What is the Physician Quality Reporting System?

Formerly known as the Physician Quality Reporting Initiative (PQRI), the Physician Quality Reporting System (PQRS) was a voluntary reporting program that provided a financial incentive for certain health care professionals, including psychologists, who participated in Medicare to submit data on specified quality measures to the Centers for Medicare and Medicaid Services (CMS). In 2015, the reporting program shifted from a voluntary program to a mandatory one in which penalties were assessed for failure to participate. PQRS ended as a stand-alone program on Dec. 31. 2016; the PQRS quality measures became part of the Merit-based Incentive Payment System (MIPS) in 2017.

Physician Quality Reporting System: Questions and answers for psychologists

Is this a pay-for-performance program?

No. Pay for performance involves realigning incentives in the delivery of health care services to reward quality improvement. The Physician Quality Reporting System will allow health care professionals to earn bonus payments through 2014 just for reporting on the program's measures, regardless of the treatment outcomes.

The program has "physician" in the title, so how can psychologists participate?

Under the terms of the legislation that created the reporting program, a number of different health care professionals, including psychologists, are eligible for the Physician Quality Reporting System.

What do I stand to gain from participating?

Health care professionals who successfully report on 50 percent of the applicable cases for any given measure will be eligible for a bonus payment equal to 0.5 percent of their total allowed Medicare charges for the 2013 reporting period. That's 0.5 percent extra for all of the claims Medicare pays you for, not just the ones you report on. The bonus payment will be 0.5 percent again in 2014. You will also receive confidential feedback reports from CMS.

So I will receive an extra 0.5 percent whenever I'm paid for a Medicare claim?

It doesn't happen that fast. All claims have to be filed before CMS calculates the bonus payments. The deadline for submitting prior year claims two months from the end of the calendar year, so bonus payments are issued in the middle of the next year.

How much work will it take to report the measures?

Reporting for the Physician Quality Reporting System is not intended to be complicated or time consuming. You will add a few codes to the electronic or paper claim form that you currently submit to Medicare. More detailed information is available on the CMS website. Information is also available from your local Medicare carrier.

Do the measures reflect the services I provide to Medicare beneficiaries?

During the initial reporting period that started on July 1, 2007, psychologists had limited opportunity to participate in the former PQRI program, as there was only one measure for mental health. The 2007 measure focused on patients suffering from major depressive disorder that had been prescribed, or at least evaluated for, the use of antidepressant medication.

Several new measures have since been developed. For 2014, psychologists have 11 measures available for claims-based reporting in PQRS, and two available for registry reporting:

Major depressive disorder: diagnostic evaluation (#106)
Major depressive disorder: suicide risk assessment (#107)
Preventive care and screening: Body mass index screening and follow-up (#128)
Documentation and verification of current medications in the medical record (#130)
Pain assessment prior to initiation of patient therapy and follow-up (#131)
Screening for clinical depression and follow-up plan (#134)
Elder maltreatment screen and follow-up plan (new measure effective in 2009)
Preventive care and screening: Tobacco use assessment and tobacco cessation intervention (#226)
Substance use disorders – counseling (#247)
Substance use disorders – Screening for depression (#248)
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions (#325)

Measures available only through registry reporting

Major depressive disorder: antidepressant medication during acute phase for patients with MDD (#9)
Preventive care and screening: Unhealthy alcohol use—screening (#173)

In addition, a new measures group for dementia has been created that can only be reported through a registry (PDF, 44KB) due to the way in which the measures must be analyzed.

Measure #9 involves reporting on patients who are suffering from Major Depressive Disorder and have been prescribed, or at least evaluated for the use of antidepressant medication. How can psychologists who lack the authority to prescribe report on a measure that involves medication?

This measure is not limited to only the health care professional who prescribed the antidepressant medication. If you are reporting through a registry and providing psychotherapy to a patient who suffers from depression and is taking antidepressant medication prescribed by a physician, you can report the measure.

What requirements do I have to meet to participate?

You must be enrolled as a Medicare provider under the clinical psychologist designation and have a national provider identifier (NPI) number. As of Jan. 1, 2011, you must also be enrolled in the Medicare PECOS system.

Do I have to apply for the PQRS in order to participate in PQRS?

No, you can simply begin reporting on services provided on or after Jan. 1 of the current year.

What is registry reporting?

Eligible professionals (either as individuals or as a group practice) may satisfy the requirements for PQRS by reporting quality measures data to a participating registry. A number of different vendors have created registries that collect and transmit the data to CMS. PQRS registries must meet criteria set by CMS such as having secure methods for data transmission and providing feedback to registry participants. More information about registry reporting (PDF, 51KB) is available on the CMS website.

Do I have to start immediately in January of each year?

No, but you should not take too long to decide. Because you must report on 50 percent of the applicable cases during the 12-month reporting period, failure to start early could prevent you from reaching this threshold and make you ineligible for the bonus payment. CMS has eliminated the 6-month reporting period for individual measures reported through claims or a registry. For 2013, individual claims should be submitted for a 12-month reporting period.

What happens if I can't find nine measures across three domains on which to report?

Those for whom fewer than nine measures across three domains apply could still qualify for the bonus. If a psychologist reports on one to eight measures, or nine measures across fewer than three domains, their claims will automatically be reviewed by CMS under the Measure Validation Process (MAV) so that CMS can determine if additional measures should have been reported. Eligible professionals who fail MAV will not earn the PQRS incentive payment for 2014 and may be subject to the 2016 payment adjustment.

Where can I learn more about PQRS reporting?

The CMS website contains detailed specification worksheets for each measure. Worksheets for the measures with numbers listed above can be found on the CMS website under the link for Measures/Codes. The 2013 Physician Quality Reporting System Measure Specification Manual is also available on the CMS website.

What if I have further questions after reviewing the material posted online?

The best place to start is with your local Medicare contractor. Questions can also be directed to government relations staff for the APA Practice Organization by phone at (202) 336-5889 or by email.

Who oversees the PQRS reporting program? Is it the same Medicare Administrative Contractor who handles the Medicare claims in my area?

PQRS is not run by the Medicare Administrative Contractors. The CMS Office of Clinical Standards and Quality administers several quality improvement programs for the agency, including PQRS.

The measures all seem to be based on patients suffering from major depressive disorder (MDD), but my practice focuses on helping patients with anxiety disorders. Does this mean I can’t participate in PQRS?

While it is true that several of the measures involve patients with MDD, other measures can be used with any diagnosis. For example, measures #130, documentation of current medications in the medical record, and #181, elder maltreatment screen and follow-up plan (for patients 65 and older), do not require specific diagnoses.

What constitutes a “group” for PQRS reporting? Could several psychologists with solo practices sign up as a group just for the purpose of reporting PQRS measures?

A group is defined as two or more providers who share a common tax identification number (TIN) and have reassigned their billing rights to that TIN. Psychologists cannot report under PQRS as a group without meeting these requirements.

If I am part of a group practice, do I still have the option of reporting individually?

If the practice has signed up to report under the group reporting option, you cannot choose to separately report PQRS measures as an individual because your National Provider Identification (NPI) number is linked to the TIN used by the group.

I received a letter from the Centers for Medicare and Medicaid Services (CMS) saying I will be penalized this year (2015) because I did not meet the PQRS requirements in 2013. Is there anything I can do about that now?

If you made no attempt to report any PQRS measures in 2013, there is nothing you can do now about the 1.5 percent penalty that CMS will attach to your payments in 2015. If, however, you did report on at least one measure in 2013 but are now being told that your participation was unsuccessful you have a limited opportunity to request a review. During the period from Jan. 1, 2015, through Feb. 28, 2015, you may request an informal review online.

The letter from CMS also talked about a reduction under something called the Value-Based Payment Modifier (VM). Will this affect my 2015 payments as well?

No, psychologists’ payments are not subject to the VM at this time. The VM is currently being applied only to payments for physicians. Nonphysicians, solo practitioners and small group practices will not be impacted by the VM until 2018. The APA Practice Organization will educate psychologists about the VM as CMS releases more information about how it will be applied to non-physicians.

History of PQRS

Date created: 2016