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About PQRS

The purpose of the Physical Quality Reporting System (PQRS) is to give individual eligible professionals (EPs)—including physical therapists, occupational therapists, and qualified speech therapists—and group practices the ability to assess the quality of care they provide to their patients, helping ensure your patients get the best care possible.

Quality of care is assessed through the reporting of certain outcome measures to Medicare. By reporting on the PQRS quality measures, therapists can quantify how often they are meeting a particular quality metric for the care that they provide.

PQRS is designed to incentivize the reporting of quality information by providers through a combination of incentive payments and negative payment adjustments. Beginning in 2015, the program will apply a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment.

PQRS is not mandatory, but if you are an eligible professional, in 2015 and beyond, you will subject to a 2% financial penalty of total Medicare payments. Turbo PT helps rehab therapists report on all required outcome measures to avoid a penalty being applied to reimbursements.

Am I an Eligible Professional?

Under PQRS covered professional services are those paid under or based on the MPFS. To the extent that eligible professionals are providing services which get paid under or based on the MPFS, those services are eligible for PQRS payment adjustments. Therefore, if you are billing under Medicare Part B for outpatient therapy services in private practice settings for physical therapy, occupational therapy, and/or speech therapy you qualify for PQRS participation.

However, some therapists may be eligible to participate in PQRS per their specialty, but due to billing method may not be able to participate:

  • Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider’s individual NPI is entered on CMS-1500 or CMS-1450 type paper or electronic claims billing, associated with specific line-item services.
  • Professionals who provide services payable under fee schedules or methodologies other than the MPFS.

How Can I Become PQRS Compliant?

In order for a rehab therapist to become PQRS compliant, they must report a certain number of individual measures or measure groups covering the NQS on Medicare patients.

What are quality measures?

Quality measures are indicators of the quality of care provided by rehab therapists and other healthcare professionals. The measure or quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. The goals of quality measures are simple: effective, safe, efficient, patient-centered, equitable, and timely care.

How is a measure calculated?

Calculating the PQRS reporting rate (dividing the number or reported numerator outcomes by denominator-eligible encounters) identifies the percentage of a defined patient population that was reported for the measure. For performance rate calculations, some patients may be subtracted from the denominator based on medical, patient, or system performance exclusions allowed by the measure.

The final performance rate calculation represents the eligible population that received a particular process of care or achieved a particular outcome (measure defined performance met outcome). It is important to review and understand each measure's specification, as it contains definitions and specific instructions for reporting the measure.

National Quality Strategy (NQS)

In 2015, measures are classified according to the NQS domains which include the following:

 

What do quality measures consist of?

Measures consist of two major components: denominators and numerators.

Numerator: The upper portion of a fraction used to calculate a rate proportion, or ratio. The numerator must detail the quality clinical action expected that satisfies the condition(s) and is the focus of the measurement for each patient, procedure, or other unit of measurement established by the denominator. That is, patients who received a particular service or providers that completed a specific outcome/process.

Eligible therapists may use the codes present in the numerator to report the outcome of the action as indicated by the measure. PQRS measure numerators are quality-data codes (QDCs) consisting of specified non-payable CPT Category II codes and/or temporary G-codes.

Denominator: The lower portion of a fraction used to calculate a rate, proportion, or ratio. The denominator must describe the population eligible (or episodes care) to be evaluated by the measure. This should indicate age, condition, setting, and timeframe (when applicable).  For example, “Patients aged 18 through 75 years with a diagnosis of diabetes.”

Physician Quality Reporting measure denominators are identified by ICD-9-CM (future ICD-10-CM), CPT Category I, and HCPCS codes, as well as patient demographics (age, gender, etc.), and place of service (if applicable).

Registry-Based vs. Claims-Based Reporting

Rehab therapists can report PQRS data in one of three different methods:

  • Registry-Based Reporting.
  • Claims-Based reporting.
  • Group Practice Reporting Option.

Choosing registry submission will automatically submit their choice through the registry. On the other hand, claims-based reporting is a manual process which submits Quality Data Codes (QCDs) for PQRS measures on their claim form for all eligible visits defined by each measure.

Both Registry-Based and Claims-Based Reporting require reporting in 2015 at least 9 measure on at least 50% or more of all eligible Medicare patients. One of the 9 measures must be a cross cutting measure (See “What are Cross-Cutting Measures?” Below). Therapist who report less than 9 measures via registry or claims will be subject to the Measure Applicability Validations (MAV) (See “What is the MAV Process?” Below) process in order to ensure that they have reported all eligible measures.

During your documentation process, the Turbo PT system will help you collect all required PQRS measures in your EMR so you can report via a registry or on your claim form. We compile PQRS data and can output a properly formatted file for submission to CMS through a qualified registry.

2015 PQRS Reporting Requirements for Individual Eligible Therapist

Eligible individual therapists wanting to satisfactorily report 2015 PQRS data to avoid the 2017 negative payment adjustment can do so by meeting one of the following criteria:

1. Report on at least 9 individual measures covering at least

3 NQS domains for at least 50% of Medicare Part B FFS patients.

  • EPs who submit quality data for less than 9 PQRS measures covering 3 NQS domains for at least 50% of the EP’s Medicare Part B FFS patients OR who submit data for 9 or more PQRS measures covering less than 3 domains for at least 50% of the EP’s Medicare Part B FFS patients eligible for each measure OR who do not report on at least 1 cross-cutting measure if had a face-to-face encounter are subject to Measure-Applicability Validation (MAV)
  • Measures with a 0% performance rate are not counted.
  • An EP who sees at least 1 Medicare patient (face-to-face encounter) must report on 1 cross-cutting measure. For this reporting mechanism, EPs should use the 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures on the Measures Codes page of the CMS PQRS website to find applicable measures.

2. Report at least 1 measures group on a 20-patient sample,

a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients.

  • For this reporting mechanism, EPs should use the 2015 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual on the Measures Codes page of the CMS PQRS website to find applicable measures groups:
  • For more information, see 2015 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups. Beginning in 2015, the only reporting period available is 12 months:

Registry Based Reporting and Group Practice Reporting Option (GPRO)

GPRO is a registry-based PQRS reporting method. It is designed for multi-therapists practices participating as a group sharing one tax ID to report outcome measures and jointly meet PQRS reporting requirements. Practices must self-nominate themselves to CMS for participation in GPRO directly. PQRS data submitted under GPRO is submitted automatically and cannot be submitted via claims.

Download PQRS Cheat Sheet for Individual Measures

Do you need help finding the most appropriate G-code by PQRS measure? Enter your email and download the PQRS Cheat Sheet for Individual Measures for PT and OT.

2015 Reporting Requirements for PQRS Group Practices

A group practice must have registered to report via qualified registry under the GPRO for 2015 PQRS. PQRS group practices can avoid the 2017 PQRS negative payment adjustment by meeting the following criteria for satisfactory reporting:

What PQRS Measures Apply to PT, OT, and SLP?

While PQRS measures are numerous, there are a limited number of PQRS measures that apply to PT, OT, and SLP. Here are the relevant PQRS measures by specialty:

1. Report on at least 9 measures covering at least 3 NQS

domains for at least 50% of the group’s Medicare Part B FFS patients.

  • Group practices that submit quality data for less than 9 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures covering less than 3 domains for at least 50% of their patients or encounters eligible for each measure OR who do not report on at least 1 cross-cutting measure if had a face-to-face encounter will be subject to MAV.
  • Measures with a 0% performance rate will not be counted. An EP who sees at least 1 Medicare patient (face-to-face encounter) must report on 1 crosscutting measure.
  • Those group practices electing to report via registry will use the 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures to find applicable measures.

 

2. Report through the GPRO Web Interface

  • A portion of the patients served by a group practice must be Medicare beneficiaries. The group practice must report on at least 1 measure for which there is Medicare patient data.
  • Report on all measures included in the GPRO Web Interface; AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, then report on 100% of assigned beneficiaries.
  • PQRS group practices of 100 or more EPs must report all CAHPS for PQRS summary survey modules via CMS-certified survey vendor (CMS WILL NOT bear the cost of administering this required survey) to supplement GPRO Web Interface reporting. CAHPS for PQRS is optional for groups of 2-99 EPs.

PT

  • #126 Diabetes Foot/Ankle Evaluation
  • #127 Diabetes - Footwear Evaluation
  • #128 BMI screening
  • #130 Current Medications
  • #131 Pain Assessment
  • #154 Falls Risk Assessment
  • #155 Falls POC
  • #182 Functional Outcome Assessment

OT

  • #128 BMI screening
  • #130 Current Medications
  • #131 Pain Assessment
  • #154 Falls Risk Assessment
  • #155 Falls POC
  • #134 Preventative Screening Clinical Depression
  • #173 Alcohol consumption Assessment
  • #181 Elderly Maltreatment Screen and Follow-Up
  • #182 Functional Outcome Assessment
  • #226 Tobacco Use Screen and Cessation Intervention

SLP

  • #130 Current Medications

Download Your 2015 PQRS Measures Chart Now

Do you know which of the PQRS measures apply to different reporting methods? How about the applicable National Quality Standard (NQS) domain or which measures are cross-cutting? Enter your email and download the 2015 PQRS Measure Chart now.

What are Cross-Cutting Measures?

Cross-cutting measures are any measures that are broadly applicable across multiple clinical settings and EPs or group practices within a variety of specialties. The requirement of reporting cross-cutting measures is new to the PQRS program beginning in 2015.

What is CAHPS?

CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. It surveys ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess, such as the communication skills of providers and ease of access to health care services.

All CAHPS surveys are in the public domain, which means that anyone can download and use these surveys to assess experiences with care. Users of CAHPS survey results include patients and consumers, quality monitors and regulators, provider organizations, health plans, community collaboratives, and public and private purchasers of health care. These individuals and organizations use the survey results to inform their decisions and to improve the quality of health care services.

What is the MAV Process?

MAV is a process applied as part of the PQRS Program to individual EPs or group practices that report less than nine measures, or nine or more measures with less than three NQS domains to determine if there were related measures that may have been reported.

MAV is triggered in situations where the individual EP or groups practice reports any combination of measures and domains with less than nine measures across three domains. The only way to avoid triggering the MAV process is to report at least nine measures across three domains. If the total of all the measures chosen to report does not equal at least nine measures AND at least 3 domains the MAV process is initiated.

For example, reporting the following combinations will trigger MAV (Please note this is not an all-inclusive list):

  • Reporting 15 measures across 2 domains will trigger MAV
  • Reporting 7 measures across 3 domains will trigger MAV
  • Reporting 5 measures across 1 domain will also trigger MAV

How Turbo PT Helps Assure Your PQRS Compliance

  • Built-in PQRS Measures in Documentation
  • Support for both claims-based and registry-based reporting.
  • Up-to-date with the latest PQRS outcome measures
  • Store and compile PQRS data that can be output in a proper format for submission to CMS through a qualified registry.

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