Payment Adjustment Information
Physician Quality Reporting System (PQRS) Payment Adjustment Information
Section 1848(a)(8) of the Social Security Act, as added by section 3002(b) of the Affordable Care Act, requires CMS to subject eligible professionals who do not satisfactorily report data on quality measures for covered professional services to a payment adjustment beginning in 2015.
The PQRS payment adjustment applies to all of the eligible professional’s (EP’s) Part B covered professional services under the Medicare Physician Fee Schedule (PFS). Accordingly, EPs receiving a payment adjustment in 2015 will be paid 1.5% less than the MPFS amount for that service. For 2016 and subsequent years, the payment adjustment is 2.0%.
Update! Physician Quality Reporting System (PQRS) and the PQRS Group Practice Reporting Option (GPRO) Registration Period is Extended to October 18, 2013
CMS has extended the registration period for the Physician Quality Reporting System (PQRS) and the PQRS Group Practice Reporting Option (GPRO) to October 18, 2013 to allow providers additional time to register for these important programs. Please message to your members that if they have not already registered, they should do so as soon as possible. Please note a PV-PQRS IACS account is required to register, and it can take time to get approval for that IACS role, so it is important to start today.
Please visit http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html for more information about registration. Please note that due to the government shutdown, we were unable to update the October 15 date listed on this website until now.
2015 PQRS Payment Adjustment
To avoid the 2015 PQRS payment adjustment, individual EPs and group practices participating in the PQRS Group Practice Reporting Option (GPRO) will have to satisfactorily report data on quality measures for covered professionals services provided in 2013. Reporting during the 2013 PQRS program year will be used to determine whether a PQRS payment adjustment applies in 2015.
Individual EPs and group practices participating in GPRO can avoid the 2015 PQRS payment adjustment by registering for the CMS-calculated administrative claims-based reporting mechanism via the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System web portal: https://portal.cms.gov/. Group practices with 100+ EPs can also avoid the 2015 value-based payment modifier payment adjustment by selecting one of three group reporting options which includes CMS-calculated administrative claims. Please note: The Value Modifier/CMS- calculated administrative claims option is not applicable to Medicare Shared Savings Program ACO GPROs.
Both individual EPs and group practices electing to report via the CMS-calculated administrative claims method must register via the PV-PQRS registration System. Please note that the ability to elect the CMS-administrative claims-based reporting mechanism will be available until 11:59pm EST on October 18, 2013, Additionally, you will need to sign-up for an IACS account (if you do not have one already) and add the appropriate PV-PQRS role, prior to registering at https://applications.cms.hhs.gov/.
For more information about the PV-PQRS Portal, CMS-calculated administrative claims reporting and the value-based payment modifier, please visit the Physician Feedback/Value-Based Payment Modifier Program webpage.
Please note: Neither individuals, nor groups will be incentivized for participating in PQRS using CMS-Calculated Administrative Claims, however, if a group practice chooses this option, individual EPs within the group may also participate in PQRS as individuals through a different reporting mechanism, and in that way they may be eligible to earn an individual incentive.
Avoiding 2015 PQRS Payment Adjustments
EPs can avoid the 2015 payment adjustment by meeting one of the following criteria during the 2013 PQRS program year:
1. EP meets the requirements outlined in the 2013 PQRS measure specifications for satisfactorily reporting (this will enable the EP to earn a 2013 PQRS incentive payment of 0.5% of their covered Medicare Part B charges)
2. EP reports at least:
o One valid measure via claims, participating registry, or through a qualified Electronic Health Record (EHR) OR
o One valid measure in a measures group via claims or participating registry
3. EP elects to participate in the administrative claims-based reporting mechanism by October 15, 2013.
Group practices participating in the Group Practice Reporting Option (GPRO) can avoid 2015 payment adjustments by meeting one of the following criteria during the 2013 PQRS program year:
1. Group meets the following requirements, outlined in the 2013 PQRS measure specification for satisfactorily reporting:
o Reports specific ACO/GPRO measures through the Web Interface based on a pre-populated patient sample (only available to group practices of 25 or more EPs) OR
o Reports at least 3 registry measures (for 80% of the group’s eligible patients for each measure) for the GPRO outlined in the 2013 PQRS Measure Specification for Claims/Registry Reporting of Individual Measures (available to all group practices of two or more EPs)
2. Group reports at least one valid measure through:
o Web Interface (only available to group practices of 25 or more EPs) OR
o Participating Registry (available to all GPRO participants)
3. Group elects to participate as a GPRO in the administrative claims-based reporting mechanism by October 15, 2013.
Payment Adjustment Regulation
The criteria for satisfactorily reporting data on quality measures in 2013 to avoid the 2015 PQRS payment adjustment are detailed in the 2013 Medicare PFS Final Rule. The criteria for the 2016 payment adjustment are also included in the 2013 PFS Final Rule. The 2014 Medicare PFS Proposed Rule includes changes in the criteria to avoid the 2016 PQRS payment adjustment, and is available for comment until September 6, 2013.
Payment Adjustment Resources
2013 Physician Quality Reporting System (PQRS): 2015 PQRS Payment Adjustment- This tip sheet provides information on the 2015 PQRS payment adjustment and guidance on how individual eligible professionals and group practices can avoid the 2015 PQRS payment adjustment. Information provided in this tip sheet is based on the 2013 Medicare PFS Final Rule.
- Page last Modified: 10/17/2013 1:28 PM
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