What is PQRS?

CMS developed the Physician Quality Reporting System (PQRS), which requires that all eligible Medicare providers—including physical therapists, occupational therapists, and qualified speech therapists—meet criteria for the satisfactory reporting of certain outcome measures. The overall goal of PQRS is to improve the quality of reporting and patient data throughout the healthcare industry, thus reducing claim fraud and optimizing the reimbursement process. Although PQRS is not technically mandatory, eligible professionals who do not meet the reporting requirements are subject to financial penalties. In 2014—and for all subsequent years unless otherwise directed by CMS—that penalty is 2% of total Medicare payments. To comply with PQRS and thus avoid the payment adjustment, rehab therapists must report on a certain number of measures for a designated percentage of eligible Medicare patients. By introducing this initiative, CMS hopes to improve the overall quality of patient data throughout the healthcare industry, which in turn reduces claim fraud and streamlines the reimbursement process.

Now, one of the most common questions regarding PQRS is, "Does it apply to me?" And for those in the rehab therapy business, the answer is usually "yes." But below are the details on PQRS eligibility.

Who are Eligible Professionals?

According to CMS, "Under Physician Quality Reporting System (PQRS), covered professional services are those paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services [that] get paid under or based on the Physician Fee Schedule, those services are eligible for PQRS incentive payments and/or payment adjustments." Based on that definition, all eligible professionals billing under Medicare Part B for outpatient therapy services in private practice settings—including physical therapists, occupational therapists, and qualified speech-language pathologists—all qualify for PQRS participation.

However, some professionals who qualify for PQRS according to their specialty may not be able to participate due to their billing method. CMS provides the following examples of providers who would not be eligible to participate:

  • Professionals who provide Medicare Part B services, but bill under Part A (i.e., at a facility or institution)
  • Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider's individual NPI is entered on CMS-1500 type paper or electronic claims billing, associated with specific line-item services
  • Professionals who provide services payable under fee schedules or methodologies other than the Medicare Physician Fee Schedule (e.g., services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals, rural health clinics, ambulance providers, and ambulatory surgery center facilities)

What Does PQRS Compliance Entail?

To comply with PQRS, rehab therapists must perform a certain number of applicable outcome measures on a designated percentage of Medicare patients. Therapists must then submit the results of each measure using a quality data code (QDC) and a QDC modifier.

What's the Difference Between Registry-Based and Claims-Based PQRS Reporting?

There are actually three different methods for reporting PQRS:

Registry-Based (Automatic Individual Submission)

When you report via a registry, the registry handles most of PQRS for you. For example, as a certified PQRS registry, WebPT merges PQRS with standard documentation. That means all you have to do is report your PQRS measures directly within the patient record. We then mine that data, compile it, and submit it to CMS on your behalf. Basically, once you select your PQRS measures, you simply document, and we manage the rest. You'll never forget to complete PQRS on an eligible patient, because we remember for you.

Group Practice Reporting Option (GPRO) (Automatic Group Submission)

GPRO is a registry-based PQRS reporting option geared toward multi-therapist practices (clinics with two or more therapists) that wish to participate as a group. It allows therapists who share one tax ID to report measures and reach the required reporting percentage together. This method is not available to those submitting PQRS data via claims. Additionally, practices wishing to participate in GPRO must sign up (self-nominate) for GPRO directly through CMS.

Claims-Based (Manual Individual Submission)

With claims-based reporting, you must manually enter your PQRS data on your claim forms before submitting them to Medicare. WebPT's claims-based reporting option allows you to use your WebPT documentation to assist you with completing PQRS. Our system will help you select the appropriate codes so you'll submit accurate data, but it's still your responsibility to make sure those codes are properly submitted with your Medicare claims. For claims-based reporting, you will record your PQRS quality data codes (QDCs) on the claim form just like any other code; however, these QDCs will have a $0.00 (or nominal) charge.

What are the Advantages of Registry-Based Reporting Over Claims-Based?

With claims-based reporting, the burden of compliance is mostly on you. You're responsible for remembering what to report, for whom, and how frequently as well as for correctly documenting and submitting the data to Medicare. With registry-based reporting, on the other hand, your EMR will take care of the heavy lifting for you. It'll prompt you to answer the necessary PQRS questions at the required times during normal documentation, compile the data for you, and electronically submit it to CMS on your behalf. Basically, a registry makes it nearly impossible not to stay compliant. Thus, we recommend registry-based reporting. At the end of the day, though, regardless of the reporting method you choose, participating in PQRS means you're better protecting your practice from penalties.

What are the PQRS 2014 Regulations and Penalties?

First, it's important to understand that PQRS is not technically mandatory. Even if you are eligible for PQRS, you can choose not to participate. However, in 2013 Medicare introduced a financial penalty for those eligible professionals who do not successfully complete the requirements for satisfactory reporting. In 2014—and for all subsequent years unless otherwise directed by CMS—that penalty is 2% of your total Medicare payments. For example, if you don't successfully complete the requirements for satisfactory reporting in 2014, you'll be subject to a 2% payment adjustment in 2016.

In 2014, Medicare also is offering an incentive bonus of 0.5% of total Medicare payments to those eligible professionals who meet certain requirements for successful reporting. This is the last year Medicare will offer such an incentive.

Two Levels of Successful PQRS Reporting

There are two levels of successful PQRS reporting:

  • Reporting merely to avoid the 2% penalty (meaning you wouldn't earn the incentive)
  • Reporting to avoid the 2% penalty and earn the 0.5% incentive

Requirements for Individual Submission: Claims and Registry

In 2014, the requirements for individual PQRS submission are the same for both claims- and registry-based reporting. Please note that for a patient to be eligible for PQRS reporting, he or she must have Medicare proper as a primary or secondary insurance. Patients who have Medicare replacement or Medicare Advantage (Part C) are not eligible for PQRS because technically, they are commercially (privately) insured.

To merely avoid the 2% penalty, you must:

  • Report at least three measures covering at least one National Quality Standard (NQS) domain on at least 50% of your Medicare Part B FFS patients.
  • Or, if fewer than three measures apply to you as the eligible professional, then report one to two measures on at least 50% of your Medicare Part B FFS patients.

To avoid the 2% penalty and earn the 0.5% incentive, you must:

  • Report at least nine measures covering at least three National Quality Standard (NQS) domains on at least 50% of your Medicare Part B fee-for-service (FFS) patients.
  • Or, if fewer than nine measures covering at least three NQS domains apply to you as the eligible professional, then report one to eight measures covering one to three NQS domains, and report each measure on at least 50% of your Medicare Part B FFS patients.

Although there are loads of individual PQRS measures, only a handful apply to rehab therapists. Here the ones that do (and that WebPT currently has in the application):

Physical Therapy

  • #126 Diabetes Foot/Ankle Evaluation (Registry only)
  • #127 Diabetes - Footwear Evaluation (Registry only)
  • #128 BMI Screening
  • #130 Current Medications
  • #131 Pain Assessment
  • #154 Falls Risk Assessment
  • #155 Falls POC
  • #182 Functional Outcome Assessment
  • #245 Chronic Wound Care
  • #246 Chronic Wound Care - Use of Wet-Dry Dressings

Outside of WebPT, there are also FOTO's Functional Deficit Measures:

  • #217 Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
  • #218 Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
  • #219 Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot, or Ankle Impairments
  • #220 Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
  • #221 Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
  • #222 Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist, or Hand Impairments
  • #223 Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments

Occupational Therapy

  • #128 BMI Screening
  • #130 Current Medications
  • #131 Pain Assessment
  • #154 Falls Risk Assessment
  • #155 Falls POC
  • #134 Preventative Screening Clinical Depression
  • #173 Alcohol consumption Assessment (Registry only)
  • #181 Elderly Maltreatment Screen and Follow-Up
  • #226 Tobacco Use Screen and Cessation Intervention

Speech-Language Pathology

  • #130 Current Medications

Requirements for Group Submission (GPRO)

Group Practice Reporting Option (GPRO) is a registry-only PQRS option available to group practices with two or more eligible professionals. In 2014, the GPRO requirements for both avoiding the penalty and earning the incentive are identical to the requirements for those using the individual registry-based option. However, the requirements for satisfactory reporting (including the 50% minimum) apply to the practice as a whole, not each individual therapist.

For example, if there are two therapists in your practice and one only reports on 25% of his or her Medicare Part B patients, but the other one reports on 75% of his or her Medicare Part B patients, the practice would still meet the 50% minimum because the two therapists together would report on an average of 50% of eligible Medicare patients.

The MAV Process

Regardless of which level of reporting you choose (i.e., whether you're reporting to merely to avoid the penalty or earn the incentive), if the number of measures that apply to you as an eligible professional is below the number of measures you are required to report, you will report as many as you can and will then be subject to the Measures Applicability Validation (MAV) process. This is the process by which Medicare determines whether an eligible professional should have reported quality data codes for additional measures.

Also, please note that under no circumstance can you resubmit a claim for an eval you've already billed for the sole purpose of adding PQRS data. That's a red flag to Medicare, and they won't accept it anyway.

Back Pain Measures Group

CMS defines a measures group as "a subset of four or more PQRS measures that have a particular clinical condition or focus in common. The denominator definition and coding of the measures group identifies the condition or focus that is shared across the measures within a particular measures group." Individual eligible professionals have a slew of group measures to report on; however, rehab therapists only qualify to report on one: the back pain measures group.

The fact that rehab therapists even have the option of reporting on a measures group is extremely important, because if you treat a high number of Medicare patients, this is absolutely the easiest way to both avoid the penalty and earn the incentive.

The back pain measures group includes four measures, all related to back pain:

Table 61: Back Pain Measures Group

NQF/PQRS Measure Title and Description Measure Developer
0322/148 Back Pain: Initial Visit: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who had back pain and function assessed during the initial visit to the clinician for the episode of back pain NCQA
0319/149 Back Pain: Physical Exam: Percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received a physical examination at the initial visit to the clinician for the episode of back pain NCQA
0314/150 Back Pain: Advice for Normal Activities: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice for normal activities at the initial visit to the clinic for the episode of back pain NCQA
0313/151 Back Pain: Advice Against Bed Rest: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice against bed rest lasting four days or longer at the initial visit to the clinician for the episode of back pain NCQA

Finalized in the CY 2013 PFS final rule (see Table 103 at 77 FR 69275).

If you choose to report on the back pain measures group, the requirements for both avoiding the penalty and earning the incentive are one and the same. You must report all four measures for at least 20 eligible patients. Please note that you must report the measures group at the patient's initial evaluation for that patient to count toward your 20 total.

Additionally, for a patient to qualify for this measures group, he or she:

  • must be age 18-79
  • must have a qualifying back pain diagnosis
  • must not have been seen or treated for back pain by any practitioner during the four months prior to the first clinical encounter with a diagnosis of back pain
  • must not be receiving post-surgery therapy unless it has been at least four months since the surgery and the patient has not received any other treatment during that time period

The ICD-9 codes that qualify for the back pain measures group are:

721.3; 721.41; 721.42; 721.90; 722.0; 722.10; 722.11; 722.2; 722.30; 722.31; 722.32; 722.39; 722.4; 722.51; 722.52; 722.6; 722.70; 722.71; 722.72; 722.73; 722.80; 722.81; 722.82; 722.83; 722.90; 722.91; 722.92; 722.93; 723.0; 724.00; 724.01; 724.02; 724.09; 724.2; 724.3; 724.4; 724.5; 724.6; 724.70; 724.71; 724.79; 738.4; 738.5; 739.3; 739.4; 756.12; 846.0; 846.1; 846.2; 846.3; 846.8; 846.9; 847.2

Heidi Jannenga PT

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