2014 Physician Quality Reporting System

National Quality Strategy Domains, Qualified Clinical Data Registry options and other changes you should know about.

Donna McCune, CCS-P, COE, CPMA
4/2/2014

Q. Does the Physician Quality Reporting System continue in 2014? Is there still an opportunity to receive a bonus for participating?

A. The PQRS does continue in 2014. Providers who successfully participate are eligible to receive a 0.5-percent bonus for all services paid under the Medicare Physician Fee Schedule.


Q. Are the requirements for successful participation in 2014 different than in prior years?

A. Yes. Successful participation has always relied on providers performing services described as “quality measures” and submitting codes to support their performance of these measures. One change for 2014 is the categorization of quality measures into National Quality Strategy domains. Successful reporting relies on reporting quality measures from three separate domains. The six domains are:

• Patient Safety;
• Person and Caregiver-Centered Experience and Outcomes;
• Communication and Care Coordination;
• Effective Clinical Care;
• Community/Population Health; and
• Efficiency and Cost Reduction.

Another change is the number of measures that must be reported to secure a bonus. In 2014, providers must report at least nine measures covering a minimum of three NQS domains. The instructions indicate that if fewer than nine measures covering at least three NQS domains apply, physicians may report one to eight measures covering one to three NQS domains.


Q. What quality measures apply to ophthalmologists?

A. The 2014 measures for eye disease, carried over from the 2013 program, are:

• Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (#12)
• Age-related Macular Degeneration (AMD): Dilated Macular Examination (#14)
• Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (#18)
• Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care (#19)
• Diabetes: Eye Exam (#117)
• Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement (#140)
• Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% or Documentation of a Plan of Care (#141)

Practices interested in measures that are not ophthalmic specific may also consider the following measures for reporting in 2014:

• Documentation of Current Medications in the Medical Record (#130)
• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (#226)
• Melanoma: Continuity of Care–Recall System (#137) (Registry only)
• Melanoma: Coordination of Care (#138) (Registry only)
• Biopsy follow up (#265) (Registry only)


Q. Are there quality measures related to cataract surgery?

A. Yes. In 2012, a “Cataracts Measures Group” was added to the program. A measures group is a subset of four or more measures that have a particular clinical condition or focus in common. The Cataracts Measures Group may only be reported through a registry. The measures group is made up of the following measures.

• Cataracts: 20/40 or Better Visual Acuity within 90 days Following Cataract Surgery (#191)
• Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (#192)
• Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (#303)
• Patient Satisfaction within 90 Days Following Cataract Surgery (#304)

When reporting this group, all applicable measures must be completed for each patient being reported. Successful reporting of the Cataract Measures Group requires reporting for 20 or more patients.


Q. If a provider reports fewer than nine measures, will there be a reduction to the Medicare reimbursement in 2016?

A. Maybe. Physicians who submit fewer than nine measures or three NQS domains are subject to a review process called “Measure Applicability Validation.”
This process allows the Centers for Medicare & Medicaid to determine whether the provider should have reported additional measures and/or measures covering additional NQS domains. If the MAV review done by CMS determines that the provider accurately submitted data and that no additional measures and/or NQS domains applied, the penalty is averted and the provider may be entitled to the PQRS bonus.


Q. Is there another option to avoiding the 2016 penalty when reporting PQRS in 2014?


A. Fortunately, yes. Eligible professionals may avoid a penalty in 2016 by successfully reporting three measures in 2014. If fewer than three measures apply, report one or two measures for at least 50 percent of Medicare fee-for-service patients. By reporting less than three, physicians may be subject to the MAV process discussed above. If the MAV process determines that three or more measures applied, but only one to two measures were reported, it would result in the physician receiving a 2-percent penalty in 2016. 


Q. What are the different ways to report PQRS measures to CMS?


A. Measures may be reported by individual providers or as a group practice. Some, not all, measures may be submitted on claims filed to Medicare. Some measures are eligible to be reported via electronic health records. Providers may choose to utilize a “registry” to report on their behalf. In 2014, a new type of registry is added for the purpose of reporting: a Qualified Clinical Data Registry option. A QCDR is a CMS-approved entity that has self-nominated and successfully completed a qualification process.

Those who want to report as a group practice must request this option from CMS and be approved to report in this manner. Reporting through an EHR also requires that the EHR vendor be approved by CMS to report via this method.


Q. Are providers required to report on every Medicare patient meeting the quality measure description?


A. No. Each measure must be reported for at least 50 percent of the Medicare Part B fee-for-service patients seen during the reporting period for providers submitting PQRS measures on their Medicare claims. For those utilizing a registry, the reporting threshold for the registry has been reduced to 50 percent in 2014. The previous threshold for the registry was 80 percent.


Q. Is the PQRS program likely to continue beyond 2014?

A. Yes, it is. The PQRS program is slated to link to the EHR bonus program and the value based performance modifier program. Reporting of quality measures is a priority for CMS as they consider the future payment systems for health-care providers.


Q. Will providers be penalized for nonparticipation?

A. Yes, there will be a penalty. Providers who did not participate in 2013 will see a 1.5-percent reduction to their Medicare reimbursement in 2015. Penalties in 2016 will depend on the provider’s level of participation and successful reporting in 2014.  


Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.