What is PQRS?

CMS developed the Physician Quality Reporting System (PQRS), which requires that all eligible Medicare providers—including physical therapists, occupational therapists, and qualified speech therapists—meet criteria for the satisfactory reporting of certain outcome measures. 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. Although PQRS is not technically mandatory, eligible professionals who do not meet the reporting requirements are subject to financial penalties. In 2015—and for all subsequent years unless otherwise directed by CMS—that penalty is 2% of total Medicare payments. To comply with PQRS and thus avoid the payment adjustment, rehab therapists must report on a certain number of measures for a designated percentage of eligible Medicare patients. By introducing this initiative, CMS hopes to improve the overall quality of patient data throughout the healthcare industry, which in turn reduces claim fraud and streamlines the reimbursement process.

Who are Eligible Professionals?

According to CMS, “Under Physician Quality Reporting System (PQRS), covered professional services are those paid under or based on the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services [that] get paid under or based on the Physician Fee Schedule, those services are eligible for PQRS incentive payments and/or payment adjustments.” Based on that definition, all eligible professionals billing under Medicare Part B for outpatient therapy services in private practice settings—including physical therapists, occupational therapists, and qualified speech-language pathologists—all qualify for PQRS participation.

However, some professionals who qualify for PQRS according to their specialty may not be able to participate due to their billing method. CMS provides the following examples of providers who would not be eligible to participate:

  • 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)

What Does PQRS Compliance Entail?

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’s the Difference Between Registry-Based and Claims-Based PQRS Reporting?

There are actually three different methods for reporting PQRS:

Registry-Based (Automatic Individual Submission)

When you report via a registry, the registry handles most of PQRS for you. For example, as a certified PQRS registry, WebPT merges PQRS with standard documentation. That means all you have to do is report your PQRS measures directly within the patient record. We then mine that data, compile it, and submit it to CMS on your behalf. Basically, once you select your PQRS measures, you simply document, and we manage the rest. You’ll never forget to complete PQRS on an eligible patient, because we remember for you.

Group Practice Reporting Option (GPRO) (Automatic Group Submission)

GPRO is a registry-based PQRS reporting option geared toward multi-therapist practices (clinics with two or more therapists) that wish to participate as a group. It allows therapists who share one tax ID to report measures and reach the required reporting percentage together. This method is not available to those submitting PQRS data via claims. Additionally, practices wishing to participate in GPRO must sign up (self-nominate) for GPRO directly through CMS.

Claims-Based (Manual Individual Submission)

With claims-based reporting, you must manually enter your PQRS data on your claim forms before submitting them to Medicare. WebPT’s claims-based reporting option allows you to use your WebPT documentation to assist you with completing PQRS. Our system will help you select the appropriate codes so you’ll submit accurate data, but it’s still your responsibility to make sure those codes are properly submitted with your Medicare claims. For claims-based reporting, you will record your PQRS quality data codes (QDCs) on the claim form just like any other code; however, these QDCs will have a $0.00 (or nominal) charge.

What are the Advantages of Registry-Based Reporting Over Claims-Based?

With claims-based reporting, the burden of compliance is mostly on you. You’re responsible for remembering what to report, for whom, and how frequently as well as for correctly documenting and submitting the data to Medicare. With registry-based reporting, on the other hand, your EMR will take care of the heavy lifting for you. It’ll prompt you to answer the necessary PQRS questions at the required times during normal documentation, compile the data for you, and electronically submit it to CMS on your behalf. Basically, a registry makes it nearly impossible not to stay compliant. Thus, we recommend registry-based reporting. At the end of the day, though, regardless of the reporting method you choose, participating in PQRS means you’re better protecting your practice from penalties.

What are the PQRS 2015 Regulations and Penalties?

First, it’s important to understand that PQRS is not technically mandatory. Even if you are eligible for PQRS, you can choose not to participate. However, in 2013 Medicare introduced a financial penalty for those eligible professionals who do not successfully complete the requirements for satisfactory reporting. In 2015—and for all subsequent years unless otherwise directed by CMS—that penalty is 2% of your total Medicare payments. For example, if you don’t successfully complete the requirements for satisfactory reporting in 2015, you’ll be subject to a 2% payment adjustment in 2017.

In 2014, Medicare offered an incentive bonus of 0.5% of total Medicare payments to those eligible professionals who met certain requirements for successful reporting. That was the last year Medicare offered such an incentive. There is no reporting incentive for 2015.

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.

2015 Reporting Requirements for Group Submission

There are three options for satisfactorily completing PQRS under GPRO and thus avoiding the 2% penalty:

  1. Report in the same manner as individual submission, which means the group will report up to nine measures (including one cross-cutting measure) across three NQS domains on 50% of Medicare Part B FFS patients.
  2. Report six measures (including at least one cross-cutting measure) across at least two NQS domains on 50% of Medicare Part B FFS patients and have a CMS-certified survey vendor complete a Consumer Assessment of Healthcare Providers   Systems, or CAHPS, survey on your behalf. This ensures objectivity.
  3. Report through CMS’s Web Interface.
    1. With this option, groups must report on all measures included in the interface for their first 248 Medicare Part B patients. If they have fewer than 248 Medicare patients, then they must report on at least one measure for 100% of their Medicare Part B patients.
    2. Only practices with 25 or more eligible professionals can report via the GPRO Web Interface.
    3. As of now, practices that use the interface are not subject to the MAV process. However, this could change.
    4. Using the interface could prove arduous as it requires double-data entry (i.e., you must manually enter all of your patient information).

Note: Groups with 100 or more eligible professionals that elect to participate in GPRO must add the CAHPS survey component regardless of which GPRO option they choose.

Although there are loads of PQRS measures, only a handful apply to rehab therapists. Here the ones that do (and that WebPT currently has in the application):

What are the Available Measures for PTs, OTs, and SLPs in 2015?

Measure NQS Cross-Cutting Registry Claims PT OT SLP
128: BMI Community/Population Health  
130: Documentation of Current Medications in the Medical Record Patient Safety
131: Pain Assessment and Follow-Up Communication and Care Coordination  
182: Functional Outcome Assessment Communication and Care Coordination  
126: Diabetes Foot/Ankle Evaluation Effective Clinical Care        
127: Diabetes - Footwear Evaluation Effective Clinical Care        
154: Falls Risk Assessment Patient Safety    
155: Falls POC Communication and Care Coordination    
134: Preventative Care and Screening : Screening for Clinical Depression and Follow-Up Plan Community/Population Health    
173: Alcohol consumption Assessment Community/Population Health        
181: Elderly Maltreatment Screen and Follow-Up Patient Safety      
226: Tobacco Use Screen and Cessation Intervention Community/Population Health      

What are NQS Domains?

Developed as part of the Affordable Care Act, the National Quality Strategy, or 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 furnished by eligible professionals. 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 Rules, 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 on top of your other required measures. You simply must ensure that one of the individual measures you report qualifies as a cross-cutting measure. So, if you’re reporting 9 measures total, one of them must be a cross-cutting measure. Even if there aren’t 9 measures that apply to you as an eligible professional—and thus, you are reporting on fewer than 9 measures—one of the measures you report 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, or 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.

As we explained earlier, one of the GPRO methods requires the completion of one of these surveys. To ensure objectivity, CMS requires a CMS-certified survey vendor complete the CAHPS survey on the participating GPRO group’s behalf.

How Does WebPT Help with PQRS?

WebPT offers both claims-based reporting and registry-based reporting. Regardless of which reporting method you choose, completing PQRS with WebPT is simple and straightforward. Our system updates the measures available within our application every year in accordance with the final rule. Plus, we narrow down the options based on your specialty, making it easier for you to select the measures on which you’d like to report. The PQRS measures on which you choose to report are built into your documentation for you, and WebPT will let you know if—and exactly where within the note—you’re not properly reporting. Pen and paper don’t offer that perk. Lastly, WebPT’s got your back—not only through our PQRS services, but through educational resources and trainings. This means you’re far more likely to meet the reporting requirements and avoid the noncompliance penalty.

Now, if you go with registry-based reporting, you get everything above and then some. WebPT eliminates the need to fill out a lengthy paper PQRS form with every applicable note (claims-based reporting). All you need to do is choose your measures and document. We manage the rest. Once we collect your reporting data, we submit it directly to CMS on your behalf through our certified CMS registry.

Heidi Jannenga DPT

Get exclusive content delivered right to your inbox.