2015 Rules for PQRS

CMS issued the 2015 Physician Fee Schedule Final Rule on October 31, 2014. The rule changes several of the quality reporting initiatives associated with PFS payments, including the Physician Quality Reporting System (PQRS).

Important 2015 PQRS Changes:

  • The penalty for not reporting 2015 PQRS is 4% for solo providers and groups with 2-9 providers (2% value modifier penalty + 2% PQRS penalty).
  • The penalty for not reporting 2015 PQRS is 6% for groups with ten or more providers (4% value modifier penalty + 2% PQRS penalty).
  • There is no incentive payment for 2015 PQRS reporting.
  • A total of 255 PQRS measures are available in 2015, including:
    • 63 outcome-based measures
    • 19 cross-cutting measures
    • Addition of 2 measures groups (Acute Otitis Externa Measures Group; Sinusitis Measures Group).
    • Removal of 4 measures groups (Perioperative Care Measure Group; Back Pain Measure Group; Cardiovascular Prevention Measure Group; Ischemic Vascular Disease Measure Group).
  • 2015 PQRS Measures Groups Specifications Manual – It include codes and reporting instructions for all PQRS measures groups available for registry-based reporting.
  • 2015 PQRS Measures Groups Release Notes – Summary of 2015 updates made to the 2014 PQRS Measures Groups Specifications.
  • 2015 PQRS Measures Group List – Identifies and describes all the measures groups used in PQRS, including measures description, corresponding PQRS number and NQF number, plus measure developers.
  • 2015 PQRS Measures Groups Single Source Code Master– Includes a numerical listing of all codes included in 2015 PQRS Measures Groups. It can be used to select the eligible patients for each PQRS measures group.
  • 2015 PQRS Quality-Data Code (QDC) Categories - Outlines, for each claims and registry measure, each QDC that should be reported for a corresponding quality action performed by the individual eligible professional as noted in the measures specification. This document identifies how each code will be used when CMS calculates performance rates. The QDC categories table also clarifies those measures that require 2 or more QDCs to report satisfactorily.
  • 2015 PQRS Measure Specifications Manual for Reporting of Individual Measures – Includes codes and reporting instructions for the 2015 PQRS measures for claims and/or registry-based reporting.
  • 2015 PQRS Individual Measures Specification Release Notes – Summary of 2015 changes made to the 2014 PQRS Individual Measures Specifications.
  • 2015 PQRS Individual Measures Single Source Code Master – This excel file includes a numerical listing of all codes (denominator and numerator) included in 2015 PQRS Individual Claims and Registry Measures. It can be used to select the eligible patients for each individual PQRS measure.
  • 2015 PQRS Measure-Applicability Validation (MAV) Process for Registry-Based Reporting of Individual Measures – provides guidance for those eligible professionals who satisfactorily submit via a Qualified Registry for fewer than nine PQRS measures or for fewer than three NQS domains, and how the MAV process will determine whether they should have submitted additional measures. This also includes the process flow depicting the MAV process.
  • The value-based payment modifier applies to all physicians. The value modifier uses PQRS quality data and Medicare cost data to determine a provider's overall value score. It rewards high-performing providers with increased payments and reduces payments to low-performing providers. This will affect approximately 900,000 physicians.
  • Quality-tiering is mandatory for all providers. However, solo providers and groups with 2-9 providers will receive only a bonus or no adjustment. Groups with 10 or more providers will receive a bonus, no adjustment or a penalty.
  • CMS will increase the maximum downward adjustment under the quality-tiering methodology for groups with ten or more EPs to -4.0%. CMS will also increase the maximum upward adjustment under the quality-tiering methodology in the CY 2017 payment adjustment period to +4.0x (‘x’ represents the upward payment adjustment factor) (CMS Fact Sheets). 
    Cost/qualityLow qualityAverage qualityHigh quality
    Low cost+0.0%*+2.0x*+4.0x
    Average cost-2.0%+0.0%*+2.0x
    High cost-4.0%-2.0%+0.0x

    * Groups and solo practitioners eligible for an additional +1.0x if reporting measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores, where `x' represents the upward payment adjustment factor.

  • "In CY 2017, CMS will apply a maximum downward adjustment of -2.0% for groups with two to nine EPs and solo practitioners, if the group or solo practitioner does not meet the quality reporting requirements for the PQRS. The maximum upward adjustment for groups of two to nine EPs and solo practitioners will be +2.0x (‘x’ represents the upward payment adjustment factor) if classified as high quality/low cost. Groups of two to nine EPs and solo practitioners will be held harmless from downward adjustments under the quality-tiering methodology for the CY 2017 payment adjustment period." (CMS Fact Sheets)
    Cost/qualityLow qualityAverage qualityHigh quality
    Low cost+0.0%*+1.0x*+2.0x
    Average cost+0.0%+0.0%*+1.0x
    High cost+0.0%+0.0%+0.0%

    * Groups and solo practitioners eligible for an additional +1.0x if reporting measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores, where `x' represents the upward payment adjustment factor.

  • CMS is requiring that eligible professionals who see at least one Medicare patient in a face-to-face encounter report measures from a newly proposed cross-cutting measures set in addition to any other measures that the eligible professional is required to report. Please reference the 2015 PQRS List of Face-To-Face Encounter Codes for the billable codes that identify face-to-face encounters for the purposes of 2015 PQRS reporting. This includes general office visits, outpatient visits, and surgical procedure codes
  • All group practices of 100 or more eligible professionals that are registered for the GPRO to report on the Consumer Assessment of Healthcare Provider and Systems survey CAHPS for PQRS regardless of the reporting mechanism the group practice chooses. The group practices will bear the cost of administering CAHPS for PQRS.

 

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