What is PQRS?

Developed by the Centers for Medicare and Medicaid Services (CMS), the Physician Quality Reporting System (PQRS) is designed to improve the quality of reporting and patient data throughout the entire healthcare industry, thus reducing fraud and optimizing the payment process. 

PQRS 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. Although PQRS is not technically mandatory, eligible professionals (EPs) who do not meet the reporting requirements are subject to financial penalties.

In 2016, that penalty is a 2% downward payment adjustment on all Medicare Part B payments in 2018. To comply with PQRS and avoid the penalty, rehab therapists who participate in the program as individuals must 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 ending?

All in all, the 2016 PQRS requirements—and penalties—are nearly the same as they were last year. However, there are hints that this year might be the last reporting year for PQRS. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 confirms that the negative payment adjustment associated with PQRS will indeed be in effect through 2018. But, the wording suggests that PQRS penalties may not impact any subsequent years—and, because the 2018 penalty is based on 2016 data, it would stand to reason that there may not be a PQRS in 2017. 

Before you start celebrating, though, remember that this next Final Rule could sing a completely differently tune, so it’s possible that PQRS could remain in effect. Furthermore, while PQRS may not be relevant next year, Medicare’s focus on quality data reporting will only intensify—as will its financial penalties for noncompliance. In 2017, Medicare plans to launch the Merit-based Incentive Payment System (MIPS), which is a conglomeration of PQRS, Meaningful Use, and Value-Based Payment Modifier (these last two programs never applied to rehab therapists).

MIPS will use the same measures and data analysis mechanisms as the old systems did, but it will apply them in a new way. Fortunately, CMS is planning a slow launch, which means rehab therapists most likely won’t have to begin adhering to MIPS regulations until 2019.

But back to PQRS in 2016.

Who are Eligible Professionals?

Any professional who provides 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 physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), and chiropractic services (DC)—in a private practice setting, you’re subject to a financial penalty if you do not satisfactorily complete PQRS. You can find the complete list of EPs here.

However, some professionals who are subject to PQRS regulations based on their specialty are exempt because of their billing method. The following are examples of providers who are exempt, according to CMS:

  • 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)

Can PTAs report PQRS?

Physical therapist assistants (PTAs) do not qualify as EPs, which means they cannot report PQRS data. They can assist in gathering PQRS data as long as the PT supervises and signs off on all quality actions performed.

What are the Differences Between Registry-Based, Claims-Based, and GPRO PQRS Reporting?

If you’re an individual provider, you can choose to report via claims or a registry, like WebPT. If you’re reporting as a group, you can use the Group Practice Reporting Option (GPRO). Here’s a breakdown of each:

Claims-Based (Manual Individual Submission)

If you decide to go the claims-based reporting route, 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.) However, it’s still your responsibility to make sure the quality data codes (QDCs) are properly submitted with your Medicare claims (just like any other code, but with a $0.00 charge).

Registry-Based (Automatic Individual Submission)

When you report PQRS measures electronically via a registry, the registry handles most of the legwork for you. For example, as a certified PQRS registry, WebPT merges PQRS reporting requirements with standard documentation, so we’ll prompt you to report your measures within the patient record. We then compile that data and submit it to CMS on your behalf.

Basically, once you select your PQRS measures, you simply document within the patient record, and we manage the rest. You never have to worry about remembering to complete PQRS on an eligible patient, because we remember for you.

Registry-based reporting is 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 operate under the same tax ID, or TIN, may use the automatic group submission (GPRO) reporting method to meet the satisfactory reporting requirements together. For example, if a practice has two eligible therapists and one therapist reports on 60% of his or her patients, the other therapists only needs to report on 40% of his or hers.

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. (Note: 2016 registration should open on April 1, 2016.)

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

When you go the registry-based reporting route, all you need to do is choose your measures and document within the patient record. Your registry (i.e., WebPT) will manage the rest, including collecting your reporting data and submitting it directly to CMS on your behalf. This means you won’t ever have to fill out a lengthy paper PQRS form for every applicable note you complete. Plus, you’ll always know which measures are available each year, because we update the system based on the annual CMS Final Rule. Furthermore, we narrow down the options based on specialty, so you’ll have an easier time selecting the measures on which you’d like to report.

In other words, a registry makes it nearly impossible not to stay compliant, which is why we highly recommend registry-based reporting.

With claims-based reporting, on the other hand, the burden of compliance is mostly on you. You’re responsible for remembering what to report, for whom, and how frequently. You’re also responsible for correctly documenting and submitting the data to Medicare. While this method can work well if Medicare makes up only a small percentage of your payer mix, there are no automated checks and balances to ensure you’re compliant.

What are the Reporting Requirements?

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 EPs who do not successfully complete the requirements for satisfactory reporting. In 2016, that penalty is a 2% downward payment adjustment in 2018.

Individual Reporting

In 2016, each EP must report on nine measures across three NQS domains for at least 50% of Medicare Part B FFS patients. If fewer than nine measures apply, the EP must report on all applicable measures available for at least 50% of Medicare Part B FFS patients. In this case, the EP will be subject to Medicare’s Measures Applicability Validation (MAV) process, which allows Medicare to determine whether the EP should have reported on additional measures. Furthermore, an EP who sees at least one Medicare patient in a billed visit during 2016 must report on at least one cross-cutting measure, even if fewer than nine measures apply. CMS will not count any measures with a 0% performance rate.

Group Reporting

There are three ways to report using GPRO:

  1. Report nine measures for at least 50% of Medicare Part B FFS patients. These measures must cover at least three NQS domains, and at least one measure must qualify as a cross-cutting measure. (WebPT’s registry-based PQRS service supports this reporting option.)
  2. 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 is required for clinics with 100 or more EPs participating in GPRO.)
  3. Report using CMS’s GPRO Web Interface, which requires groups to report on all measures included in the interface for their first 248 Medicare Part B patients. If your practice doesn’t see that many patients, you must report on at least one measure for 100% of your Medicare Part B patients. (Note: This option is for practices with 25–99 EPs.)

For 2016, Medicare added a review of cross-cutting measure applicability to the Measures Applicability Validation (MAV) process for the GPRO.

Still trying to make sense of PQRS 2016?

Watch the below webinar and become a PQRS pro. We cover everything PTs, OTs, and SLPs need to know about satisfactory reporting.

What Does it Mean to Actually Satisfy PQRS Requirements?

The purpose of PQRS is to measure quality, which is based on four factors:

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

Measure Eligibility

EPs use a set of measure specifications to determine whether they can perform that measure on a particular patient. These typically include:

Performance Criteria

This is 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 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 is a documented reason for not meeting the performance criteria). Note: Not all measures allow for exclusions.

Reporting Rate

The reporting rate is 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 must have a reporting rate of at least 50%.

Performance Rate

There’s some confusion over how performance rate is calculated. However, the major takeaway regarding 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. Rather, 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, for example, if an EP sees 500 Medicare patients in 2016, he or she would need to report a satisfactory response on at least five of those patients for each qualifying measure.

When Do I Report?

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.

What is the MAV Process?

When EPs report fewer than nine measures covering three NQS domains, they are subject to Medicare’s Measures Applicability Validation (MAV) process, which allows Medicare to identify whether an EP should’ve reported quality data codes for additional measures.

Because there are a limited number of measures available for PTs and SLPs, EPs of both specialities will automatically go through the MAV process, regardless of which reporting option they choose. OTs have enough measures available to them that this may not be the case.

Looking for detailed information on the MAV process? Click here if you’re reporting via claims and here for if you’re completing registry-based reporting.

Note: Do not resubmit a claim for an evaluation you’ve already billed in order to add PQRS data. This is an audit red flag to Medicare, and they’ll reject the claim anyway.

What Measures are Available to Me?

There are a total of 281 PQRS measures for 2016 (up from 225 in 2015). However, only a small number of them apply to rehab therapists. Here they are 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 (Note that this measure is not available within WebPT)

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

Download Your 2016 PQRS Measures Chart Now

Curious as to which measures are available for registry-based reporting, claims-based reporting, or both? Want to know which ones are cross-cutting measures? Wondering about NQS domains for each measure? Enter your email address below, and we’ll email you all this information, broken up by measure and specialty, in a PDF chart.

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How Do I Report on Measures 154 and 155?

Measure 154 (Falls Risk Assessment) and 155 (Falls Risk Assessment & Plan of Care) are linked, so if you report on 154, you also must report on 155. Both require reporting at least once per reporting period, and patients must be at least 65 years of age and have a history of falls.

As of 2016, these measures are now associated with CPT codes 92541 and 92542. These codes are typically used by chiropractors, but not frequently.

How Do I Report on Measures 126 and 127?

If you’re a PT using a registry-based reporting system, you may 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 report both at least once per reporting period at either initial evaluation or re-evaluation. The ICD-10 diagnosis codes that trigger both measures fall into the E10, E11, and E13 code families.

Measure 126

Measure 126 applies to patients who are 18 years or older with a diagnosis of diabetes mellitus and neurological exams of their lower extremities within the last year.

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.

How Does ICD-10 Affect PQRS?

Certain ICD-10 codes trigger certain PQRS codes, just as certain ICD-9 codes used to do. If you use WebPT to report PQRS, the system will prompt you to report when one of those triggers exists.

What are Cross-Cutting Measures?

Cross-cutting measures are broadly applicable measures that convey a more complete picture of the overall quality of care that EPs are providing. To meet PQRS requirements, all EPs who have had at least one in-person meeting with a Medicare patient must report one cross-cutting measure.

Please note that there are multiple cross-cutting measures availables to PTs and OTs and at least one available to SLPs. Therefore, PTs, OTs, and SLPs should be able to meet this requirement.

What Measures Groups are Available This Year?

CMS defines a measures group as “a subset of four or more PQRS measures that have a particular clinical condition or focus in common.” Other EPs have numerous measures groups on which they can report. However, there are no measures groups available to PTs, OTs, or SLPs. (For those who remember the back pain group available to physical therapists, that measures group hasn’t been available since 2014.)

Simplify PQRS reporting—and avoid penalties—with WebPT.

Schedule a free online tour of WebPT today, and discover how our certified registry + EMR take the pain out of Medicare compliance.

Heidi Jannenga

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