Frequently Asked Questions
Q: Why should I participate in PQRS?
A: Providers have the opportunity to use PQRS to improve the care of the patients they serve by measuring their care through evidence-based measures included in the program. These measures were based on clinical guidelines and were reviewed by medical professionals. Participation is a way to prepare for future pay-for-performance programs, such as Patient-Centered Medical Homes, Accountable Care Organizations and value-based purchasing. A financial incentive is available for successful participation. By 2015, professionals that do not participate will receive a payment adjustment.
PQRS using the EHR option helps the practice learn to use their EHR for quality measurement, patient safety, improving patient care, and achieving practice goals. EPs learn the essentials of documenting certain parts of the visit in structured format and in specified fields, as required by their particular vendor, to allow accurate reporting of data. This harnesses the power of an EHR—clinical data is needed to improve outcomes and to determine the effectiveness of various treatments. Accurate data capture will empower physicians with information about their practice that was not previously available.
Q: I am planning to submit using Claims. What are my options?
A: When submitting via claims, you may submit three individual measures for 50% of your Medicare Part B patients.
Q: I would like to submit using the EHR option. How do I know if my EHR is qualified?
A: The complete list of qualified EHRs can be found on the CMS Web site, under “Alternative Reporting Mechanisms”, here.
Q: I am a physician working at a rural health clinic. Am I eligible for the PQRS program?
A: Maybe. You may be eligible for the PQRS Incentive Program, but only those allowable charges billed under Medicare Part B PFS will be considered when calculating the incentive payment. Services payable under fee schedules or methodologies other than the Medicare PFS are not included in PQRS (for example, services provided in federally qualified health centers, portable x-ray suppliers, independent laboratories, independent diagnostic testing facilities, hospitals (including critical access), rural health clinics, ambulance providers, and ambulatory surgery center facilities). In addition, suppliers of durable medical equipment (DME) are not eligible for Physician Quality Reporting since DME is not paid under the PFS. Those charges filed under Part A will not be considered.
Q: What patients should be included in PQRS?
A: Only Medicare Part B PFS beneficiaries should be reported for PQRS. This includes Medicare (primary or secondary) and Railroad Retirement. PQRS does not include Medicare Part A or Medicare Advantage.
Q: Do practices need to have an EHR in order to participate in PQRS?
A: No. Practices do not need an EHR to participate in PQRS. It is possible to participate with a paper system through the Claims or Registry option. However, if a practice does have an EHR that is either integrated or interfaced with the practice management system, these systems can often be modified to capture PQRS codes for submission through claims, qualified registry or qualified EHR.
Q: May I submit PQRS using more than one alternative method?
A: Yes. CMS will review data submitted via all methods/options to determine satisfactory reporting. However, each reporting option is considered separately and the EP must successfully report within each option. EPs cannot combine reporting options to reach the 3 measure requirement, the reporting rate requirement, or the Measures Group requirement. In the event an EP satisfies the reporting criteria for multiple methods, (s)he will earn only one incentive payment for the most advantageous reporting method for which the EP qualifies. There is no penalty if multiple options are attempted.
For example, an EP could submit 3 individual measures for at least 50% of their patients via claims. Then, after the close of the year, the EP could also submit 3 measures directly to CMS using a qualified EHR. If claims submission failed to meet the 50% reporting requirement, but EHR submission satisfactorily met the reporting requirement, the EP would receive an incentive covering the full year. If both methods satisfactorily met the reporting requirements, the EP would receive one incentive based on the full year of reporting. This may be a good strategy to help the practice familiarize itself with direct reporting to CMS via the EHR, as this is where future reporting is headed. The EP could NOT submit one measure via claims and two measures via the EHR in order to meet the 3 measure reporting requirement.
Q: Can EPs participate in all three Incentive Programs—i.e., PQRS, e-Prescribe, and the EHR (Meaningful Use) programs—and receive incentives for each?
A: The three programs are distinctly separate programs. PQRS incentives and EHR (Meaningful Use) incentives are available regardless of participation in other programs. EPs that participate in the Medicare or Medicare Advantage options for the EHR Incentive Program (Meaningful Use) will not receive an incentive for participation in the e-Prescribe Incentive program. However, EPs should continue to report the e-Prescribe measure in 2012 to avoid payment adjustments.
Q: How will I know if I correctly submitted PQRS? Will I receive feedback?
A: No intermittent feedback reports are provided for EPs that submit via claims. The EP should keep the remittance notices (RA) for PQRS cases submitted. A Remark Code (N365) and a message which reads, “This procedure code is not payable. It is for reporting/information purposed only” will appear on the RA to indicate the claim was passed on for PQRS consideration. This will show that the PQRS codes were not stripped from the claim and were submitted for consideration under PQRS. However, this code does NOT indicate whether or not the PQRS codes were accurate or complete. A provider will not know if (s)he was successful until the final feedback reports are available, usually in summer of the following year.
Since PQRS reporting is only done once after the close of the year for the EHR-based option, no interim report will be given by CMS. However, EPs can run their own monitoring reports to track and improve their performance using features of the EHR.
If the provider successfully reports PQRS, CMS will send the incentive payments via the same route that all other payments to the EP are made. The remittance notice will show a code “LE” followed by “This is a PQRS Incentive Payment.”
Q: How can I improve our performance rate for PQRS measures?
A: The following suggestions may help improve performance rates:
- Have a plan ready at the start of the reporting period to achieve highest performance rates.
- Assign specific responsibilities for each requirement of the measure to an identified staff person.
- A strong statement from the physician to their patients recommending preventive services has been consistently shown to be the most effective means of improving compliance. Plan your statement, rehearse, and communicate with conviction to your patients. Make certain your staff’s message is consistent with your own.
- Make every encounter an opportunity to promote prevention services.
- If a patient refuses preventive services, ask probing questions to discover the reason. Attempt to discover a solution together with the patient.
- Make sure educational documents are available to your patients.
- Determine an efficient workflow for referring and scheduling with specialists.
- For electronic systems:
- Document all data elements used in each measure in designated structured fields. Your vendor should be able to tell you how to properly document to allow accurate reporting.
- Turn on alerts to identify patients who meet the denominator criteria for prevention measures you select.
- Ask that all orders be entered electronically using CPOE and link all results to the order so they can be tracked. Send reminders to patients with open orders.
- Run comparative monthly reports by provider showing how each is performing on the measures and post in the break room. Discuss and implement plans for improvement at staff meetings using rapid-cycle techniques.
- For paper-based systems:
- Use the worksheets provided by the AMA or other professional organizations to help collect the information for eligible patients. Have the front desk place a worksheet on the medical chart when eligible patients check-in. The clinical team should review appointment schedules to ensure all eligible patients are identified.
- Ask clinical staff to document information in a consistent manner and place within the chart. This will make it easier to locate the required information and make certain it is coded for PQRS. Example: document all orders for preventive care on an order sheet and all results on a health maintenance record.
- Keep copies of the N365 notices so you have a record of patients submitted
Q: I’ve heard about many providers who have submitted PQRS and never received payment. How can I improve my chances of success?
A: Providers are encouraged to use electronic capability for PQRS reporting in order to improve chances of success. Providers who report using a qualified EHR or registry enjoy greater than 90 percent success rates.
Q: If I have questions about PQRS, whom should I contact?
A: The CMS PQRS website has a large quantity of information available, so check there first. You may also contact the QualityNet Helpdesk:
- QualityNet Help Desk – 7:00 AM – 7:00 PM CST
- Phone: 1-866-288-8912
- TTY: 1-877-715-6222
Quality Improvement Organizations have been contracted by the Centers for Medicare & Medicaid Servgices (CMS) to provide local assistance to providers in their respective states. Primaris is the QIO for Missouri. You may contact Kristen Bird at Primaris 800-735-6776, ext.117, or e-mail Sandra Pogones at email@example.com.
For additional educational resources, please refer to the CMS Website.
var _gaq = _gaq || ; _gaq.push(['_setAccount', 'UA-1402318-16']); _gaq.push(['_trackPageview']);