2016 Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) Program is a CMS quality initiative that affects eligible providers' (EPs’) reimbursement rates for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-For-Service (FFS) beneficiaries.

Although technically a voluntary program, non-participation in the PQRS program has financial implications for future Medicare Part B FFS reimbursement. The impact on reimbursement is in the form of payment adjustments based on satisfactory reporting of PQRS measures. Understanding the PQRS program is essential to CRNAs' ability to safeguard their Medicare billings. 

CMS Disclaimer: “Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, EPs should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier (VM), etc. requirements for each of these programs.”

Who are eligible professionals (EPs) under the 2016 PQRS program?

Under PQRS, covered professional services are those paid under or based on the Medicare Physician Fee Schedule (MPFS). To the extent that EPs are providing services which get paid under or based on the MPFS, those services are eligible for PQRS payment adjustments. You can view the 2016 PQRS List of EPs or read the summary below:

Practitioners: Certified Registered Nurse Anesthetists (CRNAs)*, Anesthesiologist Assistants, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, Clinical Social Workers, Clinical Psychologists, Registered Dietitians, and Nutrition Professionals, and Audiologists.

Therapists: Physical, Occupational, and Qualified Speech-Language Therapists.

Medicare physicians: Doctors of Medicine, Osteopathy, Podiatric Medicine, Optometry, Oral Surgery, Dental Medicine, or Chiropractic Medicine.

*CRNAs have been considered EPs for quality reporting since 2007, when the PQRS program was called the Physician Quality Reporting Initiative (PQRI).

Are there EPs that are not able to participate in PQRS?

Yes. Although a provider's profession may be included on the 2016 CMS PQRS List of EPs, there are disqualifying scenarios in which these EPs who provide Medicare Part B services are not able to participate in PQRS:

  1. Provide Medicare Part B services, but bill under Part A (i.e., at a facility or institution).

  2. Do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider’s individual NPI is entered on CMS-1500 claim form and associated with specific line-item services.

  3. Provide services payable under fee schedules or methodologies other than the Medicare Physician Fee Schedule (this may include services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals, rural health clinics, ambulance providers, and ambulatory surgery center facilities).

Will EPs who work in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) be subject to the PQRS negative payment adjustment?

All individual EPs and PQRS group practices paid under or based on the Medicare PFS (MPFS) who provided professional services from January 1, 2016 through December 31, 2016 to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer), are analyzed and subject to the 2018 PQRS downward payment adjustment.

Again, for services paid under other fee schedules or methodologies outside of MPFS services furnished to Medicare Part B beneficiaries are not able to participate in the PQRS. 

What is a PQRS reporting year and payment adjustment?

The PQRS reporting year is a performance period based on a calendar year (January 1 to December 31).  A payment adjustment occurs two years after the reporting year. Calendar year 2016 is the performance period for payment adjustment applied in 2018. Individual eligible professionals (EPs) and group practices who do not satisfactorily report data on quality measures for covered professional services during the 2016 reporting year will be subject to a negative payment adjustment under the Physician Quality Reporting System (PQRS) in 2018. 

In compliance with Section 1848(a)(8) of the Social Security Act, as of the 2015 reporting year, subsequent PQRS payment adjustments are only in the form of a penalty for not satisfactory reporting; bonuses/incentives are no longer part of the PQRS payment adjustment scheme.


Please note: EPs and group practices may be subject to additional payment adjustments based on quality payment programs separate from PQRS. Please contact the respective program’s help desk for assistance. 

I received a letter from CMS notifying me of a 2018 penalty for the 2016 PQRS reporting year. Is there anything I can do at this point?

No, the final data submission timeframe for reporting 2016 PQRS quality data was January 2016 through March 2017. In order to have avoided a downward two percent (-2.0%) reduction in your Medicare PFS payments for services rendered January 1, 2018 through December 31, 2018, you must have met certain PQRS reporting criteria during the 2016 performance period.

However, EPs or group practices receiving a 2018 PQRS negative payment adjustment who believe they have been incorrectly assessed may submit an informal review request to CMS before the deadline on December 7, 2017. 

How do I avoid the 2018 penalty for the 2016 PQRS reporting year?

Payment adjustments occur in 2018 for the 2016 PQRS reporting year (January 1, 2016 – December 31, 2016). For the 2016 PQRS reporting year, EPs will incur an automatic –2.0% penalty for not reporting to the program. Additionally, EPs who do not participate in 2016 PQRS will also receive a -2.0% penalty from the Value-Based Modifier (VM) program, for which CRNAs became eligible participants beginning at the start of the 2016 PQRS reporting period.

To avoid the 2018 PQRS and VM penalties, EPs must participate in PQRS based on the specifications set forth in the 2016 reporting period. If you do not participate in the 2016 PQRS reporting year based on your chosen reporting option by the deadlines set by CMS, you will receive both penalties resulting in a total payment adjustment of -4.0% in 2018. Payment adjustments are based on Medicare Part B Fee-For-Service (FFS) only under the Medicare Physician Fee Schedule (MPFS). 

For more information about the 2016 PQRS program year, please review the 2016 PQRS Implementation Guide. The document provides guidance about how to select measures for reporting, how to read and understand a measure specification, and outlines the various reporting methods available for 2016 PQRS. 

What does it mean to satisfactorily report to PQRS for the 2016 PQRS reporting year?

Individual eligible professionals (EPs) reporting via Claims* or individual EPs/group practices reporting via Qualified Registry should:

  1. Report on at least 9 individual measures covering 3 National Quality Strategy (NQS) domains for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period 

OR

2. Report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients.   

  • Measures groups containing a measure with a 0% performance rate will not be counted.
  • For this reporting option, EPs should use the “2016 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual” and “2016 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups”.

*For the 2016 PQRS reporting year, only 1 out the 7 anesthesia-specific measures can be reported via claims; therefore, this no longer a viable reporting option for CRNAs. 

Individual EPs reporting via Qualified Clinical Data Registry (QCDR) should:

  • Report at least 9 (PQRS or Non-PQRS) measures covering at least 3 NQS domains AND report each measure for at least 50% of the EP's applicable patients (Medicare and non-Medicare) seen during the reporting period to which the measure applies.
  • Of the 9 measures, at least 2 (PQRS or Non-PQRS) measures should be outcome measures. 

Individual EPs/group practices reporting via Electronic Health Record (EHR) should:

  • Report on at least 9 PQRS measures covering 3 NQS domains for all of your Medicare Part B FFS patients using electronic clinical quality measures (eCQMs).
  • Report at least 1 PQRS measure for which there is Medicare data.

For more information go to about 2016 PQRS reporting criteria please review the 2016 PQRS Individual Measures Guide . 

Special Note: According to CMS, the term “satisfactory reporting” refers to participating in PQRS in 2016 to avoid the 2018 negative payment adjustment, while the term “satisfactory participation” refers to EPs participating in the “qualified clinical data registry (QCDR)” reporting option.

Note: If a group is reporting for PQRS through another Centers for Medicare & Medicaid Services (CMS) program (such as the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, or Pioneer or Next Generation Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to avoid the PQRS payment adjustment.

CMS Disclaimer: “Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, EPs should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier (VM), etc. requirements for each of these programs.”

What is the Measure Applicability Validation (MAV)?

8. What is the Measure Applicability Validation (MAV)? 
 
MAV is a process to review and validate an individual eligible professional’s or group practice’s inability to submit 9 measures covering 3 domains. CMS will analyze data to validate; using the clinical relation/domain test to confirm that more measures and/or domains were not applicable to the individual eligible professional’s or group practice’s scope of practice. If additional measures or domains are found to be applicable through MAV, the eligible professional would be subject to the 2018 PQRS payment adjustment. Anesthesia is a specialty recognized as having less than 9 PQRS measures across 3 NQS domains; however, it is still possible for anesthesia providers to avoid the payment adjustment with fewer measures and/or domains.  CMS has instituted the MAV process to review and validate an individual EP’s or group practice’s PQRS measures.  The MAV process is automatically triggered if at least 9 measures AND at least 3 domains are not reported.  For example, reporting 9 measures across 2 domains will trigger MAV as will reporting 8 measures across 3 domains.  The MAV process only applies to individual measures for claims-based and registry reporting.  MAV does not apply to registry Measures Group reporting nor does it apply to EHR (electronic health record), QCDR (qualified clinical data registry), or Web-Interface reporting. 
 
Once initiated, CMS utilizes MAV to validate that more measures and/or NQS domains were not applicable to the EP's or group practice’s specialty via a 2 step process: 
1) the Clinical Relation/Domain Test and 
2) the Minimum Threshold Test.  

CMS does not provide any information regarding the analytic methodology for which they determine how one passes the MAV process. Below is an overview of what MAV is and its purpose:

  • Anesthesia ClusterThe Clinical Relation/Domain Test is performed if a claims- or registry-reported measure is contained within a MAV clinical cluster. For individual EPs who report fewer than 9 PQRS measures and/or less than 3 domains, this MAV test renders a determination if additional measures or domains may also be applicable based on a specific clinical cluster. For 2016 PQRS reporting, there is an Anesthesia Care MAV cluster which includes 4 measures (#424-Perioperative Temperature Management, #426-Post-Anesthetic Transfer of Care: Procedure Room to a PACU, #427-Use of Checklist/Protocol for Direct Transfer of Care from Procedure Room to ICU, and #430-Prevention of PONV-Combination Therapy). 
  • The Minimum Threshold Test only applies to claims-based MAV; it is not analyzed for registry-based MAV. This MAV test checks the EP’s claims to verify that the EP reported on a particular measure for a minimum of 15 eligible patients or encounters.

If it is determined that there were no other quality measures the EP or group could have reported on, then the payment adjustment (penalty) could be avoided.  Additional information on the 2016 processes for claims-based MAV and registry-based MAV is available on the Analysis and Payment page of the CMS website. CMS has also developed 2016 MAV training modules for providers, which contain scenarios for not reporting at least 9 measures across 3 domains. According to the CMS 2016 PQRS MAV Process for Registry Based Reporting , "CMS may determine that it is necessary to modify the MAV process after the start of the 2016 reporting period. However, any changes will result in the MAV process being applied more leniently, thereby 1) allowing a greater number of EPs to pass validation, and 2) causing no EP or group practice that would otherwise have passed, to fail. Any modifications will be published on the CMS PQRS website as soon as possible after determination that a change is needed."

Special note for EPs or group practices with more than 15 face-to-face encounters: If it is determined that at least one cross-cutting measure was not reported, that individual provider or group practice will be automatically subject to the 2018 PQRS payment adjustment and MAV will not be analyzed. 

What 2016 PQRS reporting options can a CRNA choose from?

CRNAs may choose from the following reporting options to submit their quality data as individual EPs:

  • Claims*
  • Electronic Health Record (EHR)
  • CMS-Certified Survey Vendor
  • Qualified Registry
  • Qualified Clinical Data Registry (QCDR)

*Special Note: For the 2016 PQRS reporting year, only 1 out the 7 anesthesia-specific measures can be reported via claims; therefore, this no longer a viable reporting option for CRNAs who work in traditional anesthesia.

Group practice reporting options (GPROs) for the 2016 PQRS reporting period include:

  • Electronic Health Record (EHR)
  • Qualified Registry
  • QCDR
  • Web Interface (for 25 or more EPs)

Special Note: A group practice must have 2 or more EPs in order to participate through the PQRS GPRO. The group practice will determine its size based on the number of EPs billing under the Taxpayer Identification Number (TIN) at the time of registration. Group practices must register to report via qualified registry, EHR or Web Interface under the GPRO. The GPRO registration period for the 2016 PQRS reporting year will be announced by CMS at a later date.  

What factors should I consider when attempting to identify PQRS measures for satisfactory reporting?

When selecting measures for reporting the following factors should be considered: 

  • Clinical conditions commonly treated
  • Types of care delivered frequently – preventative, chronic, acute
  • Settings where the care is delivered – office, emergency department, surgical suite
  • Quality improvement goals for the year
  • Other quality reporting programs in use or being considered

Special Note: It is up to the individual EP or group to determine which measures are eligible to your practice.  Modifications to many PQRS measure specifications may undergo revisions and updates.  CMS provides a list of these changes via the CMS Measure Specifications Manual and Release Notes.  CMS states that “All stakeholders should be cognizant of the most up-to-date list and reference it for reporting purposes.”  In the manual, a measure will consist of a numerator, denominator, and a rationale.  The numerator describes the process or outcome required for performance measurement.  The denominator identifies which cases or patient population the measure applies to through codes (e.g., ICD-10, CPT, HCPCS) and additional criteria.  For verification purposes, it is important to identify these changes to assure that you, your group, billers and/or vendors submitting on your behalf are meeting satisfactory reporting based on any updated measure specifications.  It is also important to note that not all of these measures apply to every anesthesia setting or practice. While the AANA has provided a list of potential measures applicable to CRNAs, it is the responsibility of the CRNA to ultimately choose their measures or Measure Group.  The AANA cannot determine which measures may or may not apply to you and your practice.  For this reason, the AANA encourages EPs to contact the CMS QualityNet Help Desk at (866) 288-8912 or via email Qnetsupport@hcqis.org to ensure you are reporting applicable measures. 

The table below lists the 2016 anesthesia-specific PQRS measures that CRNAs may report. For the 2016 PQRS reporting year, only 1 out the 7 anesthesia-specific measures can be reported via claims; therefore, this no longer a viable reporting option for CRNAs.  Those who report less than 9 PQRS measures across 3 NQS domains will be subject to the Measure Applicability Validation (MAV) process when using a qualified CMS registry

Table: 2016 Anesthesia-Specific PQRS Measures That May Apply to CRNAs Depending on Specialty see the 2016 Anesthesia-Specific Measures FAQ Table





What measures should anesthesia professionals consider for 2016 PQRS reporting?

When selecting measures for reporting the following factors should be considered:

  • Clinical conditions commonly treated
  • Types of care delivered frequently – preventative, chronic, acute
  • Settings where the care is delivered – office, emergency department, surgical suite
  • Quality improvement goals for the year
  • Other quality reporting programs in use or being considered

It is up to the individual EP or group to determine which measures are eligible to your practice.  Modifications to many PQRS measure specifications may undergo revisions and updates.  CMS provides a list of these changes via the CMS Measure Specifications Manual and Release Notes.  CMS states that “All stakeholders should be cognizant of the most up-to-date list and reference it for reporting purposes.”  In the manual, a measure will consist of a numerator, denominator, and a rationale.  The numerator describes the process or outcome required for performance measurement.  The denominator identifies which cases or patient population the measure applies to through codes (e.g., ICD-10, CPT, HCPCS) and additional criteria.  For verification purposes, it is important to identify these changes to assure that you, your group, billers and/or vendors submitting on your behalf are meeting satisfactory reporting based on any updated measure specifications.  It is also important to note that not all of these measures apply to every anesthesia setting or practice. While the AANA has provided a list of potential measures applicable to CRNAs, it is the responsibility of the CRNA to ultimately choose their measures or Measure Group.  The AANA cannot determine which measures may or may not apply to you and your practice.  For this reason, the AANA encourages EPs to contact the CMS QualityNet Help Desk at (866) 288-8912 or via email Qnetsupport@hcqis.org to ensure you are reporting applicable measures.

The table below lists the 2016 anesthesia-specific PQRS measures that CRNAs may report. For the 2016 PQRS reporting year, only 1 out the 7 anesthesia-specific measures can be reported via claims; therefore, this no longer a viable reporting option for CRNAs. Those who report less than 9 PQRS measures across 3 NQS domains will be subject to the Measure Applicability Validation (MAV) process when using a qualified CMS registry. 

Table: 2016 Anesthesia-Specific PQRS Measures That May Apply to CRNAs Depending on Specialty or Setting

What is a cross-cutting measure and a face-to-face encounter?

According to CMS: “In order for eligible professionals (EPs) to satisfactorily report PQRS measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. EPs or group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter." 

A cross-cutting measure is a measure that is broadly applicable across multiple clinical settings and EPs within a variety of specialties. Please reference the 2016 Cross-Cutting Measures List for broadly applicable measures that are defined as cross-cutting. CMS defines a face-to-face encounter as “an instance in which the EP billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter.”

Reference the Face-to-Face Encounter Codes for the billable codes that identify face-to-face encounters for the purposes of 2016 PQRS reporting, which include evaluation and management codes for general office/outpatient visits such as pain management; “traditional” anesthesia is not considered a specialty with face-to-face encounters.

Special Note: If you as an individual CRNA only report on anesthesia CPT codes (00000-01999), then you do not have any associated face-to-face encounters under the PFS. Therefore, you do not have any cross-cutting measures that apply to your practice. CRNAs that do have separately identifiable postoperative management services such as pain management will be subject to reporting a cross-cutting measure based on their face-to-face encounters.  

Can an individual CRNA report a cross-cutting measure? In other words, can I “bill” for an Evaluation and Management (E/M) code for the purpose of PQRS?

According to Chapter 2 of the January 1, 2016  CMS NCCI manual the preoperative and postoperative anesthesia evaluation and assessment is part of the payment for anesthesia service. For anesthesia, the E/M codes used in PQRS claims-based and qualified registry reporting are bundled into the anesthesia codes and, therefore, should not be reported together. 

In other words, although a CRNA performing a thorough anesthesia evaluation and assessment may have explicit documentation of preforming a specific screening as identified in a population health measure (e.g., cross-cutting measure), the CRNA cannot bill for an E/M code via claims-based or registry reporting to obtain credit for PQRS. Given this bundle, CRNAs are not recognized for their potential contribution to population health. Furthermore, any money collected for E/M codes in conjunction with anesthesia codes would have to be returned to Medicare.
 

When is it appropriate for an individual CRNA to report on non-specific anesthesia measures (other PQRS measures or cross-cutting measures)?

There are a few scenarios where this is feasible.  According to Chapter 2 of the January 1, 2016 CMS National Correct Coding Initiative (NCCI) manual, “If a surgery is cancelled, subsequent to the preoperative evaluation, payment may be allowed”. Therefore, if a surgery or procedure was cancelled and a preoperative evaluation with explicit documentation of meeting the PQRS measure was met, then one can bill for the Evaluation and Management (E/M) code and report the PQRS measure.  

In addition, CRNAs may report on PQRS measures for separately identifiable postoperative management services such as pain management. In such cases, the following list of measures may be considered: 

Table: 2016 Non-anesthesia Specific PQRS Measures That May Apply to CRNAs Depending on Specialty or Setting

Special Note: When reporting on E/M codes (CPT I code denominator) for the purpose of PQRS, some of these measures may trigger other measures within another discipline’s measure cluster. In such cases, you may receive a penalty for not satisfactorily reporting to PQRS for claims-based or traditional qualified registry reporting, because the Measure Applicability Validation (MAV) process identified other potential measures that CMS believes you could have reported on. In other words, the E/M code that qualified you to report on the PQRS measure also was found in another PQRS measure within that MAV cluster.  
 
CMS has created a 2016 Measures List in the form of an Excel spreadsheet that can be sorted and filtered to your needs. This spreadsheet identifies and describes the measures used in PQRS, including all available reporting methods/options, corresponding PQRS number and NQF number, NQS domains, plus measure developers and their contact information.

For more information about 2016 PQRS Measure Specifications and Supporting documents download CMS’ zip file 2016 PQRS Individual Claims Registry Measure Specification Supporting Documents for all relevant documents. For ease, see the 2016 PQRS Individual Measure Spec Release Notes and 2016 PQRS Individual Measure Specification Manual.

What are the deadlines for the 2016 PQRS reporting year?

A general timeline for 2016 PQRS deadlines can be found here: PQRS 2015-2018.  A complete list of 2016 data submission timeframes is below:

March 13, 2017 deadlines:

  • eCQM reporting for hospitals – 1/3/17 - 3/13/17
  • CQM reporting via attestation – 1/3/17 - 3/13/17
  • Meaningful Use objectives and measures – 1/3/17 - 3/13/17

March 17, 2017 deadline:

  • Web Interface – 1/16/17 - 3/17/17

March 31, 2017 deadlines:

  • EHR Direct or Data Submission Vendor (QRDA I or III) – 1/3/17 - 3/31/17
  • Qualified Clinical Data Registries (QRDA III) – 1/3/17 - 3/31/17
  • Qualified Registries (Registry XML) – 1/3/17 - 3/31/17
  • QCDRs (QCDR XML) – 1/3/17 - 3/31/17
  • eCQM reporting for EPs – 1/3/17 - 3/31/17

What is the Value Based Modifier (VM) and how is it related to PQRS?

The Value Based Modifier (VM) is a separate and distinct payment adjustment from PQRS; however, participation in PQRS is required to avoid a VBM penalty. Solo practitioners and all practitioners in group practices who participate in Fee-For-Service Medicare under a single TIN will be subject to the value modifier in 2018 based on their performance in the 2016 PQRS reporting year. Both cost and quality data are to be included in calculating payments for all eligible professionals. 

Beginning in the 2016 reporting period, all eligible CRNAs will be subject to the application of the VM payment adjustment in 2018. 

For an overview of the VM Program, please visit the AANA's Value Modifier FAQs.

Is there a CMS website that provides guidance on the 2016 submission process for the PQRS program?

Yes. PQRS EPs and PQRS group practices can refer to the following educational resources available in 2016 based on their submission method

For more information about 2016 PQRS, please visit the CMS web page on "How to Get Started" and read the 2016 Implementation Guide.

Who should I contact for PQRS related questions?

If you have questions or need assistance with PQRS reporting, please contact the QualityNet Help Desk. 

Monday – Friday; 7:00 AM–7:00 PM CST.
Phone: 1-866-288-8912 | TTY: 1-877-715-6222
Email: Qnetsupport@hcqis.org 
Fax: (888) 329-7377
For ESRD support, e-mail: qnetsupport-esrd@hcqis.org