Local News

Avoid the Medicare Quality Reporting Penalty in 2015

By the Alameda-Contra Costa Medical Association

As part of the Physician Quality Reporting System (PQRS), Medicare will impose a 1.5% penalty in 2015 on physicians and other providers who do not successfully report at least one individual quality measure for at least one patient in 2013. The purpose of this article is to help physicians avoid the penalty in 2015 by providing guidance on how to report at least one measure for at least one patient using Medicare claims. Since most physicians already submit Medicare claims for reimbursement, adding the additional PQRS reporting information to the claim will be the least burdensome way for most physicians to avoid the penalty. This article also touches upon how physicians can qualify for a quality reporting bonus and discusses some additional PQRS reporting options. However, this article is not intended to be an exhaustive discussion of PQRS, and resources are listed at the end of the article for those desiring additional information.

Avoiding the Penalty in 2015 Through Claims-based Reporting

For many physician practices not yet participating in PQRS, the simplest way to avoid the penalty in 2015 will be to report on one quality measure for at least one patient (preferably a few patients) on your Medicare claims. The process can be broken down into three steps:

  1. Selecting an appropriate measure.
  2. Identifying your Medicare patients to whom the measure applies.
  3. Reporting the quality measure on your Medicare claims after an applicable patient encounter.

Step One: Select an Appropriate Measure

Quality measures form the basis of the PQRS program, and are intended to provide information to Medicare about an aspect of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For purposes of avoiding the penalty in 2015, physicians should select a quality measure relating to an aspect of care that you will encounter in your Medicare patient population. Review the list of individual measures that are reportable by claims at bottom, and select the most frequent measure that applies to your Medicare patients. Although there are over 100 individual measures that can be reported via claims, some physicians may not find specialty-specific measures. Nevertheless, there may be a measure that reflects a general aspect of care that is not specialty-specific that may be applicable and can be reported for purposes of avoiding the penalty.

Step Two: Learn the Details for Each Measure

After you have selected which measure to report, it is important to review the specifications for the measure with your billing staff. This will help ensure that eligible Medicare patients are appropriately identified and quality measures are accurately reported on claims. Measure specifications are developed by the Centers for Medicare and Medicaid Services (CMS), and can be accessed online at www.cms.hhs.gov/PQRS.

Although the details vary across measures, each measure specification developed by CMS shares a common format and provides important information about:

  • which Medicare patients are eligible for reporting the measure based on patient demographics (age and gender), diagnosis (ICD 9 codes), and primary service(s) provided (CPT codes);
  • the various “quality codes” that are used for reporting on Medicare claims;
  • and, the clinical rationale and information about the measure.

It is important to review this information carefully since compliance with these specifications is required for measures you report to be counted. For example, you will not get credit for reporting if the Medicare patient is outside of the age range indicated or whose diagnosis code is not listed on the measure specification.

Step Three: Start Reporting on Your Medicare Claims

Once you understand which Medicare patients are eligible and the “quality codes” and modifiers that may be used to report the measure, you are ready to start reporting. The final step is to establish a process in your office to ensure that you consistently identify eligible patients, correctly document the correlating clinical information in the patient’s chart, and accurately report the information on your Medicare claims. To ensure you successfully report for at least one patient, we recommend that you overshoot the target and report the quality measure you select for at least several patients.

With claims-based reporting, a quality code is billed like any other procedure or E/M code (on Line 24 of the CMS 1500 form or electronic equivalent). However, quality codes are billed at a $0.00 charge (or $0.01 if your billing system will not accept zero), and are denied by Medicare with remark code N365 indicating the code is not payable but is counted for tracking purposes. Quality codes are only counted when submitted in combination with an eligible diagnosis and service. Quality codes submitted by themselves or along with services that have already been paid will not be counted (i.e., no retroactive claims-based reporting).

As with any other “billed” Medicare service, quality measures should be supported by documentation in the medical record, which will provide some protection in the event of an audit. Documentation should indicate in clinical terms the basis for the quality code that is reported; it is not sufficient to simply write the code in the medical record.

Earning PQRS Incentives

Physicians and other eligible providers may earn an incentive equal to 0.5% of allowed charges for 2013 and for 2014. To qualify, physicians must report at a higher frequency on at least three different individual measures (instead of just the one measure required to avoid the penalty) or one measures group (consisting of three or more related individual measures). Individual measures must be reported for at least 50% of eligible Medicare patient encounters, and all individual measures within a measures group must be reported for at least 20 unique Medicare patients.

For claims-based reporting, the process for earning the incentive is similar to the process outlined above for avoiding the penalty: Select measures, learn the reporting requirements, and start reporting on Medicare claims. To qualify for the incentive bonus, you should identify the three most frequently occurring measures (or the most applicable measures group), and you should report the measures as frequently as you can for eligible Medicare patients. Because the threshold to receive the incentive is so high, it is advisable for physician practices to implement processes that enable 100% reporting, which will maximize your chances of receiving the incentive bonus. This might include training your front-office staff or medical assistants to screen patients for reporting eligibility prior to each visit based on demographic and diagnosis information, and placing some sort of flag in the patient’s record to indicate eligibility. Some practices may even find it helpful to use tracking forms that can be placed in the eligible patient’s chart prior to the visit, completed by the physician and clinical staff during the encounter, and then used by billing staff to complete the reporting process. (AMA has developed tracking forms for many measures). Also, physicians should be advised that the reporting period in January 1 to December 31, and it may be challenging or even impossible to meet the 50% reporting threshold for the 2013 incentive.

Regardless of whether you report individual measures or measure-groups, it is important to choose measures that occur frequently in your practice. By choosing relatively common measures or measure-groups, you will improve the likelihood of meeting the reporting thresholds. CMS encourages physicians to also consider your own quality improvement goals when selecting measures. While a physician’s goals for their patients should always be the primary driver behind any quality improvement initiative, they are unfortunately not even considered by CMS when determining penalties or incentives. Rather, avoiding the penalty in 2015 and obtaining incentives in 2013 and 2014 is entirely contingent on selecting measures that occur with enough frequency to ensure accurate reporting at or above PQRS minimum thresholds.

More Info About PQRS Reporting

EHR and Registry Reporting: In addition to claims-based reporting, physicians and other eligible providers can report PQRS measures through EHR systems (either directly or through a data-submission vendor) or through approved registries. Practices utilizing EHR systems should consult your vendors about implementing PQRS reporting in your practice, either for purposes of avoiding the penalty or earning the incentive bonus.

One advantage of utilizing registry reporting is the ability to “retroactively” report quality measures for patient encounters for which the Medicare claim has already been submitted. Registry reporting provides a mechanism for physicians to report quality measures separate from the claims process. However, registry reporting may be an additional process or system in your medical practice, and you may prefer to utilize claims-based reporting.

Group Practice Reporting Option: The PQRS Group Practice Reporting Option (GPRO) is open to medical groups of any size, and provides different options depending on the size of the medical group. For example, in 2013, group practices ranging in size from 25 to 99 eligible professionals will report 29 quality measures for 218 consecutive Medicare patients, or 411 consecutive patients for group practices with 100 or more professionals. Practices wishing to use GPRO must submit a self-nomination letter indicating interest in participation. The next opportunity for GPRO participation will be for the 2014 reporting period.

Validation Process if Less Than Three Measures Can Be Reported: If fewer than three quality measures can be reported, physicians may still earn the incentive. CMS uses a “measure-applicability validation process” to verify whether a physician could have reported on additional measures before determining whether reporting requirements for the bonus have been met. CMS analyzes claims to determine if other measures could have been reported (based on ICD-9 and CPT codes). If CMS finds that 30 or more patients / encounters during the reporting period were eligible for reporting another measure, then the physician practice will not have met the reporting requirements.

Financial Incentive Paid to TIN: PQRS tracks compliance with the reporting requirements at the individual provider level (using the NPI number), but the PQRS payment will be made to the Taxpayer Identification Number (TIN) used by the reporting physician. Participating physicians within the same practice (using a common TIN) should expect to receive the physicians’ incentives in a lump sum. Likewise, physicians who see patients on behalf of more than one practice (and, therefore, use more than one TIN when submitting Medicare claims) should expect their PQRS payment to be made to the respective TIN under which the services were reported.

Additional PQRS Resources

For more information about PQRS, CMA has published a guide that is available online at www.cmanet.org.

For official PQRS information, please visit the CMS website at www.cms.gov/pqrs.

PQRS Individual Measures That Can Be Reported Through Medicare Claims in 2013

The following is an alphabetical list of PQRS individual measures that can be reported through Medicare claims in 2013. For purposes of avoiding the 1.5% Medicare penalty in 2015, physicians are encouraged to review the list of measures and identify at least one that is applicable to your Medicare practice.

  • Acute Otitis Externa (AOE): Pain Assessment (92)
  • Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy — Avoidance of Inappropriate Use (93)
  • Acute Otitis Externa (AOE): Topical Therapy (91)
  • Adult Kidney Disease: Blood Pressure Management (122)
  • Adult Kidney Disease: Laboratory Testing (Lipid Profile) (121)
  • Adult Kidney Disease: Patients on Erythropoiesis-stimulating Agent (ESA) — Hemoglobin Level > 12.0 g/dL (123)
  • Advance Care Plan (47)
  • Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement (140)
  • Age-Related Macular Degeneration (AMD): Dilated Macular Examination (14)
  • Antibiotic Treatment for Adults With Acute Bronchitis: Avoidance of Inappropriate Use (116)
  • Anticoagulation for Acute Pulmonary Embolus Patients (252)
  • Appropriate Testing for Children With Pharyngitis (66)
  • Aspirin at Arrival for Acute Myocardial Infarction (AMI) (28)
  • Asthma: Assessment of Asthma Control (64)
  • Asthma: Pharmacologic Therapy for Persistent Asthma (53)
  • Asthma: Tobacco Use Intervention — Ambulatory Care Setting (232)
  • Asthma: Tobacco Use Screening — Ambulatory Care Setting (231)
  • Atrial Fibrilation and Atrial Flutter: Chronic Anticoagulation Therapy (326)
  • Barrett's Esophagus (249)
  • Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade (99)
  • Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor / Progesterone Receptor (ER/PR) Positive Breast Cancer (71)
  • Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy (52)
  • Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation (51)
  • Chronic Wound Care: Use of Wet to Dry Dressings in Patients With Chronic Skin Ulcers (246)
  • Chronic Wound Care: Use of Wound Surface Culture Technique in Patients With Chronic Skin Ulcers (245)
  • Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (72)
  • Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade (100)
  • Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery (44)
  • Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients With Isolated CABG Surgery (43)
  • Coronary Artery Disease (CAD): Antiplatelet Therapy (6)
  • Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy — Neurological Evaluation (126)
  • Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention — Evaluation of Footwear (127)
  • Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient (117)
  • Diabetes Mellitus: Foot Exam (163)
  • Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus (1)
  • Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus (3)
  • Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus (2)
  • Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients (119)
  • Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care (19)
  • Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (18)
  • Documentation of Current Medications in the Medical Record (130)
  • Elder Maltreatment Screen and Follow-up Plan (181)
  • Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-traumatic Chest Pain (54)
  • Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope (55)
  • Emergency Medicine: Community-acquired Pneumonia (CAP): Empiric Antibiotic (59)
  • Emergency Medicine: Community-acquired Pneumonia (CAP): Vital Signs (56)
  • Endoscopy & Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients (320)
  • Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps — Avoidance of Inappropriate Use (185)
  • Epilepsy: Counseling for Women of Childbearing Potential With Epilepsy (268)
  • Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome (267)
  • Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies) (266)
  • Falls: Plan of Care (155)
  • Falls: Risk Assessment (154)
  • Functional Outcome Assessment (182)
  • Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry (70)
  • Hematology: Multiple Myeloma: Treatment With Bisphosphonates (69)
  • Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow (67)
  • Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy (68)
  • Hemodialysis Vascular Access Decision-making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula (172)
  • Hepatitis C: Antiviral Treatment Prescribed (86)
  • Hepatitis C: Counseling Regarding Risk of Alcohol Consumption (89)
  • Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy (90)
  • Hepatitis C: HCV Genotype Testing Prior to Treatment (85)
  • Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment (87)
  • Hepatitis C: Hepatitis A Vaccination in Patients With HCV (183)
  • Hepatitis C: Hepatitis B Vaccination in Patients With HCV (184)
  • Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment (84)
  • Hypertension: Controlling High Blood Pressure (236)
  • Image Confirmation of Successful Excision of Image-localized Breast Lesion (262)
  • Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients (251)
  • Ischemic Vascular Disease (IVD): Blood Pressure Management Control (201)
  • Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein (LDL-C) Control (241)
  • Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (204)
  • Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients With MDD (9)
  • Major Depressive Disorder (MDD): Diagnostic Evaluation (106)
  • Major Depressive Disorder (MDD): Suicide Risk Assessment (107)
  • Medication Reconciliation: Reconciliation After Discharge From an Inpatient Facility (46)
  • Nuclear Medicine: Correlation With Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy (147)
  • Oncology: Cancer Stage Documented (194)
  • Oncology: Radiation Dose Limits to Normal Tissues (156)
  • Osteoarthritis (OA): Assessment for Use of Anti-inflammatory or Analgesic Over-the-counter (OTC) Medications (142)
  • Osteoarthritis (OA): Function and Pain Assessment (109)
  • Osteoporosis: Communication With the Physician Managing Ongoing Care Post-fracture of Hip, Spine, or Distal Radius for Men and Women Aged 50 Years and Older (24)
  • Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older (40)
  • Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older (41)
  • Pain Assessment and Follow-up (131)
  • Participation by a Hospital, Physician, or Other Clinician in a Systematic Clinical Database Registry That Includes Consensus Endorsements (321)
  • Pediatric Kidney Disease: Adequacy of Volume Management (327)
  • Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Levels (328)
  • Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures) (45)
  • Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-cardiac Procedures) (22)
  • Perioperative Care: Selection of Prophylactic Antibiotic — First OR Second Generation Cephalosporin (21)
  • Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics (30)
  • Perioperative Care: Timing of Antibiotic Prophylaxis — Ordering Physician (20)
  • Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) (23)
  • Perioperative Temperature Management (193)
  • Preoperative Diagnosis of Breast Cancer (263)
  • Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol (76)
  • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up (128)
  • Preventive Care and Screening: Colorectal Cancer Screening (113)
  • Preventive Care and Screening: Influenza Immunization (110)
  • Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older (111)
  • Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan (134)
  • Preventive Care and Screening: Screening for High Blood Pressure (317)
  • Preventive Care and Screening: Screening Mammography (112)
  • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (226)
  • Preventive Care and Screening: Unhealthy Alcohol Use — Screening (173)
  • Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (12)
  • Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care (141)
  • Prostate Cancer: Adjuvant Hormonal Therapy for High-risk Prostate Cancer Patients (104)
  • Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-risk Prostate Cancer Patients (102)
  • Radical Prostatectomy Pathology Reporting (250)
  • Radiology: Exposure Time Reported for Procedures Using Fluoroscopy (145)
  • Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Mammography Screening (146)
  • Radiology: Reminder System for Mammograms (225)
  • Radiology: Stenosis Measurement in Carotid Imaging Reports (195)
  • Referral for Otologic Evaluation for Patients With Acute or Chronic Dizziness (261)
  • Referral for Otologic Evaluation for Patients With Congenital or Traumatic Deformity of the Ear (188)
  • Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure (255)
  • Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis (179)
  • Rheumatoid Arthritis (RA): Disease Modifying Anti-rheumatic Drug (DMARD) Therapy (108)
  • Rheumatoid Arthritis (RA): Functional Status Assessment (178)
  • Rheumatoid Arthritis (RA): Glucocorticoid Management (180)
  • Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity (177)
  • Rheumatoid Arthritis (RA): Tuberculosis Screening (176)
  • Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older (39)
  • Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage (31)
  • Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy (32)
  • Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered (36)
  • Stroke and Stroke Rehabilitation: Screening for Dysphagia (35)
  • Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence (247)
  • Substance Use Disorders: Screening for Depression Among Patients With Substance Abuse or Dependence (248)
  • Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection (157)
  • Treatment for Children With Upper Respiratory Infection (URI): Avoidance of Inappropriate Use (65)
  • Ultrasound Determination of Pregnancy Location for Pregnant Patients With Abdominal Pain (254)
  • Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older (48)
  • Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older (49)
  • Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older (50)


Comments are closed.