Recently, we’ve received questions about what it really means to satisfy PQRS requirements. Specifically, there’s some confusion regarding what it takes to actually fulfill the requirements for satisfactory reporting of measures. So, let’s break it down. The purpose of PQRS is to measure quality, and that’s based on four factors:

  1. Measure eligibility
  2. Performance criteria or quality action
  3. Reporting rate
  4. Performance rate

Measure Eligibility

Every measure has specifications that eligible professionals (EPs) reference to determine whether they can perform that measure on a particular patient. Those specs typically include:

  • Time period for a particular condition
  • Age range
  • Procedure (CPT) code
  • Diagnosis (ICD-10) code
  • Place of service
  • Factors related to condition

Now, referencing the specifications for every measure would be pretty time-consuming. That’s why most documentation platforms determine this information in advance, and then program their systems to examine patient data and prompt EPs to complete certain measures when the patient qualifies. (WebPT does this, and we build the measures directly into the documentation, so therapists satisfy PQRS as they complete their notes.)

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Performance Criteria or Quality Action

Performance criteria refers to the number of eligible patients who meet the specifications for a particular measure, meaning an EP can perform a “quality action” for those patients. When completing a measure for an eligible patient, an EP must denote that the measure was:

  • Met (e.g., a quality action was performed);
  • Not Met (e.g., a quality action was not performed); or
  • Excluded, which means that there is a documented reason for not meeting the performance criteria. (Note: Not all measures allow for exclusions.)

Reporting Rate

Medicare calculates the reporting rate by adding together the number of patients with quality actions (i.e., “met”) the EP reported, the number of patients without quality actions (i.e., “not met”) the EP reported, and the number of patients the EP excluded. Medicare then divides that number by the EP’s total number of eligible patients. Essentially, we have:

(Met + Not Met + Excluded) ÷ Total Number of Eligible Patients X 100 = Report Rate (in percentage)

To avoid the 2% downward adjustment associated with noncompliance, EPs must have a reporting rate of at least 50%. In other words, EPs must report on nine measures across three NQS domains for at least 50% of their Medicare Part B fee-for-service patients.

Performance Rate

In addition to calculating the reporting rate, Medicare also determines an EP’s performance rate. And this is where folks tend to get confused. In the hullabaloo of PQRS, many EPs forget this essential piece of the puzzle. According to the APAPO’s PQRS Pro, performance rate is “the percentage of times that you met the measure compared to the number of eligible patient visits entered for that measure and how many times you could have met the measure (i.e., 100 patient visits, 75 met, 25 not met = 75% performance rate).” Alternatively, PQRS Solutions reports that Medicare calculates performance rate by dividing the number of patients with quality actions (i.e., “met”) by the number of excluded patients minus the total number of eligible patients. The formula looks like this:

Met ÷ (Total Number of Eligible Patients - Excluded) X 100 = Performance Rate (in percentage)

Then there’s the American Society of Breast Surgeons, which says the formula is “Performance rate = mets / (mets + not_mets).”

So, what does Medicare say? “Calculating the Physician Quality Reporting System reporting rate (dividing the numerator by the denominator) identifies the percentage of a defined patient population that was reported for the measure. For performance rate calculations, some patients may be excluded from the denominator based on medical, patient or system exclusions allowed by the measure. The final performance rate calculation represents the eligible population that received a particular process of care or achieved a particular outcome.”

No wonder there are discrepancies in the formula, right?

The Performance Rate Debacle

Regardless of the formula, the key takeaway about performance rate is this: Medicare will not count any measures that have a 0% performance rate. That means EPs cannot simply mark all eligible patients as “not met” or “excluded” for any particular measure.

Why is this a debacle? Unfortunately, there are EPs out there who have, in essence, “mailed it in” when it comes to PQRS reporting. They’ve marked all eligible patients as “not met” or “excluded” for some or all applicable measures. And as a result, they’ve been hit with downward payment adjustments. And those EPs are wondering why they’re being penalized. After all, they “reported” PQRS, but that’s a misnomer. Because Medicare will not count any measures that have a 0% performance rate, EPs must select a satisfactory answer (i.e., a quality action) for at least 1% of the patients who are eligible for each measure. So if, for example, you’ve seen 300 Medicare patients in 2015, you’d need to report a satisfactory response on at least three of those patients for each qualifying measure.

Moral of the Story: Don’t Mail It In

Honestly, you should be performing quality actions on way more than 1% of the patients eligible for any given measure. After all, these measures—and their specifications and reporting criteria—are meant to apply to the majority of patients. That’s because CMS wants the data.

PQRS isn’t some requirement imposed to waste practitioners’ time and force them to jump through hoops (though it may feel that way sometimes). PQRS data is merely one step on the long path to healthcare payment reform. To more accurately reimburse for services provided—and improve patient care—CMS needs to know who clinicians are treating, how they’re treating these patients, and what outcomes they’re achieving.

As WebPT President Heidi Jannenga said in this month’s founder letter, “If you want to not only ensure your own survival in a pay-for-performance world, but also improve the outlook—with respect to payment, patient care, and influence within the healthcare space—for the rehab therapy profession as a whole, you must collect and utilize data.” Thus, it’s imperative you don’t “mail it in” when it comes to PQRS. Sure, reporting takes time; yes, in the day-to-day, it seems like a massive hassle. But the data you’re collecting is important. To quote Heidi again, if you fail to play by the PQRS rules, you put “your future at risk. You better believe physicians groups, chiropractors, and hospitals have been reporting on PQRS measures since the beginning...They might have a pretty good head start in terms of data collection, but there’s still time to catch up. Don’t get left in the dust; don’t let them win the value game without a fight. Get out there, collect and report data, and prove your—and your profession’s—worth.” I couldn’t have said it better myself.


Still scratching your head over PQRS? Let us help. Ask all your questions in the comment section below. Want an easier way to satisfy measure requirements in 2016? Request a free, online demonstration of WebPT, and see how our certified PQRS registry works.

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