Physician Quality Reporting System (PQRS) &
Physician Value-Based Payment Modifier (VBPM)
2015 Performance Year
By way of background, this year CMS will stop issuing bonuses for PQRS and continue
penalizing for not participating or failing the PQRS measures. The penalty is potentially 2-6% of
your Medicare reimbursement in 2017 if you fail the measures or fail to report. The below tips
should help you to pass for 2015 to avoid a 6% adjustment or penalty. The average doc stands to
lose $1500- $4000 depending on their population (based on the 2012 Medicare database). While
the Name will change from PQRS to MIPS after the SGR fix when through, the concepts,
rewards and penalties will stay the same.
For a succinct summary of PQRS, click this link from the ACEP Quality Committee.
http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/PQRS
%20Flyer%20MAV%20Update.pdf
What are the different incentive and penalty quality programs?
PQRS is a reporting program that uses a combination of incentive payments and payment
adjustments to promote reporting of quality information by eligible professionals (EPs). The
program provides an incentive payment to practices with EPs, who are identified on claims by
their individual National Provider Identifier (NPI) and Tax Identification Number (TIN). EPs
satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services
furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. There are now only two
distinct PQRS programs for the 2015 performance year.
Two Distinct PQRS Programs
1. Traditional PQRS Incentive
2. PQRS MOC Incentive
3. PQRS Penalties For Failure to
Report
4. Value-Based Modifier (VBPM)*
For Failure to Report PQRS*
5. Total Penalties
2015 Performance Year (PY):
No incentive payment
No incentive payment
-2.0% in 2017
Up to -4.0%in 2017
Up to -6.0% in 2017
How many measures are needed to meet requirements? Emergency Medicine EP’s may
report utilizing the 3 measures from the Emergency Care Cluster plus one cross cutting
measure OR may report 9 measures across 3 domains and one cross cutting measure.
Claims-Based Reporting Mechanisms Via Cluster 4
Can Report using Emergency Care Cluster 4 to avoid the PQRS and
VBM penalties
To Avoid the Penalties:
3 Measures from the Emergency Care Cluster #4 for at least 50% of
applicable Medicare patients. Plus 1 cross cutting measure
Physicians participating in a group practice which is part of an Accountable Care Organization
(ACO) must report via the Group Practice Reporting Option (GRPO) registry option. Group
practices may register to participate and be analyzed as a group, or at the TIN level. Reporting
via the GPRO can also satisfy the reporting requirements for the Value-based Payment Modifier
(VM). Satisfactorily reporting through the GPRO using the EHR-based reporting method, the
Web Interface, or the enhanced Consumer Assessment of Healthcare Providers and Systems
(CAHPS) for PQRS in combination with EHR-based reporting or the Web Interface will satisfy
the clinical quality measures (CQM) component of the Medicare EHR Incentive Program.
Currently there are 33 measures ACO’s are required to report on.
Which measures can emergency EPs report on?
Emergency physicians and emergency department providers reporting as individuals should
report on the following measures in the 2015 performance year in order to avoid a 2-6% penalty
to their 2017 Medicare reimbursements. This list is used in MAV process to assess whether or
not a sufficient number of measures were reported and is referred to as Cluster 5.
2015 Performance Year
Core Quality Measures for Emergency Care Cluster # 4
Physician Quality Reporting System (PQRS) & Value-Based Payment Modifier (VBM)
PQRS
Codes
Measure Title
NQS
Reporting
Measure
Measure
Included
Domain
Mechanism Applicability
Number
Validation
Cluster
#54
ED, CC Emergency
Effective
Claims,
Claims Cluster
Medicine: 12Clinical
registry
#4
Lead ECG
Care
Performed for
Non-Traumatic
Chest Pain
#254
ED, CC Ultrasound
Effective
Claims,
Claims
Determination
Clinical
registry
Cluster#4; not
of Pregnancy
Care
assigned to
Location for
registry cluster
Pregnancy
Patients with
Abdominal Pain
#255
ED, CC Rhogam for Rh- Effective
Claims,
Claims Cluster
Negative
Clinical
registry
#4; not assigned
Pregnancy
Care
to registry cluster
Women at Risk
of Fetal Blood
Exposure
#317
Cross
Preventative
Community
Claims,
Cutting
Care and
/ Population registry,
Measure
Screening:
Health
EHR, GPRO
Screening for
Web
High Blood
Interface,
Pressure and
Measures
Follow-Up
Group
Documented
Basics of performing and documenting the four Emergency Care measures:
The big one is Measure 317: High blood pressure screening and follow up
 Population: Medicare patients with patients with pre-hypertension defined as BP 120139/ 80-89 or hypertension BP > 140/90 (Note definitions based upon JNC 7, not
updated with JNC 8 yet)
 Blood pressure must be documented and if hypertensive or pre-hypertensive,
documentation of referral to a PCP or other provider for follow up in < 4 weeks
for hypertension and <1 year for pre-hypertension. Admission to the hospital
would count as follow up documentation.
 Exclusions:
o Normal blood pressure- less than 120/80
o Patient to urgent or emergent to allow for follow up
recommendations(admission, to OR/cath lab) or immediate blood pressure
treatment undertaken, such as hypertensive crisis, hypotension
o Patient refuses blood pressure reading
o Pre-existing hypertension documented
 Fail if:
o Blood pressure not documented and reason not given for not being
documented
o Blood pressure taken and abnormal but reason for no follow up not
documented
Next up Measure 54: 12 Lead EKG performed for Non-Traumatic Chest Pain
 Population: Patients 40 or older with discharge diagnosis of non-traumatic chest pain
 Must document 12 Lead EKG performed or reason you didn’t
 Exclusions:
o Patient refused
o Document medical reason why not done
 Fail if no EKG documented and no exclusion documented
Lastly, the pregnant Medicare patient measures.
Measure 254: Ultrasound determination of pregnancy location in pregnant patients with
abdominal pain.
 Population: Medicare patients age 14-50 with chief complaint of abdominal pain or
vaginal bleeding
 Must document trans-abdominal or trans-vaginal ultrasound performed or why you
didn’t
 Exclusions:
o Document patient already has documented IUP
o Document patient has multiple visits in the last 72 hours
 Fail if No ultrasound and no reason documented why not.
Measure 255: Rhogam ordered for RH-negative patients at risk of Fetal blood exposure
 Population: Medicare patients age 14-50 at risk for fetal blood exposure who are Rh
negative
o At risk patients may include
 Abdominal trauma
 Vaginal bleeding


Ectopic pregnancy
Threatened or spontaneous Ab
 Must document Rhogam ordered for all Rh negative patients
 Exclusions:
o Prior documented Rhogam ordered within 12 weeks
o Patient refusal
 Fail if not ordered and not documented why
Are there other measures that CAN be reported?
Yes, please see below a table of 12 “other” quality measures, which could possibly be reported.
Please note that if reporting on just one additional measure outside of the above Cluster, then the
MAV process would subject a provider to reporting on additional measures within that clinical
cluster.
2015 PQRS Performance Year
Other Reportable Quality Measures
Measure
NQS
Reporti
Measure
Title
Domain
ng
Applicability
Mechan
Validation
ism
Cluster
PQRS
Measure
Number
Codes
Included
#1
ED, CC
Diabetes:
Hemoglobin
A1c (HbA1c)
Poor Control
(>9%)
Effective
Clinical
Care
Claims,
registry
Claims Cluster
#3;
Registry
Cluster #2
#65
ED
Efficiency &
Cost
Reduction
Registry
only
Registry
Cluster #15
#66
ED
Appropriate
Treatment for
Children with
Upper
Respiratory
Infection
(URI)
Appropriate
Testing for
Children with
Pharyngitis
Efficiency &
Cost
Reduction
Registry
only
Registry
Cluster #15
#76
ED, CC
Patient
Safety
Claims,
registry
Not included
in any MAV
process
#91
ED
Prevention of
CatheterRelated
Bloodstream
Infections
(CRBSI):
CVC
Insertion
Protocol
Acute Otitis
Externa
(AOE):
Effective
Clinical
Care
Claims,
registry
Claims Cluster
#8
Registry
Notes
The
performance
period for this
measure is 12
months from
date of
encounter
Needs
information on
three days
after the visit
Needs
information 30
days prior to
visit for
measure
Patient Safety
satisfies an
additional
NQS domain
of care
Each unique
occurrence is
defined as a
Topical
Therapy
#93
ED
#116
ED
#117
ED, CC
#119
Cluster #16
30-day period
from onset of
AOE
Each unique
occurrence is
defined as a
30-day period
from onset of
AOE
Acute Otitis
Externa
(AOE):
Systemic
Antimicrobial
Therapy –
Avoidance of
Inappropriate
Use
Antibiotic
Treatment for
Adults with
Acute
Bronchitis:
Avoidance of
Inappropriate
Use
Diabetes: Eye
Exam
Communicat
ion & Care
Coordinatio
n
Claims,
registry
Claims Cluster
#8
Registry
Cluster #16
Efficiency &
Cost
Reduction
Registry
only
Not included
in any MAV
process
Registry Only;
need data 3
days after visit
Effective
Clinical
Care
Claims,
registry
Claims Cluster
#3;
not included in
registry MAV
process
ED, CC
Diabetes:
Medical
Attention for
Nephropathy
Effective
Clinical
Care
Claims,
registry
Claims Cluster
#3;
Registry
Cluster #2
#163
ED, CC
Diabetes:
Foot Exam
Effective
Clinical
Care
Claims,
registry
Claims Cluster
#3;
not included in
registry MAV
process
#187
CC
Effective
Clinical
Care
Registry
only
#317
ED
Stroke &
Stroke
Rehabilitation
Thrombolytic
Therapy
Preventive
Care and
Screening:
Screening for
High Blood
Pressure
Community
/ Population
Health
Claims,
registry
Registry
Cluster #28;
not included in
claims MAV
process
Claims Cluster
#1;
not included in
registry MAV
process
Requires
documentation
of eye exam in
the
measurement
year or a
negative exam
in year prior
Requires
documentation
of nephropathy
screening test
in the
measurement
year
Requires
documented
foot exam
during the
measurement
year
Registry only
The
documented
follow up plan
must be related
to the current
BP reading
What are the National Quality Strategy domains?
1. Person and Caregiver-Centered Experience
2. Patient Safety
3. Communication and Care Coordination
4. Community and Population health
5. Efficiency and Cost Reduction
6. Effective Clinical Care
What counts as successfully reporting on a measure? For either a group or individual
physician, depending on the reporting mechanism, reporting on at least 50% of the Medicare Part
B Fee for Service patients to which a PQRS measure applies. Measures with a performance of
0% do not count as successfully reporting that measure.
What are the reporting options for emergency physicians, emergency PAs, and emergency
NPs?
1. Claims-based and qualified registry for individual eligible professionals:
 What are the requirements for an eligible professional (EP) to report
claims-based measures as an individual? To earn the incentive the EP must
successfully report on 9 measures across 3 NQS domains. If they do not meet
this requirement, then they must report on at least 3 measures for at least 50% of
Medicare Part B Fee for Service patients to whom the measure applies in order
to avoid the penalty. If the EP does not meet the 9 measures across 3 NQS
domains, they will also undergo the MAV process to see if they may earn the
incentive. As for avoiding the “adjustment”, an EP reporting less than 3
measures will likewise be subjected to the MAV process, which allows CMS to
determine whether an EP should have reported quality data codes for additional
measures and/or covering additional NQS domains. Measures with a 0%
performance rate will not be counted.

How are groups (TINs) with >2 EPs that do not elect to participate in
GPRO evaluated for VBM? To avoid the 2017 VBM penalty, the TIN must
have at least 50% of their individual EPs either earn the 2015 PQRS incentive or
avoid the adjustment. (subject to the Measure-Applicability Validation process).
 What about part-time staff? Even just one claim for the calendar year
qualifies that NPI as an EP under your TIN for purposes of the “50%
threshold.”
 What about PAs/NPs? Even just one claim for the calendar year
qualifies that NPI under your TIN for purposes of the “50% threshold.”
 Is the 50% threshold also good for the PQRS? No the 50%
requirement applies to the VBM. EPs reporting as individuals for PQRS
will avoid the penalty or receive the negative 2% adjustment as an
individual.
 If 51% of the TIN meet the criteria for reporting 2015 PQRS quality
measures what happens to the other 49% who do not? The other 49%
(or whichever percent do not satisfactorily report PQRS), would still
receive a -2% PQRS penalty in 2017 from Medicare on all of their
individual Medicare Part B FFS reimbursement.
 For the VBM adjustment, does every EP in the TIN receive the same
adjustment? For the VBM, if at least 50% of the TIN EPs successfully
report (avoid the adjustment) 2015 PQRS, then all physicians in the TIN
will be subject to the same VBM adjustment (down, neutral) regardless
of the individual EP’s PQRS performance.
 Will the PQRS penalty, VBM penalty, and VBM adjustment be
levied for non-physician clinicians (PAs/NPs)? All providers reporting
as individuals will be subject to same PQRS incentives and penalties.
The VBM adjustments will only be applied to physicians.
2. Qualified Registry (QDR) Group Practice Reporting Option (GPRO):
 If the group reports via GPRO using a registry, is the requirement for 9
measures across 3 NQS domains at the TIN level or EP level? A group may
report as a GPRO at the TIN level (as opposed to the individual level). To
successfully report via registry, the TIN must report on 9 measures across 3 NQS
domains for at least 50% of their Medicare Part B Fee for Service patients.
Measures with a reported 0% performance rate do not count as successfully
reported.
 What if a TIN group reports through GPRO registry and 1 member of the
group fails the MAV process, is the whole TIN affected and loses bonus or
receives penalty? The measure for successful reporting through this mechanism
is at the TIN level only, where the TIN must report on at least 50% of the
beneficiaries that fall into 9 measures across 3 NQS domains. Any MAV process
through GPRO registry is at the TIN level and not EP level.
 If the TIN successfully reports on 9 measures across 3 NQS domains do all
EPs in the TIN earn the incentive, avoid the penalty and receive the same
VBM adjustment? Yes
 Through GPRO are PAs/NPs considered as part of the TIN? Yes they are
considered EPs for the purpose of PQRS and VBM.
 How can my group report via a GPRO qualified registry? Groups who elect
to report via GPRO registry can select a registry vendor from among the CMS
qualified PQRS registry vendors to report. The 2014 CMS qualified data registry
vendors is posted to the CMS website here. There is not yet an updated 2015 list
of approved vendors though many of the current vendors will continue to be
eligible for 2015.
3. Web-Interface GPRO:
 If your TIN is a multi-specialty group practice that also include primary care
office visits or your group participates in the Shared Savings Program as
Accountable Care Organizations (ACOs), then your group can register with
CMS to report measures through the GPRO Web Interface for program year
2015. For groups electing this method of reporting, CMS will pre-populate the
Web Interface with a sample patient population. Successful completion of the 22
Web Interface measures for the required number of patients will determine
PQRS incentive eligibility and performance rates for the measures. To avoid the
2017 PQRS payment adjustment, group practices taking part in PQRS GPRO via
the Web Interface must meet the requirements for satisfactory reporting.
4. How does my group elect a GPRO?
 Group practices must register to participate in PQRS GPRO. Registration must
be completed through the online Physician Value-Physician Quality Reporting
System (PV-PQRS) Registration System by June 30, 2015. The PV-PQRS
Registration System is a web-based application that serves the PV and PQRS
programs. During registration, group practices must indicate their reporting
method though they may change this method at any time prior to the June 30,
2015 deadline. Groups who register for the 2015 PQRS GPRO will not be able
to withdraw their registration. Prior to signing up for your PQRS reporting
mechanism, group practices will need to register for a CMS IACS account if
they do not already have an IACS. For more information, see the CMS handout
on
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2015_PQRS_GPRO_Criteria.pdf.
 GPRO election is an annual requirement and requires active registration. Prior
year status (ie reporting as an individual or GPRO) is not carried forward.
5. If my group decides to submit claims-based measures as individuals do we have to
elect this?
 If your group intends to report on individual claims-based measures, then they
are not required to register for a GPRO, however, ACEP strongly encourages all
groups to sign up for their IACS account, so that they may obtain their Quality
and Resource Use Report (QRUR), which contains important information on
their group’s performance for prior years. This information will be essential to
determine how your group will fare under the VBM quality-tiers in future years.
 Authorized representatives of groups can access the QRURs and IEP PQRS
Performance Reports at https://portal.cms.gov using an Individuals Authorized
Access to the CMS Computer Services (IACS) account.
 Authorized representatives of groups must sign up for a new IACS account or
modify an existing account at https://applications.cms.hhs.gov . Quick reference
guides that provide step-by-step instructions for requesting each PV-PQRS
System role for new or existing IACS account are available here.
Are providers who assigned benefits to the facility for billing considered EPs in 2015? Yes,
in the past those EPs that assigned benefits to the facility for billing were not considered EPs
however for 2014 and going forward providers that billed Medicare Part B and/or Traditional
Railroad on a 1500 claims for or electronic equivalent, under their individual NPI and facility
TIN are eligible to participate in the PQRS program. Also beginning in 2014, professionals who
reassigned benefits to a Critical Access Hospital (CAH) that billed professional services at a
facility level, such as CAH Method II billing, now participate (in all reporting methods except
for claims-based). To do so, the CAH must include the individual provider NPI on their
Institutional (FI) claims.
If the EP/TIN does not successfully report on 9 measures across 3 NQS domains on at least
50% of the beneficiaries to which the measures apply then what happens? The EP/TIN
undergoes the Measure Applicability Validation (MAV) Process, which allows CMS to determine
whether an EP should have reported quality data codes for additional measures and/or covering
additional NQS domains.
1. Claims Based Reporting
 How does the MAV Process work? The MAV is a two-step validation process:
 a “clinical domain relation” test, and
2. a “minimum threshold” test.
 What is the clinical domain relation test? CMS evaluates the clinical domains or
“cluster(s)” the measure(s) the EP reported on fall into. If the EP could have
reported on additional measures within the same “cluster(s)” that the EP reported at
least one measure on, then the EP may fail the MAV process.
 What is the minimum threshold test? The minimum threshold is 15 beneficiaries
(or encounters). An EP must submit quality data codes for any measure within a
clinical cluster, if there were at least 15 patient encounters to which the measure
applies.
 What happens if the EP fails the MAV process? The EP may be subject to the
2% PQRS penalty. If <3 measures are reported, the MAV process is applied to
determine whether or not the EP would avoid the PQRS adjustment. An EP would
not count towards the VBM 50% threshold for their TIN if the EP failed to avoid
the adjustment.
 Does the EP count towards the 50% threshold for their TIN if they do not
satisfactorily report on 9 measures across 3 NQS domains, but passes the
MAV process because CMS determines that the EP could not have reported
on additional measures? Yes, if the EP passes the MAV process (for avoiding the
adjustment), then the EP counts towards the TINs 50% threshold.
Would a group of emergency physicians who successfully report as individuals via claims on
measures in Cluster 4 (Emergency Care) but do not report on additional measures in different
clusters that they could have reported on, still pass the MAV process? Yes. For the vast majority
of emergency medicine EP’s, measures #254 and 255 will not need to be reported assuming that the
EP had fewer than 15 pregnant Medicare patients in 2015 to which these measures may have applied
(i.e. possible ectopic or Rhogam need). However, reporting on any additional measures (other than
those in Cluster 4), for example PQRS #91, will trigger the MAV process to be applied to an
additional Cluster(s).
For more information on the MAV process, please see the Claims based link
(http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/2015_PQR
S_MAV_ProcessforClaimsBasedReporting_01152015.pdf) or this one for Registry
reporting(http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/2
015_PQRS_MAV_ProcessforRegistryBasedReporting_01152015.pdf) of individual measures.
2. GPRO Registry Reporting
 How does the MAV Process work? CMS evaluates the “cluster(s)” the measure(s)
the TIN reported on fall into. If the TIN could have reported on additional measures
within that cluster then the TIN would fail the MAV process.



Are there a minimum number of beneficiaries that the TIN must submit
claims on within a measure before CMS will view it as the TIN should have
reported on it? Yes, 15 beneficiaries.
Are the clusters for registry reporting different from the clusters for claims
reporting? Yes. The CMS website provides the listing for registry clusters.
What happens if the TIN fails the MAV process? The TIN and every EP within
that TIN would not earn the incentive. The MAV process would then evaluate the
eligibility as far as avoiding the incentive. The entire group is subject to the PQRS
incentive, adjustment avoidance or penalty, and the TIN would be subject to the
VBM penalty.
What is the relationship between the PQRS and the Value Modifier?
The 2015 Value Modifier and the Physician Quality Reporting System (PQRS)
In 2017 (for the 2015 performance year),
groups of physicians with 10+ eligible
professionals (EPs)
PQRS Reporters Self-nominate
for GPRO web-interface,
registries, EHR or 50%
threshold AND avoid the 2017
Payment adjustment under
PQRS
Non PQRS Reporters Do not
self-nominate for GPRO webinterface, registries, EHR or
50% threshold AND do not
avoid the 2017 Payment
adjustment under PQRS
-2.0% downward adjustment
for PQRS -AND- -4.0%
downward adjustment for
VBM
Mandatory Quality Tiering
Physician Groups with ≥ 10 EPs
Downward or no adjustment
based on quality tiering
Physician Groups with ≥ 100
EPs
Downward, or no adjustment
based on quality tiering
How is CMS going to calculate the TINs VBM adjustment amount? The Value-Based Payment
Modifier is calculated on a split with 50% based on Quality Composite Score and 50% on Cost
Composite Score as illustrated below.
Effective Clinical Care

Patient Safety

Care Coordinator

Community &
Population Health

Efficiency
Patient Satisfaction
Total Costs
Quality
Composite
Score




Value Based
Modifier
Amount

Specific Disease Total
Costs

Medicare Spending Per
Beneficiary

Cost
Composite
Score


Do all TINs have to quality tier?
 For 2015, TINs with any number of EPs are required to quality tier going forward and
may be adjusted down, or remain neutral.
How much is financially at risk with quality tiering? For the 2015 performance year for the
2017 VBM 4% is the maximum amount at risk.
What is the difference between the Total Cost Per Beneficiary (TCPB) and the Medicare
Spending Per Beneficiary (MSPB) and how will each of these cost measures be attributed?
1. Total Costs Per Beneficiary (TCPB) – overall annual and condition specific with primary
care E/M Codes used to determine plurality of primary care:
 CMS will first identify beneficiaries who have received at least one physician
primary care service from a primary care physician who is part of a particular
group/TIN. If this condition is met, the beneficiary will be assigned to the group if


the allowed charges for primary care services furnished by primary care
physicians in the group are greater than the allowed charges for primary care
services furnished by primary care physicians outside of the group/TIN.
For beneficiaries who have not received any primary care services from a primary
care physician, the beneficiary is assigned to a group/TIN only if he or she has
received at least one primary care service from any physician (regardless of
specialty) in the group/TIN and if the allowed charges for primary care services
furnished by professionals in that group/TIN (including specialist physicians,
NPs, and PAs) are greater than the allowed charges for primary care services
furnished by professionals in other groups/TINs.
The specific HCPCS/CPT codes that CMS will use to define primary care
services includes some urgent care codes, nursing home, and home health codes
as follows:
Attribution Methodology E&M Codes for Total Costs
Measures and Outcomes Composite
99201-99205
new patient, office or other outpatient visit
99211-99215
established patient, office or other
outpatient visit
99304-99306
new patient, nursing facility care
99307-99310
established patient, nursing facility care
99315-99316
established patient, discharge day
management service
99318
established patient, other nursing facility
service
99324-99328
new patient, domiciliary or rest home visit
99334-99337
established patient, domiciliary or rest home
visit
99339-99345
new patient, home visit
99347-99350
established patient, home visit
G0402
initial Medicare visit (welcome to Medicare
visit)
G0438
annual wellness visit, initial
G0439
annual wellness visit, subsequent

Will ED codes be considered for the plurality of primary care? No, the ED
E/M codes are not included; however urgent care and office based E/M codes are
included.
2. Medicare Spending Per Beneficiary (MSPB) – 3 days before through 30 days after an
index admission
 This measure is attributable to the plurality of Part B services delivered to the
beneficiary during an inpatient admission.
 Will ED providers be assigned these beneficiaries? It is unlikely that ED
providers will be assigned these beneficiaries, however in rare circumstances
where they may be delivering significant services during an inpatient code,
possibly they might be assigned a beneficiary.

Does MSPB attribution apply to OBS or just admissions? The plurality of Part
B services have to be delivered during an inpatient admission, so if they are
considered admitted (observation for 2 midnights) and no other eligible
professional submitted claims for more Part B services, then that attribution will
occur.
If cost measures are attributed to any/some NPIs in the TIN (consider multi-specialty
group with ED docs, hospitalists and primary care), are those cost measures then applied to
all EPs in the TIN for the purposes of quality tiering? Yes, the cost composite and quality
composite is at the TIN level and is applied to all physician NPI’s in the TIN.
What if less than 20 beneficiaries are attributed to the TIN for the cost measures? For those
cost measures with a sample size of less than 20 beneficiaries they will not count toward the cost
composite and the TINs cost will be considered “Average”.
Can a TIN still receive a penalty under the VBM if the TINs cost composite is “average”?
Yes, if the TIN’s “quality” composite is in the “worst 10%” (defined as greater than one standard
deviation from the mean benchmark) then the TIN would be eligible for a 2% penalty, even if
their cost is average.
Will performance be publically reported?
 Currently Physician Compare identifies individuals and group practices that have
satisfactorily reported under PQRS, e-prescribing, or Medicare EHR incentive programs.
 In 2015, CMS will publicly report 2014 PQRS performance data for individual
physicians and/or physician groups for all claims, EHR, or registry reported measures.
 CMS will provide a 30-day preview period prior to any publication of any quality data.
Updated 0629//2015