2015 Program Year Update: PQRS and Physician Value-based Modifier (VM)
The Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) is a reporting program that currently uses both incentive payments (bonus) and payment adjustments (penalty) to encourage physicians to submit quality information to CMS. The incentives and adjustments are based on payments for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service beneficiaries.
Calendar year 2014 was the last year for a PQRS incentive. In 2015 and beyond, there is potential to obtain an incentive under the Physician Value Based Payment Modifier (VM) program.
CMS issued the 2015 Physician Fee Schedule Final Rule on November 13, 2014. The rule changes several of the quality reporting initiatives associated with PFS payments, including the Physician Quality Reporting System (PQRS). See Summary of CY 2015 finalized changes for CMS quality programs.
Requirements to avoid the 2017 payment adjustment (-2.0%), based on 2015 reporting, are the same as for gaining the 2014 incentive with several additional requirements as identified below.
Individual EP reporting requirements - 9 measures across 3 National Quality Strategy domains, for 50% of Medicare Part B FFS patients relevant to reported measures (or for 50% of ALL patients when using a Qualified Clinical Data Registry (QCDR), or, using a qualified registry, report 1 measures group for at least 20 patients (majority should be Medicare Part B FFS patients) with the following additional requirements:
GPRO reporting requirements - 9 measures across 3 National Quality Strategy domains, for 50% of Medicare Part B FFS patients relevant to reported measures with the following additional requirements :
There are no new individual measures or measures groups relevant to radiology. All current measures remain available for 2015 PQRS, with the exception of measure #20, Perioperative care-timing of antibiotic. Be sure to review the new 2015 specifications for any changes to the measures.
For more information on the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule view presentation slides developed by CMS on December 2, 2014 here.
The value-based payment modifier applies to all physicians. The value modifier uses PQRS quality data and Medicare cost data to determine a provider's overall value score. It rewards high-performing providers with increased payments and reduces payments to low-performing providers. This will affect approximately 900,000 physicians. Payment adjustments may be applied if eligible providers (EPs) do not successfully report PQRS or through quality-tiering for those who do report PQRS . However for the 2015 reporting year/2017 payment adjustment year, solo providers and groups with 2-9 providers will not receive a VM penalty under quality-tiering, but may have a VM penalty if not reporting PQRS. Groups with 10 or more providers may receive an upward, neutral or downward adjustment under quality-tiering. See chart below for payment adjustment application.
2017 Value Modifier Penalty for 2015 PQRS Non-Reporters
Mandatory Quality-Tiering and Possible 2017 VM Payment Adjustment for Successful 2015 PQRS Reporters