2016 PQRS Rules

CMS issued the 2016 Physician Fee Schedule Final Rule on October 30, 2015. The rule changes several of the quality reporting initiatives associated with PFS payments, including the Physician Quality Reporting System (PQRS).

Important 2016 PQRS Highlights:

  • The penalty for not reporting 2016 PQRS is 4% for solo providers and groups with 2-9 providers: 2% PQRS penalty + 2% value modifier penalty.
  • The penalty for not reporting 2016 PQRS is 6% for groups with ten or more providers: 2% PQRS penalty + 4% value modifier penalty.
  • There is no incentive payment for 2016 PQRS reporting.  All providers are subject to quality-tiering.
  • New cross-cutting measures: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (Measure 431); Breast Cancer Screening (Measure 112); Falls: Risk Assessment and Falls: Plan of Care (Measures 154 and 155).
  • Link to:New Individual Quality Measures and those Included in Measures Groups for the PQRS to be Available for Satisfactory Reporting Beginning in 2016.
  • Link to: The description and rules regarding all 2016 PQRS Individual Quality Measures can be found here.
  • Link to: Measures for Removal from the Existing PQRS Measure Set Beginning in 2016. 
  • New measures groups: Cardiovascular Prevention; Diabetic Retinopathy; Multiple Chronic Conditions.
  • Some measures groups will change in 2016: CABG, Dementia, Diabetes, Preventive Care and Rheumatoid Arthritis
  • To avoid the PQRS penalty for the applicable 12-month reporting period, the EP would report at least 9 measures, covering at least 3 of the NQS domains, OR, if less than 9 measures apply to the EP, report on each measure that is applicable, AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.  Note:  unless a measure is considered an inverse measure (i.e. Measure 1, 331, etc) where a lower performance rate indicates higher quality of care.
  • If an EP reports on less than 9 measures, the EP would be subject to the MAV process, which would allow CMS to determine whether an EP should have reported additional measures. 
  • The MAV process CMS proposed to implement for registry reporting is a similar process that was established  for reporting periods occurring in 2015 for the 2017 PQRS payment adjustment. However, please note that the MAV process for the 2018 PQRS payment adjustment will now allow CMS to determine whether a group practice should have reported on at least 1 cross-cutting measure.
  • To avoid the PQRS penalty for the applicable 12-month reporting period, report at least 1 measures group AND report each measures group for at least 20 patients, the majority (11 patients) of which must be Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent performance rate will not be counted (unless the measure is an inverse measure). 
  • CMS will allow all group practices to voluntarily elect to administer the CAHPS for PQRS survey.
  • For group practices of 100+ EPs registered to participate in the GPRO via registry for the 2018 PQRS payment adjustment: The administration of the CAHPS for PQRS survey is REQUIRED. Therefore, if reporting via registry, these group practices must meet the following criterion for satisfactory reporting for the 2018 PQRS payment adjustment: For the 12-month reporting period for the 2018 PQRS payment adjustment, report all CAHPS for PQRS survey measures via a certified survey vendor, and report at least 6 additional measures, outside of the CAHPS for PQRS survey, covering at least 2 of the NQS domains using the qualified registry. If less than 6 measures apply to the group practice, the group practice must report on each measure that is applicable to the group practice. Of the non-CAHPS for PQRS measures, if any EP in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice would be required to report on at least 1 measure in the PQRS cross-cutting measure set
  • For group practices of 2-99 EPs registered to participate in the GPRO via registry for the 2018 PQRS payment adjustment: The administration of the CAHPS for PQRS survey is OPTIONAL: 
    • OPTION 1 (group practices that do not voluntarily elect to administer the CAHPS for PQRS survey in conjunction with the registry): For the 12-month 2018 PQRS payment adjustment reporting period, report at least 9 measures, covering at least 3 of the NQS domains. Of these measures, if a group practice has an EP that sees at least 1 Medicare patient in a face-to-face encounter, the group practice would report on at least 1 measure in the PQRS cross-cutting measure set. If the group practice reports on less than 9 measures covering at least 3 NQS domains, the group practice would report on each measure that is applicable to the group practice, AND report each measure for at least 50 percent of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.
    • OPTION 2 (group practices that voluntarily elect to administer the CAHPS for PQRS survey in conjunction with the registry): For the 12-month reporting period for the 2018 PQRS payment adjustment, report all CAHPS for PQRS survey measures via a certified survey vendor, and report at least 6 additional measures, outside of the CAHPS for PQRS survey, covering at least 2 of the NQS domains using the qualified registry. If less than 6 measures apply to the group practice, the group practice must report on each measure that is applicable to the group practice. Of the non-CAHPS for PQRS measures, if any EP in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice would be required to report on at least 1 measure in the PQRS cross-cutting measure set.
  • CAHPS for PQRS survey: CMS draws a sample of Medicare beneficiaries assigned to a practice. For practices with 100 or more eligible providers, the desired sample is 860, and the minimum sample is 416. For practices with 25 to 99 eligible providers, the desired sample is 860, and the minimum sample is 255. For practices with 2 to 24 eligible providers, the desired sample is 860, and the minimum sample is 125.
  • Of the additional measures that must be reported in conjunction with reporting the CAHPS for PQRS survey measures, if any eligible professional in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice must report on at least 1 measure in the cross-cutting measure set specified.
  • GPRO via Registry: Report at least 9 measures, covering at least 3 of the NQS domains, OR, if less than 9 measures covering at least 3 NQS domains apply to the group practice, report up to 8 measures covering 1-3 NQS domains (subject to MAV) for which there is Medicare patient data, AND report each measure for at least 50 percent of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.
  • If a group practice of 2+ EPs chooses to use a qualified registry in conjunction with reporting the CAHPS for PQRS survey measures, for the 12-month reporting period for the 2018 PQRS payment adjustment, the group practice would report all CAHPS for PQRS survey measures via a certified survey vendor, and report at least 6 additional measures, outside of the CAHPS for PQRS survey, covering at least 2 of the NQS domains using the qualified registry. If less than 6 measures apply to the group practice, the group practice must report on each measure that is applicable to the group practice. Of the non-CAHPS for PQRS measures, if any EP in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice would be required to report on at least 1 measure in the PQRS cross-cutting measure set.
  • Value Modifier: Groups and solo practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology, with the exception that groups consisting only of nonphysician EPs and solo practitioners who are nonphysician EPs will be held harmless from downward adjustments under the quality-tiering methodology in CY 2018.
  • To set the maximum upward adjustment under the quality-tiering methdology for the CY 2018 VM to +4.0 times an upward payment adjustment factor (to be determined after the performance period has ended) for groups with 10 or more EPs; +2.0 times an adjustment factor for groups with between 2 to 9 EPs and physician solo practitioners; and +2.0 times an adjustment factor for groups and solo practitioners that consist of nonphysician EPs who are PAs, NPs, CNSs, and CRNAs.
  • To set the amount of payment at risk under the CY 2018 VM to 4.0 percent for groups with 10 or more EPs:
    Cost/qualityLow qualityAverage qualityHigh quality
    * 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.
    Low cost+0.0%*+2.0x*+4.0x
    Average cost-2.0%+0.0%*+2.0x
    High cost-4.0%-2.0%+0.0x
  • To set the amount of payment at risk under the CY 2018 VM to 2 percent for groups with between 2 to 9 EPs and physician solo practitioners, and 2 percent for groups and solo practitioners that consist of nonphysician EPs who are PAs, NPs, CNSs, and CRNAs.
    Cost/qualityLow qualityAverage qualityHigh quality
    * 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.
    Low cost+0.0%*+1.0x*+2.0x
    Average cost-1.0%+0.0%*+1.0x
    High cost-2.0%-1.0%+0.0x
  • CY 2018 Value-Based Payment Modifier in Groups Consisting of Nonphysician Eligible Professionals, and Solo Practitioners who are Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists 
    Cost/qualityLow qualityAverage qualityHigh quality
    * 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.
    Low cost+0.0%*+1.0x*+2.0x
    Average cost+0.0%+0.0%*+1.0x
    High cost+0.0%+0.0%+0.0x
  • CY 2018 VM will not apply to nonphysician EPs who are not PAs, NPs, CNSs, and CRNAs (for example the VM will not apply to physical therapists). However, these nonphysician EPs are still subject to the reporting requirements under the PQRS.
  • Beginning with the CY 2017 payment adjustment period, CMS is increasing the minimum episode size for the Medicare Spending per Beneficiary measure to be included in the Value Modifier to 125 episodes for all groups and solo practitioners. Also, beginning with the CY 2017 payment adjustment period, for solo practitioners and groups with two to nine EPs, the All-Cause Hospital Readmissions measure will not be used in the quality composite calculation for the Value Modifier.
  • CMS will not apply the automatic downward adjustment applicable to TINs that do not meet the criteria to avoid the downward adjustment under PQRS, when PQRS determines on informal review that at least 50 percent of the TIN’s EPs meet the criteria to avoid the downward PQRS payment adjustment.  Also, if the group was initially determined to have not met the criteria to avoid the PQRS downward payment adjustments and consequently was initially subject to the automatic downward adjustment under the Value Modifier, then CMS does not expect to have data for calculating their quality composite, in which case they would be classified as “average quality.”
  • Beginning with the CY 2016 payment adjustment period, the TIN’s size would be determined based on the lower of the number of EPs indicated by the PECOS-generated list or by CMS analysis of the claims data for purposes of determining the payment adjustment amount under the VM. For example, for the CY 2016 payment adjustment period, if the PECOS list indicates that a TIN had 100 EPs in the CY 2014 performance period, but an analysis of claims shows that the TIN had 90 EPs based in CY 2014, then CMS would apply the payment policies to the TIN that are applicable to groups with between 10 to 99 EPs, instead of the policies applicable to groups with 100 or more EPs. Alternatively, if the PECOS list indicates that a TIN had 90 EPs in the CY 2014 performance period, but an analysis of claims shows that the TIN had 100 EPs based in CY 2014, then CMS would apply the payment policies to the TIN that are applicable to groups with between 10 to 99 EPs, instead of the policies applicable to groups with 100 or more EPs.
  • During the 2014 PQRS submission period, CMS received feedback from groups who experienced difficulty reporting through the reporting mechanism they had chosen at the time of 2014 PQRS GPRO registration. For example, some groups registered for the group EHR reporting mechanism and were subsequently informed that their EHR vendor could not support submission of group data for the group EHR reporting mechanism. CMS proposes to allow groups that register for a PQRS GPRO but fail as a group to report PQRS to avoid the VM payment adjustment if at least 50 percent of the group’s EPs meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals. 
  • CMS plans to make available for public reporting on Physician Compare all 2016 PQRS measures for individual EPs collected through a registry, EHR, or claims.
  • CMS plans to publicly report on Physician Compare an item or measurelevel benchmark derived using the Achievable Benchmark of Care (ABC™) methodology. ABC™ starts with the pared-mean, which is the mean of the best performers on a given measure for at least 10 percent of the patient population – not the population of reporters.
  • CMS proposes to use the ABC™ methodology to generate a benchmark which can be used to systematically assign stars for the Physician Compare 5 star rating.
  • CMS is proposing to continue to require the reporting of at least 1 applicable cross-cutting measure if an EP sees at least 1 Medicare patient. 
  • EPs in Critical Access Hospitals Billing under Method II (CAH-IIs) may participate in the PQRS using ALL reporting mechanisms available, including the claims-based reporting mechanism.
  • EPs Who Practice in Rural Health Clinics (RHCs) and/or Federally Qualified Health Centers (FQHCs) will not be subject to the PQRS payment adjustment.
  • EPs Who Practice in Independent Diagnostic Testing Facilities (IDTFs) and Independent Laboratories (ILs): claims submitted for services performed by EPs who perform services as employee of, or on a reassignment basis to, IDTFs or ILs would not be subject to the PQRS payment adjustment.
  • The 2018 PQRS payment adjustment is the last adjustment that will be issued under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA. CMS sought comment related to other MACRA provisions in the CY 2016 PFS proposed rule and in a previously published Request for Information.

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