The Centers for Medicare and Medicaid Services (CMS) established the Physician Quality Reporting System (PQRS) to provide financial incentives and adjustments aimed at encouraging accurate reporting of quality medical and reimbursement information by eligible healthcare professionals. Although like a lot of CMS initiatives, the PQRS system may seem daunting, following a few relatively simple steps will help ensure you use the system correctly.
1. First, you must determine if you qualify as an eligible healthcare professional. The CMS website offers a list of eligible professionals to help you determine if you qualify. Professionals who receive CMS reimbursement under fee schedules other than the Physician Fee Schedule (PFS) may not be eligible.
2. Next, consider which reporting method is the best one for your practice. Currently, eligible professionals may choose one of the following PQRS data submission methods: claims-based, registry-based, electronic health records (EHRs), or group practice. Each method involves specific reporting criteria; for instance, the EHR option requires professionals to use vendors to submit their data. Review each method carefully to ensure the option you choose is the best and appropriate one for your practice.
3. Now you’ll need to choose between individual measures and group measures. Again, you’ll need to carefully review the criteria required for either option to ensure accurate reporting. If you decide to use individual measures, be prepared to submit three or more clinically applicable measures when you attempt to qualify for your PQRS incentive. Fewer than three and CMS will use a “measure-applicability validation” (MAV) process to determine your eligibility.
4. Depending on which measures group you select, you will have to choose three or more specific measures for the individual option or one measure for the group option in order to report to CMS successfully. It’s important to note that all of the PQRS specifications and requirements are updated each year and those updates are posted before the program year begins. That means you’ll need to review those specifications for any revisions that have occurred during the prior year. Additionally, note that every measure has its own requirement for reporting frequency or timeframe for each patient seen during the reporting period. Team members should be instructed to carefully record reporting data regarding these criteria to ensure accurate reporting. In general, a claim is considered to be PQRS eligible only when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes that are on the claim match the diagnosis and encounter codes that are listed in the measure specification denominator criteria. Also note that some measures also allow the use of the 1P, 2P, 3P and 8P modifiers to be applied with the CPT II code. Only allowable CPT II modifiers may be used and eligible professionals should be careful not to overuse the 8P modifier in their reports.
5. Finally, review PQRS payment adjustment information carefully. Each measure uses a quality data code, or QDC, which is required in order to receive the incentive. In order to avoid a PRS adjustment in the future, you’ll need to do one of the following: ensure that the QDC numerator is reported at least once during any 12-month reporting period; report 80 percent or more of all eligible events if reports are made via registry; report 50 percent of eligible events if reporting selected measures by claims.
Used accurately, the PQRS system can help practices remain compliant and receive regular incentives; but, like many coding initiatives, adhering to the precise and often complex requirements of the system is a time- and labor-intensive process, and it can be difficult for many practices to dedicate the necessary resources.
Drawing from years of success in the coding and compliance arena, M-Scribe professionals are ready to help your practice participate in the CMS incentive program and remain compliant in every phase of coding and billing.
To learn more about the solutions we provide, call M-Scribe Billing Services at 888-727-4234.