New Rules: The Physician Quality Reporting System

Click here for a Expanded Charts and Easy-To-Read PDF Version of the PQRS

Click here for a complete PDF Version of the 2013 Value Based Modifier

By Richard Newell, M.D., MPH, FACEP, Quality and Performance Committee, ACEP

Stacie Schilling Jones, MPH, Director, Quality & HIT, ACEP

Rachel Groman, MPH, VP, Clinical Affairs and Quality, Hart Health Strategies

The Centers for Medicare and Medicaid Services (CMS) has released final rules for the 2013 Medicare Physician

Quality Reporting System (PQRS). Although more emergency physicians participate in PQRS than any other

medical specialty, participation is now more important than ever. The 2013 PQRS has four distinct components

of incentives and penalties (Table 1),each with its own distinct criteria applicable to individuals or groups

depending on group size.

Table 1. Total Potential Impact of PQRS Participations

2013: Four PQRS Programs:
Based on Reported
2013 Claims
Based on Reported
2014 Claims 


1.Traditional PQRS Incentive
+0.5%  payment in 2014
+0.5% payment in 2015


2.PQRS MOC Incentive
+0.5% payment in 2014
+0.5% payment in 2015


Total Potential PQRS Incentives
+1.0% in 2014
+1.0% in 2015


3.PQRS Penalties For Failure to Report
-1.5% in 2015
-2.0% in 2016


4.VBM for Failure to Report PQRS* 
-1.0% in 2015 
-1.0% in 2016 






Potential PQRS Penalties, 2015-2016
-2.5% in 2015
-3.0% in 2016



*VBM applies to groups ≥100 eligible professionals only

2013 PQRS Eligible Professionals
The definition of “eligible professionals” (EPs) for the 2013 PQRS includes physicians, physician assistants,

nurse practitioners, clinical social workers, and other mid-level clinicians.

 
2013 PQRS Measures 
Importantly several key ED relevant measures have been eliminated for 2013. As a result solely reporting

pneumonia measures will no longer satisfy the criteria for the PQRS incentive that requires reporting 3

individual measures (See Table 2). Please note that due to the retirement of PQRS measures #57 and #58

there is no longer an Emergency Medicine Measures Group for 2013.

Table 2. 2012 PQRS Emergency Relevant Measures Retired for 2013

PQRS Measure
2012 Retired Measures
Steward	Available
Rep.Mechanism(s)


#57
Emergency Medicine: Community Acquired Pneumonia(CAP): Assessment ofO2 Saturation
AMA/PCPI-NCQA
RETIRED


#58
Emergency Medicine: Community Acquired
AMA/PCPI-NCQA
RETIRED


 
Pneumonia (CAP): Assessment of Mental Status
 
 


#92
Acute Otitis Externa (AOE):  Pain Assessment
AMA PCPI
RETIRED


#253
Pregnancy Test for Female Abdominal Pain Patients
ACEP
RETIRED

2013 PQRS measures maintained from 2012 and relevant to emergency medicine are listed in Table 3, below.

Table 3. 2013 PQRS Quality Measures Relevant to Emergency Medicine



PQRS Measure
2013 Reportable Measures
Steward
Available Reporting Mechanism(s)


#28
Aspirin at Arrival for AMI
AMA/PCPI-NCQA
claims, registry


#31
Stroke & Stroke Rehabilitation: DVT ProphylaxisforIschemicStroke or Intracranial Hemorrhage
AMA/PCPI-NCQA
claims, registry


#35
Stroke & Stroke Rehab: Screening for Dysphagia
AMA/PCPI-NCQA
claims, registry


#54
Emergency Medicine: 12-Lead ECG Performed forNon-Traumatic Chest Pain
AMA/PCPI-NCQA
claims, registry


#55
Emergency Medicine: 12-Lead ECG Performed for Syncope
AMA/PCPI-NCQA
claims, registry








#56
Emergency Medicine: Community Acquired Pneumonia (CAP):Vital Signs
AMA/PCPI-NCQA
claims, registry


#59
Emergency Medicine: Community Acquired Pneumonia (CAP):Empiric Antibiotic
AMA/PCPI-NCQA
claims, registry


#76
Prevention of Catheter-Related Bloodstream Infections(CRBSI:Venous Catheter(CVC) Insertion Protocol
AMA PCPI
claims, registry


#91
Acute Otitis Externa (AOE):  Topical Therapy
AMA PCPI
claims, registry


#93
Acute Otitis Externa (AOE):  Systemic Antimicrobial Therapy –Avoidance of Inappropriate Use
AMA PCPI
claims, registry


#187
Stroke & Stroke Rehabilitation: Thrombolytic Therapy
AHA/ASA/TJC
claims







#228
Heart Failure (HF): Left Ventricular Function (LVF) Testing
CMS/QIP......
registry


#252
Anti-coagulation for Acute Pulmonary Embolism Patients
ACEP
claims, registry


#254
Ultrasound Determination of Pregnancy Location for PregnancyPatients withAbdominal Pain
ACEP
claims, registry


#255
Rhogam for Rh-Negative Pregnancy Women at Riskof Fetal Blood Exposure
ACEP
claims, registry


#317
Preventive Care and Screening: for High Blood Pressure (not requently reported by ACEP members.... 
CMS QIP
claims, registry,EHR, GPRO Web Interface


 
 
 
 

Individual Reporting Options to Earn the PQRS Incentive
Under the individual reporting options, quality measure performance is reported based on national provider identifier (NPI) number. However, payment of the PQRS incentive (and penalty) is provided to the Tax ID Number (TIN) of the reporting entity.

Traditional Claims: Report appropriate quality-data codes for each PQRS measure specification on Medicare Part B claims as part of the routine billing process.
Qualified Registry: Most emergency care related traditional claims-based measures in Table 2 will also be available for reporting via qualified registry in 2013. Registry data can be entered or uploaded retrospectively up to 2 months following the end of the PQRS reporting year.
EHR Reporting: These measures do not apply to emergency physicians at this time, but other EPs may choose to submit measures directly from their own qualified EHR system or through a qualified EHR data submission vendor."

Group Practice Reporting Options (GPROs) to Earn the PQRS Incentive
EPs may report as individuals or as a “group practice.” For the 2013 PQRS, CMS has expanded the definition of group practice as being comprised of 2 or more EPs practicing under the same TIN. Group practices with 99 or fewer EPs may continue to report as individuals using one of the multiple reporting options for individuals described above, or elect to participate as a group. Group practices with 100 or more EPs are required to participate as a group in order to avoid the Value-based Modifier (VBM).

Unlike the individual reporting options, group practices that elect to participate as a group must do so by submitting a self-nomination statement via the web from July - October 15, 2013. In the meantime your group practice should register for an Individuals Authorized to Access CMS Computer Services (IACS) account, which will allow an authorized user to register your practice for the GPRO when the web registration system opens.

Please note: Once a group elects a reporting option, this is the only method of reporting that will be available to the group and all individuals within the group. An individual physician who is a member of a group practice who has elected a GPRO (except the new administrative claims option) is no longer eligible to earn a separate PQRS incentive as an individual.

Group Reporting Options Include
GPRO Web Interface: Available only to group practices ≥25 EPs.Report on a set of 18 primary care and prevention measures for beneficiaries CMS assigns.Due to the office visit E/M code attribution, no beneficiaries for these measures can be assigned to an emergency department visit.This option is NOT recommended for emergency department only or hospital-based TINs and will not meet the criteria for the incentive for hospital based group practices.
GPRO Qualified Registry: Available to 2 or more EPs.
NEW Administrative Claims Option: Does NOT earn an incentive for the 2013 reporting period, but does avoid 2015 PQRS and 2015 VBM penaltiesOnly group option that allows individual EPs to use the traditional claims or registry options to earn the PQRS incentive for the 2013 reporting period.

2013 PQRS Penalties

If EPs or group practices do not satisfy PQRS reporting requirements in 2013, a payment adjustment of -1.5 percent will be applied to their total allowable Medicare Part B charges in 2015. Please note that there is a separate, but lower threshold for avoiding the penalties as outlined below, than for earning the incentive as outlined above. 

Individual Reporting Options to Avoid the PQRS Penalty

Reporting as an Individual
There are 3 ways for an individual professional to meet the criteria for satisfactory reporting to avoid the 2015 PQRS payment adjustment: 

Successfully meet the criteria for the 2013 PQRS Incentive (see above); or
Successfully report at least 1 valid measure; or
Elect to be analyzed under the new administrative claims option outlined below (ACEP does not recommend that individuals use this option as it cannot be used to earn the incentive).

Reporting as a Group Practice
There are 3 ways that a group practice may avoid the 2015 PQRS payment adjustment:

Successfully meet the criteria for the 2013 PQRS Incentive under the GPRO (see above); or
Successfully report 1 valid measure; or
Elect to be analyzed under the new administrative claims option outlined below (in addition the individuals within the group practice can continue traditional PQRS reporting as individuals to earn the incentive).

Group Practices ≥ 100 Eligible Professionals: NEW Administrative Claims Option
The new administrative claims option provides groups with an additional opportunity to avoid the 2015 PQRS penalty. Under this option, CMS will analyze a groups Medicare claims for a set of 17 measures for assigned beneficiaries, and specific quality data codes do not have to be submitted to CMS. However, because of the primary care office visit E/M codes used to assign beneficiaries, no beneficiaries will be assigned to emergency department visits. Under this less stringent option, and this option only, even if the group has a denominator of zero for all measures, they can still avoid the 2015 PQRS penalty.

Beginning with the 2013 reporting year, group practices ≥100 or more EPs will be subject to a separate Value-Based Payment Modifier (VBM) in 2015, if they do not self-nominate to participate in the GPRO or elect the new administrative claims option by October 15, 2013. Although participation in the new administrative claims option does NOT earn a PQRS incentive for the 2013 reporting period, if a group practice elects this option, the members of the group may still use the traditional claims or registry options to qualify for the 2013 PQRS incentive.PQRS and ACOs

ACO participant TINs and individual ACO providers cannot earn a separate PQRS incentive outside of the Medicare Shared Savings Program, but also will not be subject to either the PQRS or VBM penalties. 

Further Information

For more detailed information on each of the reporting options outlined above, please go to the January online issue of ACEP News at www.acepnews.org

Sign Up Now for 2012 PQRS MOC Incentive Program!

The American Board of Emergency Medicine’s (ABEM) MOC program has been vetted and approved by the Centers for Medicare & Medicaid Services (CMS) for the MOC incentive program. To qualify for the PQRS MOC incentive, ABEM diplomates must meet the annual requirements of the ABEM MOC program, complete required activities, including practice improvement activities and a patient experience of care survey, and participate in the MOC program more frequently than is required to qualify for or maintain board certification status for the calendar year.  CMS permits each qualified MOC Program to define “more frequently” as it feels is appropriate.  Participation in both the PQRS and PQRS MOC Program is voluntary and ABEM certification of those who choose not to participate in PQRS in 2012 will not be affected.