PQRS: An Overview of the Physician
Quality Reporting System
Don Gettinger, BS, CHTS-IM
Conflict of Interest Disclosures
 No Conflicts to Disclose
What is PQRS?
o PQRS is a Medicare program that provides an
incentive payment to eligible providers (EPs) who
voluntarily report specific clinical quality measures
(CQMs) for their qualifying Medicare patients.
o Providers who successfully report data can earn an
additional 0.5 % of their total allowable Medicare
charges in and 2014.
o In 2016, payment adjustments will be made to
providers who choose not to report. This adjustment
will be based upon participation in 2014.
Who is Eligible?
Eligible & Able to Participate
Medicare Physicians –
Practitioners –
• Doctor of Medicine (MD)
• Physician Assistant (PA)
• Doctor of Osteopathy (DO)
• Nurse Practitioner (NP)
• Doctor of Podiatric Medicine
• Registered Dietician (RD)
(DPM)
• Doctor of Dental Medicine
(DMD)
• Doctor of Chiropractic (DC)
• Clinical Social Worker (CSW)
Therapists –
• Physical Therapist (PT)
• Occupational Therapist (OT)
• Qualified Speech Therapist
Who is Eligible?
Eligible BUT not able to Participate
Professionals paid under or based upon PFS billing Medicare
Carriers/Medicare Administrative Contractors (MACs) who do not
bill directly.
Federally Qualified Health Clinics (FQHCs), Rural Health Clinics
(RHCs), ambulatory surgery center facilities
Significant Changes for 2014 Reporting
• Last year to receive incentive and avoid 2016
payment adjustment
• Must report nine measures representing three of
the six National Quality Strategy domains
• Killing three birds with one stone, PQRS reporting
can satisfy requirements for Stage 2 Meaningful
Use Clinical Quality Measures (CQMs) and for the
2014 Value-based Modifier
• New reporting methods added
How is the data reported?
o To successfully report and receive the incentive, providers
must select and submit at least nine measures.
o Submission of measures can be through claims, registry, a
certified EHR or data submission vendor*, or a qualified
clinical data registry*.
o Eligible providers may report measures as individual
providers or as a group practice (GPRO).
*These methods align with Meaningful Use
Reporting Methods
 Claims-Based Reporting
 Individual EPs only
 Report on 9 measures across at least three NQS domains
 Must report on at least 50% of applicable Medicare part B fee
for service (FFS) patients
Reporting Methods
 Registry-Based Reporting
 Individual or Group
 Report on 9 measures across at least three NQS domains
 Must report on at least 50% of applicable Medicare part B fee
for service (FFS) patients
Reporting Methods
 EHR-Based reporting
 Certified Direct EHR-Based Product or Certified Data
Submission Vendor
 Individual or Group
 Report on 9 measures across at least three NQS domains
Reporting Methods
 Qualified Clinical Data Registry-Based
 Individual EPs only
 Report on 9 measures across at least three NQS domains
 Must report on at least 50% of applicable Medicare part B fee
for service (FFS) patients

The list of QCDRs should be available on the CMS PQRS
website by the end of May, 2014
Reporting Methods
 Additional Group Reporting methods
 To Report using the Group Practice Reporting Option (GPRO)
you must register your intent with CMS by September 30, 2014
 GPRO Web Interface
Must have 25 or more eligible professionals
 Report on assigned patient sample


Certified Survey Vendor (CG-CHAPS)
Optional for groups of 25-99 EPs
 Required for groups of 100+ EPs

Reporting Alignment
PQRS
EHR INCENTIVE PROGRAM
VALUE-BASED MODIFIER
Step 1 - Am I an eligible professional for both
programs?
 Check eligibility for the Meaningful Use program
 http://cms.gov/apps/ehealth-eligibility/ehealth-eligibilityassessment-tool.aspx
 Check eligibility for the PQRS program
 http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Downloads/PQRS_List-ofEligibleProfessionals_022813.pdf
Eligible Providers Meaningful Use
Medicare
 MD
 DO
 Dentists and Oral
Surgeons
 Podiatrists
 Optometrists
 Chiropractors
Medicaid






MD
DO
NP
Certified Nurse-Midwife
Dentists
Physician assistant (PA)
who furnishes services in a
Federally Qualified Health
Center of Rural Health
Clinic that is led by a
physician assistant
Eligible Providers PQRS & VM
 Doctor of Medicine
 Doctor of Osteopathy
 Doctor of Podiatric
 Clinical Nurse Specialist
 Certified Registered Nurse












Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic
 Nurse Practitioner
 Certified Nurse Midwife
 Physician Assistant
Anesthetist (and
Anesthesiologist Assistant)
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologists
Physical Therapist
Occupational Therapist
Qualified Speech-Language
Therapist
MU and PQRS Alignment
 9 Clinical Quality Measures that cover at least 3 of
the 6 Nation Quality Strategy (NQS) Domains






Patient and Family Engagement
Patient Safety
Care Coordination
Population/Public health
Efficient Use of Healthcare Resources
Clinical Process/Effectiveness
Choose Reporting Option
PQRS EHR Based
Reporting
Qualified Clinical Data
Registry
 Submit PQRS measures
 New for 2014
data directly through the
certified electronic health
record technology
(CEHRT)
 Submit PQRS quality
measure data extracted
from their CEHRT to a
qualified EHR Data
Submission Vendor
 The data submitted to
CMS via a QCDR
covers quality
measures across
multiple payers and is
not limited to Medicare
beneficiaries.
Group Reporting (GPRO)
Option A
Option B
 EPs in an ACO (Medicare
 EPs who satisfy the
Shared Savings Program
or Pioneer ACO) who
satisfy requirements of
the Medicare Shared
Savings Program using
Certified EHR Technology
requirements of PQRS GPRO
option using Certified EHR
Technology
Value-based Modifier
 Cost data and Quality measures included
 Per-claim adjustment Applied at the Group Level
 CY 2015 – CMS will apply the VM to groups of physicians
with 100 or more eligible professionals (EPs) based on
2013 performance.
 CY 2016 - CMS will apply the VM to groups of
physicians with 10 or more EPs based on 2014
performance.
 CMS is required to apply the VM to all physicians and
groups of physicians starting in 2017.
Value-based Modifier
PQRS Reporters
Non-PQRS Reporters
 Groups with 10-99 EPs
 Upward or no VM based
on quality tiering
 -2.0% (Automatic VM
 Groups with 100+ Eps
 Upward, neutral, or
downward VM based on
quality tiering
downward adjustment)
 Separate from the
PQRS payment
adjustment and
payment adjustments
from other Medicare
sponsored programs.
Value-based Modifier
Low Cost
Average Cost
High Cost
Low Quality
Average
Quality
High Quality
0.0%
+1.0x%*
+2.0x%*
-0.5%
0.0%
+1.0x%*
-1.0%
-0.5%
0.0%
"x” refers to a payment adjustment factor yet to be determined
* higher performing groups serving high-risk beneficiaries
(based on average risk scores) are eligible for an additional
adjustment of +1.0x%
Why CQMs?
 Clinical Quality Measures support achievement of
health care goals (Triple Aim)



Better Health
Better Health Care
Lower Cost
Selecting CQMs To Report
 3 questions to ask about your practice
setting
 Are there any existing quality
improvement efforts in place?
 What is the patient population served?
 What is my EHR capable of reporting?
Examples of Measures for Each Domain
• Patient and Family Engagement
o PQRS # 377 -Functional Status Assessment for Complex
Chronic Conditions
o Percentage of patients aged 65 years and older with heart
failure who completed initial and follow-up patient-reported
functional status assessments
Examples of Measures for Each Domain
• Patient Safety
o
o
PQRS # 130 -Documentation of Current Medications in the Medical
Record
Percentage of visits for patients aged 18 years and older for which the eligible
professional attests to documenting a list of current medications using all
immediate resources available on the date of the encounter. This list must
include ALL known prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain the
medications’ name, dosage, frequency and route of administration
Examples of Measures for Each Domain
• Care Coordination
o PQRS # 374 - Closing the Referral Loop: Receipt of Specialist
Report
o Percentage of patients with referrals, regardless of age, for
which the referring provider receives a report from the
provider to whom the patient was referred
Examples of Measures for Each Domain
• Population/Public Health
o PQRS # 226 - Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
o Percentage of patients aged 18 years and older who were
screened for tobacco use one or more times within 24 months
AND who received cessation counseling intervention if
identified as a tobacco user
Examples of Measures for Each Domain
• Efficient Use of Healthcare Resources
o PQRS # 312 -Use of Imaging Studies for Low Back Pain
o Percentage of patients 18-50 years of age with a diagnosis of
low back pain who did not have an imaging study (plain X-ray,
MRI, CT scan) within 28 days of diagnosis
Examples of Measures for Each Domain
• Clinical Process/Effectiveness
o PQRS # 236 - Controlling High Blood Pressure
o Percentage of patients 18-85 years of age who had a diagnosis
of hypertension and whose blood pressure was adequately
controlled (< 140/90mmHg) during the measurement period
Resources
 PQRS reporting options and measures
 www.cms.gov/pqrs
 Value-based Modifier information
 http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/index.html
 EHR Incentive Program
 www.cms.gov/ehrincentiveprograms
 Institute for Healthcare Improvement
 http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/defa
ult.aspx
Questions?
Health Care Excel
Population Health Team
Don Gettinger, BS,
Program Manager
812.234-1499 x336
dgettinger@inqio.sdps.org
Stacy Colson, RN
Clinical Advisor
812.234-1499 x314
scolson@inqio.sdps.org