PQRS regulations change every year, which makes it tough to stay on top of the requirements. That’s why I’ve organized the most common questions regarding PQRS 2015 and posted them here. Have additional questions? Share them in the comments section, and I’ll post a second Q&A post at the end of the month following our PQRS webinar.

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General Questions

What is PQRS?

Created by the Centers for Medicare and Medicaid Services (CMS), Physician Quality Reporting System (PQRS) requires that all eligible Medicare providers meet criteria for satisfactory reporting of certain outcome measures in order to avoid a payment adjustment. (P.S. While PQRS involves G-codes, it is not the same as functional limitation reporting.)

What is the purpose of PQRS?

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.

Does PQRS apply to rehab therapists?

Any professional providing services paid under or based on the Medicare Physician Fee Schedule is subject to PQRS regulations. This means that if you bill under Medicare Part B for outpatient therapy services—including PT, OT, SLP, and DC—in a private practice setting, you’re subject to a financial penalty if you do not satisfactorily complete PQRS. (Click here to view the full list of eligible professionals.)

Who is not eligible to participate in PQRS?

Some professionals who are eligible for PQRS according to their specialty may not be able to participate due to their billing method. Such professionals include:

  • 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).

Is PQRS mandatory?

Although participation in PQRS is not technically mandatory, Medicare will penalize those eligible professionals who do not successfully complete the requirements for satisfactory reporting. In 2015, that penalty is 2% of total Medicare payments (assessed as a payment adjustment in 2017).

How do I complete PQRS?

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 is the difference between registry-based and claims-based PQRS reporting?

With claims-based reporting, you submit all of your own reporting information to CMS. With registry-based reporting, on the other hand, your EMR handles most of PQRS for you. To learn more about the differences between these two reporting methods and why we recommend registry-based reporting, check out this blog post.

Questions Regarding 2015 Regulations

What is the penalty for not completing PQRS in 2015?

The penalty for eligible providers who do not successfully complete the requirements for satisfactory reporting in 2015 is 2% of total Medicare payments (assessed as a payment adjustment in 2017).

Is there an incentive for successfully completing PQRS in 2015?

No. Medicare has phased out its PQRS incentive program; 2014 was the last year participants were eligible to receive incentive payments for successful completion of reporting requirements.  

What are the 2015 reporting requirements for individual submission?

To satisfactorily complete PQRS and thus avoid the 2% penalty, eligible professionals must:

  • Report on nine measures—at least one of which must be a cross-cutting measure—across three NQS domains on at least 50% of your Medicare Part B FFS patients. These requirements apply to both claims-based and registry-based reporting. That being said:
    • For claims-based, there are nine measures available to OTs, but only six measures for PTs and one for SLPs. Thus, PTs and SLPs will be subject to the MAV process.
    • For registry-based reporting, there are eight measures available to PTs, ten for OT, and one for SLP with registry-based reporting. Thus, PTs and SLPs will be subject to the MAV process.

What are the 2015 reporting requirements for GPRO?

There are three options for satisfactorily completing PQRS under GPRO and thus avoiding the 2% penalty. View those three options here.

What if there aren’t enough measures that apply to me?

If the number of measures that apply to you is below the number of measures you’re required to report, you will 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.

What if the measure(s) for my specialty aren’t applicable to my patient base?

If a Medicare beneficiary doesn't qualify for a particular measure, you’d simply document that the patient doesn't qualify. In the WebPT application, in the PQRS section, you'd check that the patient doesn't meet the measure requirements, and then explain why in your documentation. This will satisfy PQRS reporting, and it's still valuable data for Medicare.

How do I know which measures apply to me?

Check out this blog to find out.

How often do I need to report PQRS?

It depends on the measures you choose; some measures require you to report at the initial examination (97001, 97003) and at the re-examination (97002, 97004); others only require you to report at the initial exam; and some require you to report at every visit.

Where on my claim form do I report PQRS data codes?

If you use electronic claim forms, you will record your PQRS quality data codes (QDCs) on the claim just like any other code; however, these QDCs will have a $0.00 (or nominal) charge. If you use paper claim forms, click here to see a CMS-1500 Claim PQRS example.

Terminology Questions

What is an NQS domain?

Developed as part of the Affordable Care Act, the National Quality Strategy (NQS) sets priorities and lays out a strategic plan with a three-part aim of promoting better health care for individuals, improving the health of populations, and lowering healthcare costs in America. Based on these objectives, CMS established the following six domains of measurement:

  1. Patient and Family Engagement
  2. Patient Safety
  3. Care Coordination
  4. Population and Public Health
  5. Efficient Use of Healthcare Resources
  6. Clinical Processes/Effectiveness

Each PQRS measure addresses one or more of these domains, and CMS requires measures to cover at least three domains to ensure richer data.

What is the MAV process?

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.

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.

What are cross-cutting measures?

According to the 2015 Final Rule, CMS is dedicated to collecting data that paints a better picture of the overall quality of care that eligible professionals provide. Therefore, CMS now requires cross-cutting measures, which are broadly-applicable measures. This will provide CMS with quality data on more varied aspects of an eligible professional’s practice. According to the Final Rule, it is CMS’s intention to move towards requiring the reporting of more cross-cutting measures in the future.

It’s important to understand that you do not have to report your cross-cutting measure in addition to your other required measures. You simply must ensure that one of the individual measures you report on qualifies as a cross-cutting measure. So, if you’re reporting nine measures total, one of them must be a cross-cutting measure. Even if there aren’t nine measures that apply to you as an eligible professional—and thus, you are reporting on fewer than nine measures—one of the measures you report on still must qualify as a cross-cutting measure. Please note that there is at least one cross-cutting measure that applies to PTs, OTs, and SLPs—with multiple cross-cutting measures that apply to PTs and OTs—so fulfilling this requirement should not be an issue.

What is CAHPS?

CMS develops, implements, and administers several different patient experience surveys, known as Consumer Assessment of Healthcare Providers & Systems (CAHPS) surveys.  These surveys ask patients (or in some cases their families) about their experiences with, and ratings of, their healthcare providers and plans, including hospitals, home healthcare agencies, doctors, and health and drug plans. The surveys focus on matters that patients themselves say are important to them and for which patients are the best and/or only source of information. Some GPRO options require the completion of these surveys. To ensure objectivity, CMS requires a CMS-certified survey vendor complete the CAHPS survey on the participating GPRO group’s behalf.


Have additional PQRS questions? Ask them in the comments section below. I’ll answer them in a post at the end of the month following our PQRS webinar.

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