Under the PQRS Tab
DELETE:
In 2012, eligible providers who bill under the physician fee schedule (includes all therapists who bill on the 1500 claim
form) can receive a bonus payment of 0.5% if reporting on quality measures (for 2011 the bonus was 1% and
previous years were 2%).
Twelve (12) month option: 0.5% bonus payment is on all allowable charges on all Medicare claims from January 1December 31, 2012 or 0.5% bonus on all allowable claims from July 1- December 31, 2012
Under PQRS, providers will receive a 0.5% bonus in 2012, 2013 and 2014. Eligible professionals who do not
successfully report quality data during the designated quality reporting period will have their payments reduced by
1.5% in 2015 and by 2.0% in 2016 and each subsequent year.
For 2012, reporting options for therapists include: Reporting Individual quality measures or Group quality measures to
CMS
Individual measures and group measures may be reported on Medicare Part B 1500 claim form or electronic
equivalent or to a qualified PQRI registry (FOTO and WebPT). Practitioners who file claims on UB-02 (Rehab
Agencies/CORFs, Outpatient hospital settings, etc.) are not eligible to participate in the PQRS program.
In order to participate in PQRS using individual measures an individual therapist (per NPI number) must report on a
minimum of 3 measures for 50% of all Medicare patients seen during the reporting period when using a claim form or
80% if using the Registry.
REPLACE with:
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 there are three essential purposes for participating in the Physician Quality Reporting
System. They are:
1. Eligible professionals will have the opportunity to use participation
in the PQRIS program to improve the care of the patients they serve
through the evidence based measures that are based upon clinical guidelines
2. Eligible professionals participating in PQRS will have the opportunity to prepare for future pay-forperformance programs
3. Eligible professionals will be entitled to a monetary incentive bonus which has been made
available to reward participating professionals
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.
Effective 2013 providers may participate under a ‘Group Practice Reporting Option” which does require
enrollment and CMS approval.
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.
Under the PQRS Tab
Components of PQRS Measures
1. Denominator describes the eligible cases for a measure:
a.
Defined by evaluation and re-evaluation CPT Category I Codes
b.
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 and 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
Remarks:
1. Quality data codes (QDC) can be reported in one of three methods:
a. On the CMS 1500 claim form or its electronic equivalent
b. Through a data warehouse (Approved Registry—see APTA’s website for approved
Registries)
c. Through a compliant and approved electronic health record
2. If utilizing the claims submission option all quality measures must accompany either an evaluation
code or a re-evaluation code (per the measure specification) i.e. they must be performed,
documented and submitted on the same claim form on the same date of service
3. If utilizing the qualified registry option the concurrent submission of billing data with clinical data is
not required, i.e. the numerator and the denominator can be affixed on separate dates of service
4. The professional designation modifier (GP, GO & GN) must not be affixed on the same line as the
quality data codes as that will result in a non-processible measure. (This is just the opposite of
the Functional Limitation codes which require the professional designation on all of the codes
selected).
5. There are two classifications for measures reported by individuals
d. Measures, Individual
e. Measures, Group (there is a new classification “Group Practice” this requires an
application
6. The number of quality measures required for individual reporting varies based on the reporting
tool and the classification of the measure:
f. Claim form- Measures, Individual
i. Three or more measures
ii. Fifty percent of the Medicare patients seen
g. Registry & Electronic Health Record-Measures, Individual
i. Three or more measures
ii. Eighty percent of the Medicare patients seen
h. Claim form- Measures, Group
i. One or more measures
ii. Fifty percent of the Medicare patients seen
i. Registry & Electronic Health Record-Measures, Group
i. One or more measures
ii. Eighty percent of the Medicare patients seen
Under the PQRS Tab
7. The PQRS individual reporting period for 2013 is January 1, 2013 through December 31, 2013
however, an exception was made for the reporting of Measures, Group via a registry which allows
for a July 1, 2013-December 31, 2013 reporting period.
The benefits of participating in PQRS are:
1. Therapists have a head-start on Pay for Performance coding
2. Therapists have an opportunity to receive a bonus for participating
3. If a therapists reports in 2013 and/or 2014 he/she will receive .5% bonus for all successful
submissions
4. Therapists have an opportunity to be recognized ‘publically’ for participating
The risks of not participating are just the opposite of the benefits but also include a future penalty for not
participating:
1. If a therapist does not report any measure successfully in 2013 he/she will be penalized 1.5% in
2015 based on 2013 data
2. If a therapist does not report any measure successfully in 2014 he/she will be penalized 2.0% in
2016 based on 2014 data
3. For all subsequent years of not reporting the 2.0% penalty will apply based on the previous years’
data
NOTE: If a therapist reports, successfully, at least one measure on one patient or one group
measure in the year 2013 he/she will be exempt from the 2015 penalty application.
The following list of measures is representative of ones that maybe utilized by physical therapists and
occupational therapists via claims or registry options. For detailed explanations and guidance refer to
www.bcmscomp.com (site to be updated by 12-28-12); www.apta.org and https://www/cms.gov/PQRS/
Measures Individual: Approved for PT and/or OT (look for 97001-02-03-04to validate eligibility)
#126: Diabetes Mellitus: Foot and Ankle Care, Peripheral Neuropathy and Neurologic Evaluation
#127: Diabetes Mellitus Foot and Ankle Care, Prevention of Ulcers and Evaluation of Footwear
#128 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (Updated
from 2012)
#130 Documentation and Verification of Current Medications in the Medical Record
#131 Pain Assessment Prior to the Initiation of Patient Treatment (Updated from 2012)
#134 Screening for Clinical Depression and Follow-Up Plan
#154 Falls: Risk Assessment
#155 Falls: Plan of Care
#173 Preventative Care and Screening: Unhealthy Alcohol Use – Screening
#181 Elder Maltreatment Screening and Follow-Up Plan
#182 Functional Outcome Assessment (Updated from 2012)
#217 Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
#218 Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
#219 Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle
Impairments
#220 Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
#221 Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
#222 Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments
#223 Change in Risk-Adjusted Functional Status for Patients with a Functional Deficit of the Neck,
Cranium, Mandible, Thoracic Spine, Ribs or Other General Orthopedic Impairment
# 226 Screening for Tobacco Use and Cessation
Measures-Group: Approved for PT and or OT (look for 97001-02-03-04to validate eligibility)
#148 Back Pain: Initial Visit
#149 Back Pain: Physical Exam
Under the PQRS Tab
#150 Back Pain: Advice for Normal Activities
#151 Back Pain: Advice Against Bed Rest
Green = OT Eligible
Yellow = PT Eligible