Blog Post

It’s Time for Your Mid-Year PQRS Audit

Make sure your practice is on the right track to avoid big PQRS penalties. Click here to learn more and be prepared for the PQRS Audit.

Bradley LaFave
5 min read
June 21, 2016
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With temperatures soaring—especially here in Phoenix—summertime is definitely upon us. That means you’re probably making family vacation plans, relaxing poolside, and doing a mid-year PQRS compliance audit—er, okay, maybe not that last one. But, in all seriousness, this is the perfect time of year to check your clinic's PQRS compliancy. After all, we’re halfway through the calendar year—which means we’ve reached the midpoint of the 2016 PQRS reporting period.

Before we jump into the nitty-gritty of auditing your PQRS compliance, I want to emphasize the importance of PQRS: failure to meet the criteria for satisfactory reporting this year will result in a 2% penalty for all of your Medicare payments in 2018. Do the little extra work now and you’ll save big later.

Okay, on to the audit! To assess your compliancy, you need to understand two critical requirements:

  • You must have a reporting rate of at least 50%. The reporting rate is the number of patients an eligible professional (EP) reported (met, not met, and excluded) divided by the EP’s total number of eligible patients.
  • You must have a performance rate of at least 1%. CMS will not count any measures with a 0% performance rate. This is an important detail, because it means EPs cannot simply mark all eligible patients as “not met” for any particular measure. Rather, EPs must select a satisfactory answer (i.e., take a quality action) for at least 1% of the patients who are eligible for each measure.

Auditing your mid-year PQRS compliance entails verifying the reporting and performance rates for each measure on which you’re required to report. Of course, you may be wondering what, exactly, constitutes a performance or satisfactory response. To better understand this concept, let's look at an example:

Measure 128 requires the EP to calculate the patient’s BMI and indicate a follow-up plan if it is above or below normal parameters. There are seven possible responses for this measure:

  1. BMI Calculated as Normal, No Follow-up Plan Required
  2. BMI Documented as Above Normal Parameters and Follow-up Documented
  3. BMI Documented as Below Normal Parameters and Follow-up Documented
  4. BMI not Documented, Patient not Eligible
  5. BMI Documented Outside of Normal Limited, Follow-up Plan Not Documented, Patient not Eligible
  6. BMI not Documented, Reason not Given
  7. BMI Documented Outside of Normal Parameters, Follow-Up Plan not Documented, Reason not Given

Responses 1-3 are considered performance responses. This means that the actions required by the measure were completed and fully-documented. Performance responses count toward both the reporting (>50%) and performance (>1%) rates.

Responses 4-5 are considered performance exclusion responses. These responses are typically used to indicate that a patient is not eligible for the measure. Performance exclusion responses count toward the reporting rate (>50%), but they do not count toward the performance rate (>1%).

Responses 6-7, are considered non-performance responses. These answers indicate that the actions required for successful reporting of the measure were not completed and that no further information or reason was provided. Non-performance responses count toward the reporting rate (>50%), but they do not count toward the performance rate (>1%).

Note: WebPT Members can see all PQRS measure response breakdowns in this WebPT Community article.

Now, determining your mid-year reporting and performance rates for every applicable measure might seem like a daunting task. For WebPT Members with registry-based PQRS, though, checking compliance through our PQRS Status Report is a snap. The report is a tool clinic admins can use to assess high-level reporting and performance data. If issues exist—that is, if either the reporting or performance rate is not met for a particular measure—the user can investigate the reason for the deficiency with a single click. The clinic can then adjust reporting practices accordingly, thus ensuring compliance by the end of the year. With all that time saved, you’ll have more room in your schedule for important decisions—like choosing where to go for that family vacation.


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