Physician Quality Reporting System

& Value Based Payment Modifier Don Gettinger, Quality Data

Reporting Manager

QSource

Medicare - Pay for Performance

CMS is seeking to promote higher quality of care and

more efficient health for all Medicare beneficiaries.

CMS is doing this by implementing an increasing

number of quality measures, value based payment and

quality reporting programs.

Measures are based on high priorities and assess

clinical quality, care coordination, patient safety,

population health, patient and care giver experience.

Medicare Quality Reporting

Existing programs are being aligned/consolidated to

develop quality-tiering which will result in upward,

neutral or downward payment adjustments.

Medicare Quality Reporting (cont.)

Examples:

Hospital Value Based Payment (VBP)

• Inpatient Quality Reporting (IQR)

• Outpatient Quality Reporting (OQR)

• Readmission Reduction Program

• Meaningful Use (EHR incentive)

Physician Value Based Payment Modifier (VBPM)

Physician Quality Reporting System (PQRS)

Meaningful Use (EHR incentive)

Physician Quality Reporting System

(PQRS)

PQRS has been voluntary Medicare incentive payments

from 2005 – 2012

CY 2013

“Required to avoid a penalty”

PQRS History/Background

Reporting Year Incentive Year Incentive Payment Penalty Year Penalty Reduction

2005 2007 + 1.5%

2006 2008 + 1.5%

2007 2009 + 2.0 %

2008 2010 + 2.0%

2009 2011 + 1.0%

2010 2012 + 1.0%

2011 2013 + 0.5%

2012 2014 + 0.5%

2013 2015 - 1.5%

2014 2016 - 2.0%

2015 2017 - 2.0%

Adjustments are a percentage of all Medicare allowable FFS

charges.

There is a two year lag

between the reporting

year & the payment

impact year!

Failed to report - 2013

Over 7,000 professionals in Indiana received a penalty letter

in November 2014.

The penalties are based on TIN + NPI

If you believe this letter is in error – ask for an “informal

review” before Feb. 28, 2015.

All informal review requests must be submitted via a web-

based tool, the Quality Reporting Communication Support

Page (Communication Support Page), during the informal

review period, Jan. 1, 2015 through Feb. 28, 2015.

How are the penalties applied?

A negative 1.5% payment reduction will be applied to

all Medicare Part B MPFS covered allowable charges

in 2015.

The negative payment reduction will occur for those

TIN/NPI combinations that did NOT report in 2013.

Only 2015 bills with the TIN/NPI combination will

result in a payment reduction.

CY 2014

Failure to report in 2014 will result in a negative 2%

PQRS payment reduction in 2016.

Only limited options remaining:

Deadlines for reporting 2014 data:

February 28, 2015 (Direct EHR methods)

March 31, 2015 (Registry methods)

Qualified registries are listed online:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Registry-Reporting.html

PQRS Eligibility

Critical Access Hospitals (CAHs)

New Note: Beginning in 2014, professionals who reassign

benefits to a Critical Access Hospital (CAH) that bills

professional services at a facility level, such as CAH Method II

billing, can 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.

PQRS Eligibility

Cannot Participate

Providers who do not bill Medicare at an individual NPI

level, where the rendering provider’s individual NPI is not

entered on the CMS-1500 paper or electronic claim

• FQHCs

• RHCs

• Ambulatory Surgery Centers

• Independent Labs (including “81” place of service)

CY 2015

Start Planning NOW!

Deadlines impact your options

Claims based reporting

G codes must be submitted with each claim

throughout the year.

Group practice options

Groups must register in PV-PQRS between

April 1 – June 30, 2015.

Penalties consolidated and increased over time

CY 2015

CMS is consolidating PQRS and VBPM in 2015

Groups sized 1 – 9 EPs

Failure to report in 2015 results in a negative 4%

payment reduction in 2017.

◉ 2% for not PQRS reporting

◉ 2% for value based purchasing

Groups sized 10+ EPs

Failure to report in 2015 results in a negative 6%

payment reduction in 2017.

◉ 2% for not PQRS reporting

◉ 4% for value based purchasing

PQRS Eligibility All billing for covered Part B services under MPFS – TIN/NPI on 1500 claim

Medicare Physicians

Doctor of

Medicine

Doctor of

Osteopathy

Doctor of

Podiatric

Medicine

Doctor of

Optometry

Doctor of

Oral Surgery

Doctor of

Dental

Medicine

Doctor of

chiropractic

Practitioners & Therapists

Physician

Assistant

Nurse

Practitioner

Clinical Nurse

Specialist

Anesthetist Certified

Nurse Midwife

Clinical Social

Worker

Clinical

Psychologist

Registered

Dietician

Nutrition

Professional

Audiologist Physical

Therapist

Occupational

Therapist

Qualified

Speech-

Language

Therapists

2015 PQRS Reporting Methods

Individual EP Reporting Options Group Practice Reporting Options

(GPRO)

Claims GPRO Web-Interface

Direct EHR (CEHRT) Direct EHR (CEHRT)

EHR Data Submission Vendor (DSV) CEHRT EHR Data Submission Vendor (DSV) CEHRT

Qualified Registry Qualified Registry

Qualified Clinical Data Registry (measures are

selected by the QCDR)

Qualified Clinical Data Registry (measures are

selected by the QCDR)

CMS Certified Survey Vendor for (CG-CAHPS)

Individual EP

Reporting Options

Considerations

Claims Clinic collects data and submits quality codes on each 1500

claim as billed.

Direct EHR (CEHRT) EHR vendor must support direct reporting and EPs must be

using the system. Clinic must have an IACS account and

keep passwords up to date. Must submit data yourself via

portal before Feb 28, 2016.

EHR Data Submission Vendor

(DSV) CEHRT

EHR must support DSV reporting and EPs must be using the

system. Vendor extracts data from system, arranges IACS

account & submits data by Feb 28, 2016.

Qualified Registry Contract relationship with vendor, some extract from EHR and

some allow direct entry. Vendor arranges IACS account &

submits data by March 31, 2016.

Qualified Clinical Data Registry

(measures are selected by the

QCDR)

Contract relationship with vendor, often specialty, EHR or

health system related. Vendor arranges IACS account &

submits data by Feb or March 2016 depending on type of files

submitted.

2015 PQRS Reporting Methods

GROUP Reporting Considerations

Update group information in PECOS Register group in PV-PQRS by April – June 2015

Select reporting option & measures Measures: Entire group must report same set of measures

Reporting Options Available based on size group

GPRO Web Interface Only available to groups 25+ EPs: Enter data on 250

patients randomly selected from your claims data – answer

all applicable measures

Direct CEHRT EHR All group sizes: EHR must support direct reporting and all

EPs must be using the system.

EHR Data Submission Vendor (DSV)

CEHRT

All group sizes: EHR must support DSV reporting and

all EPs must be using the system

Qualified Registry All group sizes: Contract relationship with registry and have

a method to collect measures during the year.

Qualified Clinical Data Registry

(measures are selected by the QCDR)

All group sizes: Contract relationship with registry and have

a method to collect measures.

2015 PQRS Reporting Methods

2015 Reporting Requirements

High Level Overview

9 measures across 3 National Quality Strategy

Domains

One cross-cutting measure (face-to-face visits)

Groups 25+ begin reporting CAHPS

(patient satisfaction surveys)

National Quality Strategy (NQS)

NQS Domains

Patient Safety

Person & Caregiver-Centered Experience & Outcomes

Communication & Care Coordination

Effective Clinical Care

Community/Population Health

Efficiency & Cost Reduction

Same domains used for MU Clinical Quality Measures

2015 Reporting Links

2015 PQRS Implementation Guide:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf

2015 Measures List:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

2015 Cross-cutting Measure List

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015_PQRS_CrosscuttingMeasures_12172014.pdf

2015 Individual Claims/Registry Measures Specifications

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_IndividualMeasureSpecs_Su

pportingDocs_111214.zip

2015 Measures Group Specifications

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_MeasuresGroupsSpecs_Sup

portingDocs_111214.zip

Value Based Payment Modifier (VBM)

Cost and Quality

“Quality tiering” methodology based on quality

and cost metrics in comparison to national averages

A per-claim adjustment under the MPFS

Positive, negative, or no adjustment

This is in addition to any PQRS negative

adjustment

VBPM (cont.)

Applied to the Medicare paid at the TIN level to

physicians billing under the TIN

Aligned with and based on PQRS participation

2013/2015

100+ Physicians

2014/2016

10-99 Physicians

2015/2017

ALL Eligible Providers

VBPM (cont.)

Reports Based on TIN

Your Value-Based Payment Modifier

The highlighted payment adjustment will be applied to your

Medicare Physician Fee Schedule reimbursements in CY 2015.

Low Quality

Average Quality High Quality

Low Cost

+0.0%

+ 1.0 x AF + 2.0 X AF

Average Cost

-0.5%

+0.0%

+ 1.0 X AF

High Cost

-1.0%

-0.5%

+0.0%

Note: The displayed payment adjustment includes the high-risk bonus adjustment, if applicable. The precise size of the reward for higher-performing groups will vary from year to year, based on an adjustment factor (AF) derived from actuarial estimates of projected billings. The AF for 2015 will be posted athttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html.

Impacts Groups by Size

Size based on eligible professionals billing to your TIN that did not

participate in the Medicare Shared Savings Program (MSSP), the

Pioneer ACO Model, or the Comprehensive Primary Care (CPC)

initiative.

Value Based Modifier

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

Performance Year 2014 Benchmarks

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/PY2014-Prior-Year-

Benchmarks.PDF

Practice Size Performance Year Impact Year

100+ EPs 2013 2015

10 + EPs 2014 2016

1 + EPs 2015 2017

Quality & Resource Use Reports (QRUR)

All TINs (groups and solo practitioners) nationwide that meet the

following two criteria will receive a 2013 QRUR:

• At least one physician billed under the TIN in 2013, AND

• The TIN had at least one eligible case for at least one of the

quality or cost measures included in the QRUR.

TINs with one or more physicians that participated in the Medicare

Shared Savings Program, the Pioneer ACO Model, or the

Comprehensive Primary Care Initiative in 2013 will not receive a 2013

QRUR.

What Information is Contained in the QRUR?

1. Your Quality Composite Score

2. Your Cost Composite Score

3. Your Quality Tiering Performance

What Information is Contained in the

QRUR? (Cont’d)

Quality Composite Score Elements

PQRS Reported Data

For 2013 QRURs, only GPRO data is included

CMS Calculated Data Elements

CMS-1 Acute Conditions Composite

Bacterial Pneumonia, Urinary Tract Infection, Dehydration

CMS-2 Chronic Conditions Composite

Diabetes, Chronic Obstructive Pulmonary Disease (COPD)

or Asthma, Heart Failure

CMS-3 All-Cause Hospital Readmission

Cost Composite Score Elements

Per Capita Cost for All Attributed Beneficiaries

Per Capita Costs for Beneficiaries with Specific

Conditions

Diabetes, Heart Failure, COPD, Coronary Artery Disease

How to Use the QRUR Reports

Determine your payment adjustment for 2015 (Groups

of 100+ eligible providers only)

Review past performance to prepare for the 2016

payment adjustment based on 2014 reporting year

(Groups of 10+ eligible providers)

Identify opportunities to improve the quality and

efficiency of care delivered

How to Access QRUR Reports

Authorized representatives of groups and solo practitioners can

access the QRURs at https://portal.cms.gov using an Individuals

Authorized Access to the CMS Computer Services (IACS) account

with one of the following Physician Value (PV)-PQRS System roles:

For groups with 2 or more EPs (TIN with 2+ NPIs):

• PV-PQRS Group Security Official (primary or back-up)

• PV-PQRS Group Representative

For solo practitioners (TIN with 1 NPI):

• PV-PQRS Individual (primary or back-up)

• PV-PQRS Individual Representative

How to Access QRUR Reports

A quick reference guide, which provides step by step instructions for

accessing the2013 QRUR, is available at :

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Downloads/Quick-Reference-

Guide-for-Accessing-2013-QRURs.pdf

IACS Account Required

Obtaining An IACS Account is Required

To access the Registration System in order to register for a 2015 PQRS

GPRO or obtain a QRUR report, an authorized representative of the group

must have an IACS account.

If the group does not yet have an authorized representative with an IACS

account, then one person representing the group must sign up for an IACS

account with the primary “PV-PQRS Group Security Official” role.

If the group has a representative with an existing IACS account, but not one

with the primary “PV-PQRS Group Security Official” role, then please

check with the QualityNet Help Desk that the account is still active and add

this role to that person’s existing IACS account.

IACS Account Required (cont.)

Obtaining An IACS Account is Required

Group representatives can sign up for a new IACS account or

modify an existing account at https://applications.cms.hhs.gov.

Please complete this step NOW to avoid any last minute delays in

obtaining an IACS account.

Also, please note that it takes approximately 24 hours for CMS to

process an IACS account request; therefore, an IACS account must

be obtained in advance so that the group’s registration can be

submitted by June 30, 2015.

A guide with step-by-step instructions for obtaining an appropriate

IACS account is available in the “Downloads” section of CMS’

Registration website listed above.

Contact Information

Don Gettinger

Don.Gettinger@area-G.hcqis.org | 812-243-0847

This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services (DHS). Content does not necessarily reflect CMS policy. 15.SS.MS.D1.001

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