
obtaining an IACS account.
Also, please note that it takes approximately 24 hours for CMS to
process an IACS account request; therefore, an IACS account must
be obtained in advance so that the group’s registration can be
submitted by June 30, 2015.
A guide with step-by-step instructions for obtaining an appropriate
IACS account is available in the “Downloads” section of CMS’
Registration website listed above.
Contact Information
Don Gettinger
[email protected] | 812-243-0847
This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services (DHS). Content does not necessarily reflect CMS policy. 15.SS.MS.D1.001
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