The advent of the voluntary Physician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative, (PQRI), is intended by the Center for Medicare and Medicaid Services (CMS) to improve the quality of healthcare reporting. For reporting purposes, patient groups are categorized according to condition or illness, age or type of care or medical treatment provided. Individual measures, which generally include all Medicare Part B fee for service (FFS) patients who meet inclusion criteria, fall within these groups for PQRS reporting.

The PQRS program offers two methods of reporting health care data to the CMS: Registry and Claims-based reporting. Not all health professionals are eligible to use the PQRS program, however, so it is important to first know whether a practice qualifies.

What are the eligibility requirements for participation?

According to the CMS website, professional services covered under the PQRS program are paid under or based upon Medicare’s physician Fee Schedule (PFS). Those services are also eligible for PQRS incentive payments and adjustments.

Some of the PSRS-eligible professionals include:

• Doctor of Medicine
• Doctor of Chiropractic
• Physician Assistant
• Clinical Social Worker
• Clinical Psychologist
• Doctor of Optometry

To see additional professionals included in the CMS list of eligible practices, visit their website’s Quality Initiatives Patient Assessment Instruments PDF.

What are the differences between the two methods?

• Registry – Eligible professionals can earn PQRS incentives by reporting electronically-submitted data with quality measures to qualified registries, which must pass stringent criteria. Eligible professionals must report on at least 80% of instances that qualify or, if the reporting includes measure groups, report on a sample of 30 patients. The registry stores the data and then submits the measure/ measures individual or group data to CMS for the providers or professionals. At the end of each reporting period, the registries give the performance rates and other reported data to CMS.
• Claims-based – The measures used are linked with the CPT codes on reported claims. Submission of clinical data is the responsibility of the practice, although a billing company can often help with this for an additional fee. Eligible professionals intending to qualify for the incentive need only report 50% of the qualifying instances, with three measures, compared to the 80% necessary when reporting to registries.

Which reporting method should a practice use?

• With claims-based reporting, the practice controls the data from start to finish, the process of self-audit is tailored to specific clinical needs, fewer (usually 50%) eligible patients need to be reported, and the cost is usually less than registry-reporting.

If the practice is small or has few Medicare or Medicaid-eligible patients, then claims-based reporting is probably a better way to go, provided that there are personnel in the practice who understand the often-tiresome process of audits, the PQRS forms, procedures and reporting requirements. If there are many Medicare or Medicaid patients, this could create a significant workload for billing and accounting personnel.

• Registry reporting may be the preferred method for those practices that have a high volume of Medicare patients or are part of a large practice. The advantages include having the measures automatically updated annually as well as no need for internal audits. Billing and accounting staff do not need to create or submit forms, resulting higher productivity. On the other hand, there is enforced data collection for all eligible patients as well as somewhat higher upfront costs. Using the services of health care billing professionals such as M-Scribe can reduce the time and financial impact of claims coding, documentation and PQRS reporting for professionals and practices of all kinds.

Image courtesy of www.texmed.org