A. The PQRS program does continue in 2015. However, 2014 was the final year for a bonus; there is no bonus for participation in 2015.
Q. Will providers be penalized for non-participation?
A. Yes. Providers who did not successfully participate in 2013 received letters from the Centers for Medicare & Medicaid Services in late 2014 indicating a 1.5-percent reduction to their Medicare reimbursement for 2015. Penalties in 2016 and 2017 will depend on the provider’s level of participation and successful reporting in 2014 and 2015 respectively.
Q. Are the requirements for successful participation in 2015 different than in prior years?
A. Successful participation has always relied on providers performing services described as “quality measures” and submitting codes to support their performance of these measures. One change for 2015 is the need to report one measure categorized as a cross-cutting measure. Several measures meet this criterion, including ones that many have previously reported. They include:
• Documentation of Current Medications in the Medical Record (#130); and
• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (#226.)
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• Patient Safety;
• Person and Caregiver-Centered Experience and Outcomes;
• Communication and Care Coordination;
• Effective Clinical Care;
• Community/Population Health; and
• Efficiency and Cost Reduction.
To successfully report in 2015, providers must report at least nine measures covering at least three National Quality Strategy domains and include one cross-cutting measure. The instructions indicate that if fewer than nine measures covering at least three NQS domains apply, you may report one to eight measures covering one to three NQS domains.
Q. If a provider reports fewer than nine measures or is unsuccessful utilizing another reporting method, will there be a reduction to the providers Medicare reimbursement in 2017?
A. Physicians who submit fewer than nine measures or three NQS domains are subject to the review process called “Measure Applicability Validation.” This process, introduced in 2014, will be applied for the first time to those providers who reported fewer than nine measures in 2014. This process allows CMS to determine whether the provider should have reported additional measures and/or measures covering additional NQS domains. If the MAV review done by CMS determines the provider accurately submitted and that no additional measures and/or NQS domains applied, the penalty is averted.
In order to avoid a 2-percent PQRS reduction in 2017, eligible professionals must be successful in some manner with PQRS.
Q. Are there any changes to how eligible professionals report PQRS measures to CMS?
A. No. Measures may be reported by individual providers or as a group practice. Some, not all, measures may be submitted on claims filed to Medicare. Some measures are eligible to be reported via electronic health records. Providers may choose to utilize a “registry” to report on their behalf. Reporting through a Qualified Clinical Data Registry continues to be an option. A QCDR is a CMS-approved entity that has self-nominated and successfully completed a qualification process. The American Academy of Ophthalmology’s IRIS registry is a QCDR.
Those who want to report as a group practice must request this option from CMS and be approved to report in this manner. Reporting through an EHR also requires that the EHR vendor has been approved by CMS to report via this method.
Q. Are providers required to report on every Medicare patient meeting the quality measure description?
A. No. Each measure must be reported for at least 50 percent of the applicable Medicare Part B fee-for-service patients seen during the reporting period for eligible professionals submitting PQRS measures on their claims. For those utilizing a registry, the reporting threshold for the registry is also 50 percent.
Q. What quality measures apply to eye-care providers?
A. The 2015 measures for eye disease carried over from the 2014 program are:
• Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation (#12);
• Age-related Macular Degeneration (AMD): Dilated Macular Examination (#14);
• Diabetic Retinopathy:
• Communication With the Physician Managing Ongoing Diabetes Care (#19);
Diabetes: Eye Exam (#117);
• Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement (#140); and
• Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care (#141).
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Most eye-care practices will need to report measures that are not ophthalmology-specific. See Table 1 for a list of possible options. This list is not exhaustive, but will give you a starting point.
Q. Were any new ophthalmic measures added in 2015?
A. Yes; these new measures must be reported through a registry:
• Adult Primary Rhegmatogenous Retinal Detachment Repair Success Rate (#384);
• Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate (#385);
• Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy);
• Cataract Surgery: Difference Between Planned and Final Refraction.
Q. Does the Cataract Measures Group still exist?
A.Yes, but the Cataracts Measures Group may only be reported through a registry. In 2015, the Measures Group consists of the measures listed in Table 2.
When reporting the measures group, all applicable measures must be completed for each patient being reported. Successful reporting of the measures group requires reporting for 20 or more patients with at least 11 being traditional Medicare Part B patients.
Q. Does the PQRS link to any other CMS initiatives?
A. Yes, it does. The Value Based Payment Modifier links directly to the PQRS program and rewards or penalizes providers for the quality and cost of care provided. In 2015, all providers are subject to the VBPM. Performance in 2015 will affect reimbursements in 2017, making success with PQRS in 2015 critical. Failure with PQRS in 2015 results in a 2 percent PQRS penalty plus a 2 to 4 percent VBPM penalty, depending on the size of the practice in 2017. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.
