Yesterday, we hosted a webinar focused on PQRS 2016. We received a lot of questions during the live session—so many, in fact, that we’ve amassed them here in a handy FAQ. Got a question and don’t see an answer below? Ask it in the comment section at the bottom of this post.

New Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Regular BannerNew Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Small Banner

Eligibility

Do I have to participate in PQRS? What makes me an eligible provider?

If you are a healthcare professional providing services paid under or based on the Medicare Physician Fee Schedule, then you are eligible to participate in PQRS. So, if you bill under Medicare Part B for outpatient therapy services—including PT, OT, SLP, and DC—then you must meet the requirements for satisfactory reporting, regardless of setting. Otherwise, you will incur a financial penalty in the form of a 2% negative adjustment of all 2018 Medicare Part B payments.

However, there are some exceptions. According to CMS, “Some professionals may be eligible to participate per their specialty, but due to billing method may not be able to participate,” including “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 or CMS-1450 type paper or electronic claims billing, associated with specific line-item services.”

Check out the full list of 2015 PQRS eligible professionals here.

Do Medicare Part A facilities have to complete PQRS reporting?

No. PQRS does not apply to professionals billing under Medicare Part A.

What other factors make someone ineligible for PQRS?

You are not eligible for PQRS if you:

  • Provide Medicare Part B services, but bill under Part A (i.e., at a facility or institution).
  • Do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider’s individual NPI is entered on CMS-1500 claim form and associated with specific line-item services.
  • Provide services payable under fee schedules or methodologies other than the Medicare Physician Fee Schedule (this may include services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals, rural health clinics, ambulance providers, and ambulatory surgery center facilities).

Can a PTA enter PQRS data?

PTAs do not qualify as eligible professionals. Thus, they cannot report PQRS. While they can assist in gathering PQRS data, the PT must supervise/sign off on all quality actions performed.

Will other payers, besides Medicare, require PQRS in the future?

While the future of PQRS remains uncertain, it likely will become part of Medicare’s Merit-based Incentive Payment System (MIPS), which is set to go into effect in 2019 (with reporting beginning in 2017). So, while other payers may not adopt PQRS in its current form, you can expect to see a greater emphasis on quality data across the entire payer spectrum as the US healthcare system shifts to a more value-based payment environment.

I don’t use an EMR. Do I still report PQRS?

Regardless of whether you use an EMR, if you’re an eligible professional, you must satisfy PQRS requirements in order to avoid incurring the 2% penalty. If you do not report via a registry (which is the option most convenient for EMR users), then you can report via claims. That means you must record the appropriate PQRS quality data codes directly on the billing claim. To learn more about the differences between registry- and claims-based reporting, check out this blog post.

Reporting

How do the various reporting methods differ?

Registry reporting means you submit your data electronically via a registry, rather than reporting the information at the individual claims level. When you use WebPT's registry, you report on all of your measures as you complete your documentation. Then, we compile all of it and submit it to CMS on your behalf. Claims-based reporting, on the other hand, requires that you select and add the appropriate PQRS data codes to each individual claim. Finally, GPRO is a registry-based reporting option that allows practices with multiple eligible professionals to satisfy the reporting requirements as a group, rather than as individuals. For a more detailed breakdown of each option, refer to this blog post.  

Does Therabill automatically report like WebPT does?

No, Therabill is not a certified registry like WebPT. Thus, it does not offer the automatic registry submission option.

When do I report on PQRS? Does it work like functional limitation reporting?

While PQRS and FLR both involve the use of G-codes, they are completely separate reporting programs. With FLR, participants must report data codes at each qualifying initial evaluation, at every tenth visit, and at discharge. With PQRS, the reporting intervals vary from measure to measure. To find out when you need to report on a particular measure, check the measures specifications guide, which you can download here. For more information on the difference between FLR and PQRS, check out this blog post.

Where can I go to check my reporting progress?

If you use PQRS in WebPT, you can check your reporting rate using the PQRS Report. However, please note that this report analyzes only quantitative—not qualitative—PQRS reporting data. Thus, it does not reflect performance rate. This is because performance rate is tied to quality actions. You can also check on your reporting progress in the CMS reporting portal found here.

How do I report on measures 154 and 155?

In order to report on either measure, the patient must be 65 years of age or older and have a history of falls. (A patient with a history of falls, as defined by Medicare, has had two or more falls occurring within the past year or has had one fall with injury.) Both of these measures must be reported at least once per reporting period. Keep in mind that there’s not a diagnosis associated with these measures. If you report on measure 154 (Falls Risk Assessment), you also must report on measure 155 (Falls Risk Assessment & Plan of Care).

New for 2016: These measures are now associated with CPT codes 92541 and 92542. These codes are typically used by chiropractors, but not often.

What about measures 126 and 127?

Measures 126 (Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation) and 127 (Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear) are available only to PTs using registry-based PQRS reporting. Both of these measures must be reported at least once per reporting period at either initial evaluation or re-evaluation.

Measure 126

Measure 126 applies to patients who are 18 years or older with a diagnosis of diabetes mellitus. Eligible patients also must have had neurological exams of their lower extremities within the last year. The ICD-10 diagnosis codes that trigger this measure fall into the E10, E11, and E13 code families.

Measure 127

The denominator that applies to 126 also applies to this measure. Eligible patients also must have been evaluated for proper footwear and sizing within the last year. The ICD-10 diagnosis codes that trigger this measure fall into the E10, E11, and E13 code families.

As a rehab therapist, how many measures do I need to report on?

Good question. While the general requirements for reporting are the same across the board—nine measures across three NQS domains, including at least one cross-cutting measure—many rehab therapists will find they are unable to report on nine measures, because fewer than nine apply to them. If you’re one of those therapists, the number of measures you must report depends on your specialty and which reporting method you choose. Here’s the breakdown of available measures:

Individual Claims-Based
  • PTs: Six measures
  • OTs: Nine measures
  • SLPs: Three measures
Individual Registry-Based
  • PTs: Eight measures
  • OTs: Ten measures (Note that only nine measures are available within WebPT)
  • SLPs: Three measures
GPRO

For this reporting method, you have two options, and each option has its own requirements:

  1. Report on at least nine measures across three NQS domains for at least 50% of your Medicare Part B FFS patients. (Note that WebPT only offers this option for GPRO reporting.)
  2. Report on six measures across two NQS domains, and complete a CAHPS survey. (Please note that this survey is required for groups with 100 or more eligible professionals.)

When do I report on the measures?

Each measure has its own specifications for reporting intervals. Some measures are reported at only the initial evaluation or re-evaluation; others are reported at every visit. To download the 2016 measures specifications, visit this page.

What are cross-cutting measures?

Cross-cutting measures are broadly-applicable measures that help paint a better picture of the overall quality of care furnished by eligible professionals. You do not have to report your cross-cutting measure on top of your other required measures, so long as one of the individual measures you report qualifies as a cross-cutting measure. Please note that there is at least one cross-cutting measure available to PTs, OTs, and SLPs—with multiple cross-cutting measures available to PTs and OTs—so fulfilling this requirement should not be an issue.

Where can I see which measures apply to my specialty, which are cross-cutting measures, and the reporting method(s) available for each measure?

You’ll find a list of the measures that apply to each rehab therapy specialty—as well as a form where you can download a measures chart—in this blog post.

Is there still time for me to participate in PQRS 2015 so I avoid the 2% penalty in 2017?

While it's too late in the game to start reporting for 2015 using WebPT, now would be the perfect time to get set up for registry-based reporting in 2016 in order to avoid the penalty in 2018. Click here to get started. Or, if you’re already a WebPT Member, email membervalue@webpt.com to start using our PQRS feature.

How does ICD-10 affect PQRS?

Just like certain ICD-9 codes trigger certain PQRS measures, ICD-10 codes will do the same. If you use WebPT to report on PQRS, our system will prompt you to report when one of those triggers exists.

Do I have to report on nine measures for each qualifying patient?

You must report on as many measures as you can, based on your specialty. The number of measures available to you also may vary depending on the reporting method you choose (e.g., claims, registry, or GPRO).

What if none of the eligible patients I see meet the criteria for a particular measure?

Only the eligible patients who meet the criteria for a measure will count toward your performance rate for that measure. You cannot—and should not—report a measure for a patient who does not meet the reporting criteria.

Where can I access the 2016 PQRS measures specifications?

You can find the 2016 PQRS measure specifications here.

GPRO

Can I use WebPT to report via GPRO?

Yes. However, if you choose to participate in GPRO, you must do so using our registry-based reporting option, as GPRO is not available to eligible professionals completing PQRS via claims.

How does GPRO work?

Groups with two or more eligible professionals can complete satisfactory reporting via GPRO using one of two methods:

  1. Report on at least nine measures across three NQS domains for at least 50% of your Medicare Part B FFS patients. (Note that WebPT only offers this option for GPRO reporting.)
  2. Report on six measures across two NQS domains, and complete a CAHPS survey. (Please note that this survey is required for groups with 100 or more eligible professionals.)

As with the first two reporting options, EPs who report via GPRO are subject to these requirements:

  • If fewer than nine (or six) measures apply, your group must report on all the measures available to you (up to eight measures) for at least 50% of your Medicare Part B FFS patients.
  • When fewer than nine (or six) measures covering three NQS domains are reported, the group practice is subject to the MAV process, which allows Medicare to determine whether a group practice should have reported quality data codes for additional measures. So, if your group consists of only SLPs, it’ll automatically go through the MAV process—which includes a review of cross-cutting measure applicability.
  • If your group sees at least one Medicare patient in a billed visit during 2016, the group must report on at least one cross-cutting measure.

There’s one final GPRO option for large groups. Groups with 25 or more—but fewer than 99—eligible professionals can choose to report via the GPRO Web Interface. While CMS has yet to release information regarding any 2016 changes, as far as we can tell, the requirements are the same as last year:

  • Your group must report on all measures included in the Web Interface for your first 248 Medicare Part B patients.
  • If your group has fewer than 248 Medicare patients, it must report on at least one measure for 100% of your Medicare Part B patients.

Is GPRO only available via registry?

Yes, GPRO is only available via registry. For more information, check out this blog post.

Does WebPT recommend GPRO?

WebPT only recommends GPRO if you are absolutely certain you can satisfactorily report as a group. This is not the case in many instances. So, your group’s safest bet is to report as individuals via our registry.

What is CAHPS? And how does it work?

CAHPS stands for: Consumer Assessment of Healthcare Providers & Systems. CMS uses these surveys to ask patients (or, in some cases, their families) about their experiences with their healthcare providers, health and drug plans, hospitals, home healthcare agencies, doctors, and hospitals. The patients are asked to rate and describe their experiences, and the surveys focus on what’s important to the patients themselves. Some GPRO options require the completion of a CAHPS survey.

To ensure objectivity, providers don’t administer the surveys. A CMS-certified survey vendor completes the CAHPS survey on the participating GPRO group’s behalf.

My group completed PQRS via WebPT’s GPRO option in 2015, but we did not complete a CAHPS survey. Does that mean we won’t meet the requirements for satisfactory reporting?

No. Our system does not support the GPRO option that requires the CAHPS survey, so if you completed PQRS using our GPRO option, there was no need for you to complete a CAHPS survey.

Do I have to re-enroll in GPRO every year through CMS?

Yes. You must complete the GPRO self-nomination process each year you wish to participate in GPRO. For more details, visit this CMS page.

Performance Rate

What does performance rate mean? And how does CMS calculate it?

CMS has established reporting specifications for every PQRS measure. Eligible professionals can reference this specifications—which are available for download here—to determine whether they can perform that measure on a particular patient (specifications include things like age range, eligible CPT and ICD-10 codes, and place of service).

Your EMR should prompt you when a Medicare patient is eligible for a particular measure based on those specifications. You, as the eligible professional, then perform the measure, thus taking a quality action. If you take a quality action, the measure is considered “met”; if you don’t, it’s considered “not met.”

If you simply skip performing the measure or decide to exclude the patient based on a documented reason, then you’ve failed to take a quality action. Sometimes, you’re justified in skipping the measure or excluding the patient—and your documentation should justify that decision—but if you simply exclude the patient as a way to get around having to actually complete the measure, then you won’t take any quality actions. And that, in turn, means you’ll have a 0% performance rate for the measure—and Medicare won’t count it toward the 50% minimum threshold.

And when it comes to calculating the performance rate, Medicare explains that, “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.”

Can you give an example of a quality action?

To satisfactorily report on any given measure, you, as an eligible provider, must perform a quality action during the patient’s visit. That quality action differs from measure to measure, but each quality action will allow you to report a satisfactory response. If you “exclude” a patient, you are indicating that you did not perform a quality action. There are very few cases in which you’d want to exclude a patient from reporting. If you do exclude a patient, you must document your reasoning.

What if my patient doesn’t qualify for a measure? Does that affect performance rate?

Your performance rate is only affected if the percentage of quality actions doesn’t outweigh your exclusions. At the very least, you have to report quality actions for at least 1% of your eligible patients for each of your measures. We recommend reporting at a much much higher rate.

How do I view my performance rate within WebPT?

In order to review your performance rate, you’ll need to enter the CMS reporting portal here. WebPT plans to make updates to our PQRS Report to track performance rate.

Review Processes

What happens if I’m unable to report on the required number of measures due to my speciality?

You must report on as many measures as apply to you based on your speciality and reporting method. If the number of measures that apply to you 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, or MAV, process. This is the process by which Medicare determines whether an eligible professional should have reported quality data codes for additional measures.

How does the MAV process work?

Regardless of which reporting method you choose, if the number of measures that apply to you 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, or MAV, process. This is the process by which Medicare determines whether an eligible professional should have reported quality data codes for additional measures.

CMS offers detailed resources that explain how the MAV process works for both claims-based and registry-based reporting.   

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.

I received a letter from CMS that said I didn’t comply with PQRS 2014. What do I do?

You have have until December 16, 2015, to submit an informal review electronically via the Quality Reporting Communication Support Page (CSP). Per a recent CMS email bulletin, “All informal review requestors will be contacted via email of a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final, and there will be no further review.”


Here are a few additional items of note:

  • For full instructions and further information on the informal review process, visit the following resource page: 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment - Informal Review Made Simple (available on the Analysis and Payment section of the PQRS website).
  • If you have additional questions regarding the informal review process, contact the QualityNet Help Desk at 1-866-288-8912 (Monday–Friday from 7:00 AM to 7:00 PM Central time) or Qnetsupport@hcqis.org.
  • Think You Know PQRS? [Quiz] Image

    articleDec 2, 2015 | 1 min. read

    Think You Know PQRS? [Quiz]

    PQRS 2016 is on the horizon, and whether you’re an old pro or a reporting rookie, the details of this Medicare quality data program can be tough to keep straight. And with a potential 2% negative payment adjustment on the line, it’s imperative that you understand every facet of this quality data reporting program from A to Z—er, P to S. Think you’ve got PQRS down pat? Prove your smarts with our ten-question quiz. Need a bit …

  • articleNov 5, 2013 | 3 min. read

    Founder Letter: PQRS 2014

    Well, it’s November already, and that means two things: Thanksgiving and Physician Quality Reporting System (PQRS). Sure, PQRS doesn’t involve mouthwatering roasted turkey, savory stuffing, or creamy mashed potatoes, but it has become quite the November tradition for us here at WebPT. You see, this is the time of year that the Centers for Medicare & Medicaid Services (CMS) typically confirms the details of next year’s reporting requirements, thus allowing us to update our PQRS solution (claims- …

  • MIPS FAQ for PTs, OTs, and SLPs Image

    articleJan 25, 2017 | 9 min. read

    MIPS FAQ for PTs, OTs, and SLPs

    Unless you’ve been intentionally avoiding all discussions of healthcare changes for 2017, you’ve probably heard at least mention of CMS’s Merit-Based Incentive Payment System (MIPS), which consolidates aspects of the Meaningful Use (MU), Physician Quality Reporting System (PQRS) , and Value-Based Payment Modifier (VM) programs. While MIPS went into effect on January 1, 2017, physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) aren’t eligible to participate until at least 2019. And we’re all still waiting …

  • Hot Out of the Oven: Highlights of the 2017 Final Rule for PTs, OTs, and SLPs Image

    articleNov 9, 2016 | 8 min. read

    Hot Out of the Oven: Highlights of the 2017 Final Rule for PTs, OTs, and SLPs

    Halloween may be over, but if you didn’t get your fill of scares, I’ve got the perfect activity for you: reading through 1,401 pages of pure Medicare gobbledygook. Screaming yet? (Or should I check back at around page 500?) I kid, of course; there’s no need for you to slog through this year’s extra meaty Final Rule —which details the Medicare fee schedule and other important Medicare regulatory and reimbursement changes for physical therapy, occupational therapy, and …

  • Odd Provider Out: Why PT Exclusion from MIPS is Bad for Future Payments Image

    articleMay 4, 2016 | 6 min. read

    Odd Provider Out: Why PT Exclusion from MIPS is Bad for Future Payments

    It’s official: rehab therapists are just a sashay away from exiting the PQRS dance floor. That’s because last week, the Centers for Medicare & Medicaid Services (CMS) issued a proposed final rule that, if adopted, will put into effect the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). And that, in turn, will give the green light to the Merit-based Incentive Payment System (MIPS) , a brand spankin’-new quality data reporting program that consolidates PQRS , …

  • Breaking News: 2017 MACRA Final Rule Hits Image

    articleOct 17, 2016 | 4 min. read

    Breaking News: 2017 MACRA Final Rule Hits

    After months of heated debate and public commentary—much of it coming from physicians who felt they needed more time to prepare themselves to participate in a brand-new quality reporting program—the Department of Health & Human Services (HHS) on Friday released its final rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) . This act, which will go into effect January 1, 2017, reimburses eligible Medicare physicians based on the quality of care they deliver …

  • webinarDec 20, 2013

    Preparing for PQRS 2014

    In December, we hosted a webinar focused on the new PQRS regulations. This session broke down all the rules for 2014 to ensure you’ll be prepared to play by them and therefore not incur any penalties. During this presentation, we: Detailed the PQRS requirements for 2014 Described the different reporting methods Explained how you can ensure you successfully report

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. Questions related to: • WebPT • Modifier 59 • Other Modifiers • Coding • ICD-10 • …

  • The Rehab Therapist’s Quick Guide to the 2016 Final Rule Image

    articleNov 4, 2015 | 6 min. read

    The Rehab Therapist’s Quick Guide to the 2016 Final Rule

    November is finally here, which means we here at WebPT can’t stop thinking about a juicy, flavorful, hot-out-of-the oven—Medicare Final Rule. While your tastebuds probably aren’t jumping with joy over the thought of chewing over a bunch of regulatory gobbledygook, the good news is that this year’s final rule shouldn’t be too tough to swallow (and if it is, you can always add more gravy). We’ve already picked out the most important pieces and served ’em up …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.