What is PQRS?
Developed by the Centers for Medicare and Medicaid Services (CMS) in 2006, the Physician Quality Reporting System (PQRS) was designed to improve the quality of reporting and patient data throughout the entire healthcare industry, thus reducing fraud and optimizing the payment process.
Under PQRS, all eligible Medicare providers—including physical therapists, occupational therapists, and qualified speech therapists—were required to meet criteria for the satisfactory reporting of certain outcome measures. Although PQRS was never technically mandatory, eligible professionals (EPs) who did not meet the reporting requirements were subject to financial penalties.
Though the program ended in 2017, financial penalties continued affecting claims throughout 2018—with a maximum downward adjustment of 2% on all Medicare Part B payments. To comply with PQRS and avoid the penalty, rehab therapists who participated in the program as individuals were required to report on nine measures across three NQS domains for at least 50% of their Medicare Part B fee-for-service (FFS) patients. (Click here to learn more about reporting requirements, including group reporting.)
Is PQRS gone for good?
In October 2016, Medicare released its Final Rule, which mandated the end of PQRS at the conclusion of the 2016 reporting year. But, that didn’t mean mandatory quality reporting was gone for good. On January 1, 2017, CMS launched the Merit-based Incentive Payment System (MIPS), which uses elements of PQRS in its quality category. Specifically, MIPS repurposed some PQRS measures for its quality category, generally retaining the same measure specifications that applied for PQRS. These are the therapy-related PQRS measures that are currently used in MIPS reporting:
- 050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
- 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
- 127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
- 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
- 130: Documentation of Current Medications in the Medical Record
- 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- 155: Falls: Plan of Care
- 181: Elder Maltreatment Screen and Follow-Up Plan
- 182: Functional Outcome Assessment
- 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- 281: Dementia: Cognitive Assessment
- 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
- 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
- 288: Dementia: Education and Support of Caregivers for Patients with Dementia
- 318: Falls: Screening for Future Fall Risk
Who were considered eligible professionals for PQRS?
Under PQRS, any professional who provided services paid under or based on the Medicare Physician Fee Schedule was subject to PQRS regulations. That meant if you billed under Medicare Part B for outpatient therapy services—including physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), and chiropractic services (DC)—in a private practice setting, you were subject to a financial penalty if you did not satisfactorily complete PQRS requirements. If you’re interested, CMS has the complete list of eligible professionals.
Could PTAs report PQRS?
Physical therapist assistants (PTAs) did not qualify as EPs, which meant they could not report PQRS data. They could, however, assist in gathering PQRS data as long as the PT supervised and signed off on all quality actions performed.
What were the differences between registry-based, claims-based, and GPRO PQRS reporting?
Individual providers could choose to report via claims or via a registry (like WebPT’s). If you reported as a group, you were allowed to use the Group Practice Reporting Option (GPRO). Here’s a breakdown of each reporting method:
Claims-Based (Manual Individual Submission)
If you decided to go the claims-based reporting route, you had to manually enter your PQRS data on your claim forms before submitting them to Medicare. WebPT’s claims-based reporting option also allowed you to use your WebPT documentation to assist in completing PQRS. (Our system helped you select the appropriate codes in order to submit accurate data.) However, it was still your responsibility to make sure the quality data codes (QDCs) were properly submitted with your Medicare claims (just like any other code, but with a $0.00 charge).
Registry-Based (Automatic Individual Submission)
When EPs reported PQRS measures electronically via a registry, the registry handled most of the legwork. For example, as a certified PQRS registry, WebPT merged PQRS reporting requirements with standard documentation, so our system prompted you to report your measures within the patient record. We then compiled that data and submitted it to CMS on your behalf.
Basically, once you selected your PQRS measures, you simply documented within the patient record, and we managed the rest. You never had to worry about remembering to complete PQRS on an eligible patient, because we remembered for you.
Registry-based reporting was the easiest reporting method for EMR users.
Group Practice Reporting Option (GPRO) (Automatic Group Submission via a Registry)
Clinics with two or more therapists who operated under the same tax ID, or TIN, were able to use the automatic group submission (GPRO) reporting method to meet the satisfactory reporting requirements together. For example, if a practice had two eligible therapists and one therapist reported on 60% of his or her patients, the other therapist only needed to report on 40% of his or hers.
This method was not available to those submitting PQRS data via claims. Additionally, practices wishing to participate in GPRO had to sign up (self-nominate) for GPRO directly through CMS.
What were the advantages of registry-based reporting over claims-based reporting?
Therapists who went the registry-based reporting route needed only to choose their measures and document within the patient record. Their registry (e.g., WebPT) would then manage the rest, including collecting their reporting data and submitting it directly to CMS on their behalf. This meant they didn’t have to fill out lengthy paper PQRS forms for every applicable note they completed. Plus, WebPT registry users always knew which measures were available each year, because we routinely updated the system based on the annually-published CMS Final Rule. Furthermore, we narrowed down the options based on specialty, so users had an easier time selecting the measures they wanted to report.
In other words, a registry made it nearly impossible not to stay compliant.
With claims-based reporting, on the other hand, the burden of compliance was mostly on the practitioner. He or she was responsible for remembering what to report, for whom, and how frequently. The practitioner was also responsible for correctly documenting and submitting the data to Medicare. While this method could’ve worked well if Medicare made up only a small percentage of a provider’s payer mix, there were no automated checks and balances to ensure compliance.
What were the reporting requirements?
First, it’s important to understand that PQRS was never technically mandatory for rehab therapists. Even if you were eligible for PQRS, you could choose not to participate. However, in 2013, Medicare introduced a financial penalty for those EPs who did not successfully complete the requirements for satisfactory reporting. In 2016, that penalty was a 2% downward payment adjustment for all claims submitted during the 2018 payment year.
Individual Reporting
In 2016, each EP had to report on nine measures across three NQS domains for at least 50% of Medicare Part B FFS patients. If fewer than nine measures applied, the EP had to report on all applicable measures available for at least 50% of Medicare Part B FFS patients. In this case, the EP was subject to Medicare’s Measures Applicability Validation (MAV) process, which allowed Medicare to determine whether the EP should have reported on additional measures. Furthermore, an EP who saw at least one Medicare patient in a billed visit during the 2016 reporting year had to report on at least one cross-cutting measure, even if fewer than nine measures applied. CMS did not count any measures with a 0% performance rate.
Group Reporting
There were three ways to report using GPRO:
- Report nine measures for at least 50% of Medicare Part B FFS patients. These measures had to cover at least three NQS domains, and at least one measure had to qualify as a cross-cutting measure.
- Report six measures across two NQS domains for at least 50% of Medicare Part B FFS patients—and conduct a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey using a CMS-certified vendor. (Note: This survey was required for clinics with 100 or more EPs participating in GPRO.)
- Report using CMS’s GPRO Web Interface, which required groups to report on all measures included in the interface for their first 248 Medicare Part B patients. If your practice didn’t see that many patients, you had to report on at least one measure for 100% of your Medicare Part B patients. (Note: This option was for practices with 25–99 EPs.)
In 2016, Medicare added a review of cross-cutting measure applicability to the Measures Applicability Validation (MAV) process for the GPRO.
What did it mean to actually satisfy PQRS requirements?
The purpose of PQRS was to measure quality, which was assessed via four factors:
- Measure eligibility
- Performance criteria or quality action
- Reporting rate
- Performance rate
Measure Eligibility
EPs used a set of measure specifications to determine whether they could perform that measure on a particular patient. These specifications typically included:
- Time period for a particular condition
- Age range
- Procedure (CPT) code
- Diagnosis (ICD-10) code
- Place of service
- Factors related to condition
Performance Criteria
This is the number of eligible patients who met the specifications for a particular measure, meaning an EP could perform a “quality action” for those patients. When completing a measure for an eligible patient, an EP had to mark that the measure was:
- Met (i.e., a quality action was performed);
- Not Met (i.e., a quality action was not performed); or
- Excluded (i.e., there was a documented reason for not meeting the performance criteria).
Note: Not all measures allowed for exclusions.
Reporting Rate
The reporting rate was the number of patients an EP reported (met, not met, and excluded) divided by the EP’s total number of eligible patients. To avoid the penalty, professionals were required to have a reporting rate of at least 50%.
Performance Rate
Under PQRS, there was some confusion over how performance rate was calculated. However, this was the major takeaway regarding performance rate: Medicare did not count any measures that had a 0% performance rate. That meant EPs could not simply mark all eligible patients as “not met” or “excluded” for any particular measure. Rather, EPs had to select a satisfactory answer (i.e., a quality action) for at least 1% of the patients who were eligible for each measure. So, for example, if an EP saw 500 Medicare patients in 2016, he or she had to report a satisfactory response on at least five of those patients for each qualifying measure.
When was reporting required?
The reporting intervals varied from measure to measure based on CMS specifications.
What was the MAV process?
When EPs reported fewer than nine measures covering three NQS domains, they were subject to Medicare’s Measures Applicability Validation (MAV) process, which allowed Medicare to identify whether an EP should’ve reported quality data codes for additional measures.
Because there were a limited number of measures available for PTs and SLPs, EPs of both specialties automatically went through the MAV process, regardless of which reporting option they chose. OTs had enough measures available to them that this may not have been the case.
Which measures applied to rehab therapists?
There were a total of 281 PQRS measures in 2016, the final year of the quality-reporting program (up from 225 in 2015). However, only a small number of them applied to rehab therapists. The measures were broken out by specialty:
Physical Therapy
- 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
- 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
- 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
- 130 Documentation of Current Medications in the Medical Record
- 131 Pain Assessment and Follow-Up
- 154 Falls: Risk Assessment
- 155 Falls: Plan of Care
- 182 Functional Outcome Assessment
Occupational Therapy
- 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
- 130 Documentation of Current Medications in the Medical Record
- 131 Pain Assessment and Follow-Up
- 134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
- 154 Falls: Risk Assessment
- 155 Falls: Plan of Care
- 181 Elder Maltreatment Screen and Follow-Up
- 182 Functional Outcome Assessment
- 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- 431 Preventive Care and Screening: Unhealthy Alcohol Use – Screening and Brief Counseling
Speech-Language Pathology
- 130 Documentation of Current Medications in the Medical Record
- 131 Pain Assessment and Follow-Up
- 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
How did EPs report on measures 154 and 155?
Measure 154 (Falls Risk Assessment) and 155 (Falls Risk Assessment & Plan of Care) were linked, so if you reported on 154, you also had to report on 155. Both required reporting at least once per reporting period, and patients had to be at least 65 years of age and have a history of falls.
In 2016, these measures became associated with CPT codes 92541 and 92542—which are typically used by chiropractors, but not frequently.
How did EPs report on measures 126 and 127?
If you were a PT using a registry-based reporting system, you were allowed to use measures 126 (Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation) and 127 (Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear) as long as you reported both at least once per reporting period at either initial evaluation or re-evaluation. The ICD-10 diagnosis codes that triggered both measures fell into the E10, E11, and E13 code families.
Measure 126
Measure 126 applied to patients who were age 18 or older with a diagnosis of diabetes mellitus and had neurological exams of their lower extremities within the last year.
Measure 127
The denominator that applied to Measure 126 also applied to this measure. Eligible patients also had to have been evaluated for proper footwear and sizing within the last year.
How did ICD-10 affect PQRS?
Certain ICD-10 codes triggered certain PQRS codes, just as certain ICD-9 codes used to do. If you used WebPT to report PQRS, the system prompted you to report when one of those triggers existed.
What were cross-cutting measures?
Cross-cutting measures were broadly applicable measures that conveyed a more complete picture of the overall quality of care that EPs provided. To meet PQRS requirements, all EPs had to have at least one in-person meeting with a Medicare patient and were required to report one cross-cutting measure.
Note: There were multiple cross-cutting measures available to PTs and OTs, and at least one available to SLPs. Therefore, PTs, OTs, and SLPs should have been able to meet this requirement.
What measures groups were available in 2016?
CMS defined a measures group as “a subset of four or more PQRS measures that have a particular clinical condition or focus in common.” Other EPs had numerous measures groups on which they could report. However, only one measures group was available to rehab therapists—occupational therapists, to be exact—in 2016, and that was the Multiple Chronic Conditions group. (For those who remember the back pain group available to physical therapists, that measures group hadn’t been available since 2014.)
Multiple Chronic Conditions Measures Group
Though it wasn’t available within the WebPT application, the Multiple Chronic Conditions Measures Group was a measures group that became available in 2016 for occupational therapists. Measures included:
- 128 BMI Screening
- 130 Current Medications
- 131 Pain Assessment
- 134 Preventive Screening, Clinical Depression
- 154 Falls: Risk Assessment
- 155 Falls: Plan of Care