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PQRS Reporting in 2014 is Critical for Orthopaedic Practices

Wednesday, December 10th, 2014

William R. Pupkis, CMPE, Healthcare Consultant

The Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs). PQRS in 2014 is critical for Orthopaedic practices. Non-participation in 2014 will result in a 2016 penalty or payment adjustment decrease of 2.0% on ALL claims.

Consider this, if your practice has revenue of $20 million per year and you report successfully on three claims, you’ll receive a $100,000 bonus. However, if you do nothing and do not report on at least one PQRS quality measure on a Medicare claim in 2014, your reduction in reimbursement (2.0% penalty) will be $400,000. The difference from doing nothing to qualifying via “self-nominating” could be as much as a half a million dollars ($500,000).

Orthopaedic practices can elect the penalty avoidance option if the goal is simply to avoid the 2.0% penalty, or a reduction in reimbursement in 2016. This method requires you to submit at least half, (50%) of your eligible Medicare patients visits for at least three (3) measures.

The Registration System can be accessed at using a valid “Individuals Authorized Access” (IACS) to the CMS Computer Services User ID and Password.

A “group practice” is defined as a single Medicare billing Taxpayer Identification Number (TIN) with 2 or more individual EPs (as identified by their individual National Provider Identifier (NPI) who have reassigned their billing rights to the TIN.

IMPORTANT: filing using the Group Practice Reporting Option (GPRO) requires self-nomination by September 30, 2014. PQRS reporting in 2014 is critical for Orthopaedics practices; non-participation in 2014 will result in a "payment adjustment" (penalty) of -2% in 2016.

If your goal is the incentive payment option, to meet the reporting requirement, enter data from 20 unique patient visits, a majority of which – at least 11 – must be Medicare Part B Fee-For-Service (FFS) patients. Submitting for the incentive payment successfully avoids the -2% Payment Adjustment in 2016.

Note that measures with a 0% Performance Rate will not count – you must meet the quality action when able at least once for the selected measures or measures group to be incentive eligible.

There are different ways for a practice to report these measures: through a claim, a registry, GPRO, or through an EHR. Ask your EHR vendor to see if your practice can submit through an EHR and how to file for PQRS incentives.

CMS has established different reporting requirements for various sizes of practices. CMS finalized its proposal for 2013 to change the definition of “group practice” from 25 or more eligible professionals (EPs) to only two [2] or more to allow groups of smaller sizes to participate as a group. When considering numbers of EPs within your practice, it’s important to note that Physical Therapists, Nurse Practitioners and Physician Assistants are included in PQRS’s definition of EPs.

CMS has defined a numerator and a denominator that permit the calculation of the percentage of patient visits that achieve appropriate reporting of quality measures. According to CMS: “Quality measures consist of a unique denominator (eligible case) and numerator (clinical action) that permit calculating the percentage of a defined patient population receiving a particular process of care or achieving a particular outcome.” In order to be eligible for the PQRS bonus for registry submissions, the threshold is 80% for at least 3 measures. For claims submissions, the threshold is 50% for 3 measures.

If fewer than nine measures apply, the EP can meet the satisfactory reporting requirement by reporting those that do apply—as few as one or as many as eight measures. This is similar to the exception to the current requirement, if fewer than three measures apply. CMS will continue to use the Measure Applicability Validation (MAV) process to test whether the EP should have reported additional measures.

For more information you can use the link below to get to CMS self-nomination/registration through the PV-PQRS registration system:

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