Physician Quality Reporting System

What is the History of the PQRS?

The current PQRS originated from multiple prior acts of federal legislation. In 2006, the Tax Relief and Health Care Act (TRHCA) established a PQRS, which included a 1.5% incentive payment with a cap for eligible physicians who satisfactorily reported data on quality measures for covered services furnished to Medicare. In 2007 the Medicare, Medicaid, and SCHIP Extension Act authorized continuation of the PQRS for 2008 and 2009. This provided a 1.5% incentive payment in 2008 and removed the cap established by the TRHCA. In 2008, the Medicare Improvements for Patients and Providers Act established the PQRS as a permanent program. It also increased the incentive payment to 2% of the total allowed charges for PFS-covered professional services in 2008 and 2009.

What Changes Are Expected in the Incentive Payment Plan?

The Affordable Care Act, signed into law by President Obama in 2010, made a number of changes to the PQRS, including a gradual decrease in the incentive payment, eventually requiring that quality measures be met to receive the maximum Medicare payment for services. In 2011, the program decreased the incentive payment to 1% of the total allowed charges for PFS-covered professional services. The incentive will further decrease to 0.5% in 2012–2014 and will eventually become a penalty starting in 2015 if not met. The expected penalty is a 1.5% reduction in the total allowed charges for PFS-covered professional services. In 2016, there will be further reduction to 2% in payment for services if the reporting measures are not met.

What Measures Does the PQRS Cover?

The PQRS consists of more than 200 quality measures for Medicare patients including various aspects of care, such as prevention, chronic and acute care management, procedure-related care, resource use, and care coordination. Fourteen of these quality measures apply to radiologists: fluoroscopy, 1; nuclear medicine, 1; mammography, 2; stroke, 2; perioperative care, 4; preventive care and screening, 2; health information technology, 2.

At least 3 measures are applicable to a neuroradiologist in practice: 1) Measure 10, Stroke and Stroke Rehabilitation: Computed Tomography, or MR Imaging Reports refer to the percentage of final reports for CT or MR imaging studies within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage or at least 1 documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction; 2) Measure 195, Stenosis Measurement in Carotid Imaging Reports is the percentage of final reports for all patients, regardless of age, for carotid imaging studies (neck MR angiography, neck CT angiography, neck duplex sonography, carotid angiogram) performed that include direct or indirect reference to measurements of the distal internal carotid diameter as the denominator for the stenosis measurement; and 3) Measure 145, Radiology-Exposure Time Reported for Procedures Using Fluoroscopy is the percentage of final reports for procedures using fluoroscopy that include documentation of the radiation exposure or exposure time.

How Does the PQRS Work?

The PQRS is a voluntary program. Submission of quality data codes through claims or a qualified registry indicate intent to participate. In claims-based individual reporting, each eligible physician must report a minimum of 3 measures if applicable to his or her practice. There must be 50% compliance in a minimum of 3 measures to qualify for the incentive payment. However, if an eligible physician has less than 3 measures applicable to their practice, they are still able to participate in the program reporting on only their applicable measures.

Each measure consists of 2 major components for determining compliance: 1) “denominator” refers to all eligible cases for a particular measure in your practice, and 2) “numerator” refers to successful reporting of the measure. “Reporting compliance” refers to the percentage of eligible cases that have a PQRS code assigned. The incentive plan is based on obtaining reporting compliance. Physician performance data are published on-line as a list of the eligible professionals who satisfactorily reported PQRS measures for the 2009 program year and beyond. “Quality compliance” refers to the percentage of reported cases that have completed the quality measure. Currently, quality compliance data are collected and monitored by the CMS.

How Do I Get Started?

The next cycle begins January 1, 2012. To get started, there are 5 main steps:

• 1) Determine whether you are eligible to participate. A list of professionals who are eligible is provided on the CMS Web site (www.cms.hhs.gov).

• 2) Determine which reporting option best fits your practice (claims-based or registry-based reporting of either individual measures or measure groups).

• 3) Determine which PQRS measures are applicable to your practice. Eligible professionals who choose to report individual measures should select at least 3 applicable measures to qualify for the incentive payment. If fewer than 3 measures are reported, CMS may apply a measure-applicability validation process to determine eligibility for the incentive payment.

• 4) Once you have selected the measures, carefully review the following documents:

  • A) Physician Quality Reporting System Measure Specifications Manual for Claims and Registry (http://www.acg.gi.org/members/nataffairs/thisweek/2011PQRSMeasureSpecificationManualforClaimsandRegistryReporting.pdf) (instructions for reporting claims or registry-based measures). A review of the documents for the current year should be performed.

  • B) Physician Quality Reporting System Implementation Guide (http://www.astro.org/PublicPolicy/PQRIInformation/documents/2011implementationguide.pdf) (describes important reporting principles and rationale for measures).

• 5) Proper documentation is needed in your reports to qualify for the measures! Developing templates for standardized reporting may be helpful. Review the operational procedures in your practice to ensure accurate reporting. Education of the staff, billing office, residents, and fellows (if applicable) is important for obtaining compliance.

Where Can I Find More Information about the PQRS?

More information and details can be found at the CMS Web site: www.cms.hhs.gov/PQRS, including information on eligibility criteria, reporting measures, and reporting statistics by year and specialty.