Physician Quality Reporting System &

Value Based Payment Modifier

Eduardo Porras CPC, CPMA AHIMA Certified ICD10 Instructor

PQRS & VBPM

Agenda

• PQRS Introduction How Does PQRS Work?

PQRS and Payment Adjustments Reporting Methods

Reporting Considerations Future of PQRS and

Value-Based Payment Modifier

• Questions2

PQRS & VBPM

Physician Quality Reporting (PQRS) Introduction

•In an effort to improve the quality and lower the cost of health care, the Centers for Medicare and Medicaid Services (CMS) is moving toward performance-based reimbursement and away from the fee-for-service (FFS) payment model.

•PQRS is one of several initiatives designed to accomplish that goal

•PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). 

•Beginning in 2015, the program applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.

PQRS & VBPM

How does PQRS work?

•Eligible Professionals (EPs) report data on quality measures for covered Physician Fee Schedule (PFS) furnished to Medicare Part B FFS beneficiaries

•Must be based on the patients diagnosis and clinical context

•EPs must report on each unique NPI/TIN combination

•Commonly Asked Question

•I work for 2 different organizations, so I have 2 different reporting NPI/TINs I bill under. Which one do I use for reporting?

•Eligible Professionals must report for each NPI/TIN combination they used to bill Medicare during the 2014 calendar year in order to avoid the 2016 PQRS payment adjustment.

PQRS & VBPM

PQRS and Payment Adjustments

•2015 program year incentive: 0%•There is no incentive payment associated to PQRS reporting in 2015.

•2015 program year penalty: -2%

•Payment adjustment for reporting year 2015 will apply to Medicare reimbursements in 2017.

•2014 reporting year was the last year to earn an incentive

•Payment penalties will continue•Failure to report PQRS in 2015 will result in a payment adjustment in 2017, and so on

•These penalties are in addition to Meaningful Use penalties and Value-Based Modifier penalties.

PQRS & VBPM

PQRS Payment Adjustments 2014/2016

• A payment adjustments occurs two years from the reporting year. The PQRS reporting year is based on a calendar year (January 1 to December 31).

• For the 2014 PQRS reporting year, eligible professionals may see a payment for +0.5% for satisfactory reporting or will incur a -2.0% penalty for non-reporting (i.e., not participating in PQRS).

• Payment adjustments occur in 2016 for the 2014 PQRS reporting year.

PQRS & VBPM

PQRS Payment Adjustments 2015/2017

• The payment adjustment for the 2015 PQRS reporting year will occur in 2017.

• For the 2015 PQRS reporting year, eligible professionals will incur a -2.0% penalty for non-reporting (i.e., not participating in PQRS)

• Note: All EPs who do not meet the criteria for satisfactory reporting or participating for 2015 PQRS will be subject to the 2017 negative payment adjustment with no exceptions.

PQRS & VBPM

Your Practice and PQRS

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PQRS & VBPM

Your Practice and PQRS•Why should I participate in PQRS?

•Avoid Medicare penalties

•Value-Based Modifier

•Currently applies only to group practices •Going forward, will apply to all practices, including single providers

•Can result in penalties of up to -4%

•Example: Group of 3 providers bills $2,000,000 to Medicare

•If NOT successful in PQRS reporting •PQRS Penalty = -$40,000 AND•Value-Based Modifier Penalty = -$80,000

•Total penalty for not reporting = $120,000

PQRS & VBPM

Your Practice and PQRS

Steps for your practice

1.Determine eligibility2.Choose a reporting method3.Choose measures4.Collect and organize data5.Submit data

PQRS & VBPM

PQRS Eligible Professionals

• Practitioners: Certified Registered Nurse Anesthetists, Anesthesiologist Assistans, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, Clinical Social Workers, Clinical Psychologists, Registered Dietitians, Nutrition Professionals, and Audiologists

• Therapists: Physical, Occupational, and Qualified Speech-Language Therapists

• Physicians

PQRS & VBPM

Commonly Asked Question

•Commonly Asked Question

•Is there a minimum number of Medicare patients I need to see to qualify and need to report PQRS?

•Eligible Professionals who had at least 1 eligible Medicare Part B FFS patient encounter during 2015 must report PQRS data. If the provider does not report, they will be subject to a -2% payment adjustment in 2017 for failure to report.

PQRS & VBPM

PQRS Reporting Methods

• Individual EPs or Groups of individual EPs reporting on quality measures can utilize any of the following methods:

1. Medicare Part B claims2. Qualified PQRS registries3. Direct electronic health records (EHR) using Certified

EHR technology (CEHRT)4. Data submission vendor that employs CEHRT5. Qualified clinical data registry (QCDR)

• Note: Payment adjustments are based on the Medicare Part B FFS only under the Medicare Physician Fee Schedule (PFS)

PQRS & VBPM

Reporting Considerations

Individual Measures and Measures Group• Individual Measures

• Report on at least 50% of eligible encounters• All measures must have a >0% performance rate• 9 measures across 3 NQS domains = avoid 2017 Medicare

payment adjustment (-2%)

• Measure Groups• EP chooses 1 measures group of related measures• Report on all applicable measures for 20 eligible patients (majority must

be traditional Medicare Part B beneficiaries)• All measures must have a >0% performance rate

PQRS & VBPM

Commonly Asked Question

•Commonly Asked Question

•I have a low Medicare volume, so I don’t have 20 patients to report (or 11Medicare patients) for any Measure Group. Can I report on less than 20 and avoid the payment adjustments?

•For 2015, EPs reporting a Measures Group must report all applicable measures for 20 eligible patients (11+ Medicare FFS patients) in order to avoid the 2017 PQRS payment adjustment. If an EP does not have the enough patients to achieve this with a certain measures group, the EP can choose another measures group that can be reported for 20 patients. Otherwise the EP will need to report individual measures using all 2015 Medicare patients.

PQRS & VBPM

Measure-Applicability Validation (MAV) Process

• MAV is a general validation process used by CMS to determine satisfactory reporting to PQRS for claims or registry reporting only.

• If an EP has less than 9 measures, or 9 measures covering less than 3 domains, the MAV process will be applied.

• The MAV process determines if an EP is eligible for an incentive despite reporting less than 9 measures, 9 measures covering less than 3 domains.

PQRS & VBPM

Factors to Consider When Choosing a Measure?

• When choosing measures, be familiar with the following:

• Clinical conditions commonly treated• Types of care delivered frequently - preventive, chronic,

acute• Settings where the care is delivered - office, emergency

department, surgical suite• Quality improvement goals• Other quality reporting programs in use or being considered

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PQRS & VBPM

The Six NQS Domains

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PQRS & VBPM

2015 Satisfactory Reporting (Individual Measures)

• Report on at least 9 Measures covering 3 National Quality Strategy (NQS) domains for at least 50 percent of the Medicare Part B FFS patients via claims or a qualified registry

PQRS & VBPM

Value Based Payment Modifier (VBPM) Impact

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PQRS & VBPM

Value Based Payment Modifier (VBPM) Impact

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PQRS & VBPM

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Questions?

ICD-10 Regulatory Compliance into Strategic Advantage

Thank You

If you would like more information on this topic or other ways to increase your

reimbursements, contact us directly.

• Call us: 1-877-AVISENA • E-Mail: marketing@avisena.com• Visit us at www.avisena.com

Presenter:Eduardo Porras CPC, CPMADirector of OperationsAvisena, IncMobile 305-776-9632Eporras@Avisena.com

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