Physician Quality Reporting System

Physician Quality Reporting System (formerly Physician Quality Reporting Initiative)

There are many criteria involved in the Physician Quality Reporting System (PQRS) but only those that are relevant to therapists will be included in this summary. It is important that each participant have a global knowledge of the PQRS.

According to CMS the essential purposes for participating in the Physician Quality Reporting System is that eligible professionals will have the opportunity to use participation in the PQRS program to improve the care of the patients they serve through the evidence based measures that are based upon clinical guidelines.

The PQRS is the first step, of many, toward pay for performance. While PQRS was initially reserved for physicians, many other healthcare practitioners have been permitted to participate, therapists billing on CMS 1500 claim forms are included in this group of eligible professionals. There is no required registration or application process; a therapist is only required to be enrolled as a supplier with Medicare in Part B and have an individual National Provider Identification Number to participate.

Unfortunately, at this time rehab agencies, outpatient hospital departments, and SNF (Part B) are unable to participate because the UB-04 claim form required for facilities does not accommodate an individual NPI number.

Components of PQRS Measures

  1. Denominator describes the eligible cases for a measure:
    • Defined by specific CPT Category I Codes (typically evaluation and re-evaluation codes)
    • Includes all Medicare beneficiaries in a specified age range
  2. Numerator describes the clinical action required by the measure for reporting and performance and are reported using CPT Category II codes

Numerator Coding & Grading

  1. Each CPT Category II code should be reported, utilizing modifiers as applicable, to assure that it qualifies for successful reporting even if the measure was not performed
  2. When an Exclusion Modifier is used it removes it from the ‘eligible population’ in the denominator
  3. When a Reporting Modifier is used it does not remove it from the ‘eligible population’ in the denominator but does count as a successful report

Steps:

  1. Select the applicable number of quality measures for therapy services, patient demographics and the reporting measure tool (claim or registry)
  2. Complete and document the testing, screening and/or other procedures per the data collection sheet
  3. Select the corresponding quality data codes (QDC) for the measures
  4. Affix the appropriate numerators and denominators on the reporting tool

Claims-Based PQRS Reporting

  1. The PQRS incentive (bonus) program was terminated by CMS December 31, 2014.
  2. Eligible professionals (EP) for the purpose of PQRS reporting, are Part B suppliers: Physical Therapist, Occupational Therapist, Speech-Language Pathologists and Audiologists. EP’s who did not report on at least one (1) quality measure in 2013 will incur a 1.5% decrease in payment on all Medicare claims submitted in 2015.
  3. EPs who chose not to report according to the minimum requirements in 2014 will incur a 2% penalty on all claims filed in 2016. However, EPs who reported on at least three (3) measures for 50% of eligible patients in 2014 will avoid that penalty.

Physical Therapist Claims-Based Available Measures:

  1. #128     Body Mass Index Screening & Follow Up
  2. #130     Documenting & Verification of Current Medication
  3. # 131    Pain Assessment Prior to Treatment
  4. # 154    Falls: Risk Assessment
  5. # 155    Falls: Plan of Care
  6. # 182    Functional Outcome Assessment

Occupational Therapist Claims-Based Available Measures:

  1. #128     Body Mass Index Screening & Follow Up
  2. #130     Documenting & Verification of Current Medication
  3. # 131    Pain Assessment Prior to Treatment
  4. # 134    Screening for Clinical Depression & Follow-Up Plan
  5. # 154    Falls: Risk Assessment
  6. # 155    Falls: Plan of Care
  7. # 181    Elder Maltreatment Screening & Follow-Up Plan
  8. # 182    Functional Outcome Assessment
  9. # 226    Preventive Care and Screening: Tobacco Use; Screening & Cessation

Speech-Language Pathologist Claims-Based Available Measures:

  1. #130     Documentation & Verification of Current Medications in the Medical Record
  2. #131     Pain Assessment Prior to Treatment
  3. #317     Screen for high blood pressure and follow up*

Audiologist Claims-Based Available Measures:

  1. # 130    Documentation & Verification of Current Medications in the Medical Record
  2. # 134    Screening for clinical depression and follow-up plan
  3. # 261    Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

National Quality Strategy Domains (NQSD)

EPs (Eligible Providers) must report with measures that are covered by at least three National Quality Strategy Domains (the NQSD), if they are available and should document which domains are covered. The NQSD and the corresponding measure numbers are listed below:

  1. # 128    Population/Public Health
  2. # 130    Patient Safety
  3. # 131    Population/Public Health
  4. # 134    Population/Public Health
  5. # 154    Patient Safety
  6. # 155    Care Coordination
  7. # 181    No Domain
  8. # 182    Care Coordination
  9. # 245    Effective Clinical Care
  10. # 261    Care Coordination

NQSD Available to Therapy services: 

Patient Safety

  • #130 Documentation of Current Medications (PT, OT, SLP)
  • #181 Elderly Maltreatment Screen and Follow-up (OT)

Communication and Care Coordination

  • #182 Functional Outcome Assessment (PT, OT)

Community and Population Health

  • #128 BMI (PT, OT)
  • #131 Pain Assessment (PT, OT, SLP)
  • #134 Screening for Clinical Depression (OT)
  • #226 Tobacco use Screening and Cessation Intervention (OT)
  • #317 Screen for high blood pressure and follow-up (SLP)

Note:  There is no opportunity to report Group Codes via the Claims-Based Process

Measure-Applicability Validation (MAV) Process (Credit: CIPROMS News and Events 2-5-15)

For Medicare providers participating in the Physician Quality Reporting System (PQRS) via claims or registry, measure applicability validation (MAV) is the process the Centers for Medicare and Medicaid Services (CMS) uses to determine if providers can still avoid the payment adjustment penalties even if they reported fewer than the required measures or domains.

Generally, to avoid the 2.0 percent payment adjustment in 2017, eligible providers who participate in PQRS via claims or registry for the 2015 reporting year must report 9 measures across 3 National Quality Strategy Domains (NQSD) for at least 50 percent of the denominator-eligible encounters. In addition, providers who have at least one face-to-face encounter with a Medicare patient must report at least 1 cross-cutting measure of the 9 measures reported.

However, for some specialities like anesthesiology, the PQRS program does not offer at least 9 measures covering 3 NQSDs. As well, anesthesiologists who report only ASA codes on their Medicare claims would not be considered to have had a face-to-face encounter. In situations like these where the conditions for successful reporting are not met, CMS will use MAV to determine if providers can still avoid the payment adjustment.

The MAV process is basically two steps and requires providers to successfully report 1 cross-cutting measure along with 1-8 total measures or 9 or more measures in only 1 or 2 NQSD.

Step one of MAV determines if measures that were successfully submitted fall within a clinically-related cluster. If so, if the cluster contains measures that weren’t submitted or measures in domains that weren't submitted, CMS will consider those as possible measures that should have been reported.

For registry reporting, that means the provider should have reported those measures and will receive the 2.0% payment adjustment.

For claims reporting, step two of MAV establishes whether there were 15 or more eligible encounters identified in the denominator for the possible measures. If yes, then the provider should have reported those measures and will receive the 2.0 percent payment adjustment.

If there were no additional measures or domains that could have been reported or if additional measures had fewer than 15 denominator-eligible encounters, then the provider will be considered a successful PQRS reporter and will be spared the 2.0 percent payment adjustment.

The following resources will provide additional information about MAV, cross-cutting measures, and the PQRS program in general:

Medicare Payments are Subject to Sequestration

Payments made to eligible professionals and group practices have been and will continue to be reduced by 2% secondary to sequestration. For example: An EP has $100,000 in allowed charges; it will be reduced by 2% which would equal $2000..

Remittance Advice Codes

Claims with $0.00 associated with Quality Data Codes on the same claim line item:

  • Will receive a RARC N620 which indicates that the PQRS codes were received into the CMS National Claims History (NCH) database
  • Will note that the N620 reads:  This procedure code is for quality reporting/informational purposes only

Claims with $0.01 associated with Quality Data Codes on the same claim line item:

  • Will receive a CARC CO 246 & RARC N572 which indicates that the PQRS codes were received into the CMS National Claims History (NCH) database
  • Will note that the N620 reads: The non-payable code is for required reporting only

Points of Clarification

  • If a measure specification states “at each visit” this means each visit that the specified CPT code is compliantly utilized; typically this will be evaluation and re-evaluation CPT codes; but there are two individual measures that stipulate the use of other CPT codes as well (Measure #130 and #131 with the use of CPT Code 97532)
  • Techs and aides, under proper supervision with competency established, may assist with BMI measurements i.e. height and weight
  • Individual EP penalties only apply to therapists who have worked in a practice for the full calendar year
  • Therapists reporting via the claims-based reporting method will have their data analyzed by QualityNet. Feedback reports are available quarterly and a comprehensive annual feedback report is typically available in the fall, for the previous reporting year. Eligible providers and practices must register with QualityNet to access these reports electronically at this link: https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
  • Providers reporting via registry should receive feedback reports on a quarterly basis from their vendor.

Reporting Reminders:

  • Use $0.01 in Block 24F (Charges), if possible
  • Use 1 in Block 24G (Day or Units)
  • Do not affix the Professional Modifiers (GN, GO, GP) in Box 24D (modifier)
  • Do not affix the KX modifier in Box 24D (modifier)
  • Do not affix the CCI edit modifier (59) in Box 24D (modifier)

2016 PQRS Measure Summary Spreadsheet

2016 CMS PQRS Individual Measures Specifications

2015 Summary of Individual Measures Via Claims PT, OT, SLP

2015 Summary of PQRS Reporting Options Individual & Group Measures

2015  Cross-Cutting Measures

2015 PQRS Implementation Guide

2015 PQRS Measures Specifications Manual

Getting Started with PQRS

Confidential PQRS Reports via Quality Net

Registry Information

Group Practice Reporting Option

CMS Educational Resources

APTA Educational Resources

AOTA Educational Resources

ASHA Educational Resources

Forms:

  • 2015 Medication Spreadsheet for Measure 130  BCMS
  • 2015 APTA Data Collection Worksheets