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Frequently Asked Questions

Answer: Any Eligible Professional (EP) who had at least 1 eligible Medicare Part B FFS patient encounter during 2016 qualifies for PQRS reporting. See Q.16. for information on penalties for failure to report.
Answer: Eligible Professionals must report for each NPI/TIN combination they used to bill Medicare during the 2016 calendar year in order to avoid the 2018 PQRS payment.
Answer: Eligible Professionals who are assigned to a Shared Savings Program ACO Participant TIN for reporting year 2016 will avoid the 2018 PQRS payment adjustment (-2%), as long as the ACO Primary TIN reports on all measures included in the GPRO Web Interface for the 12-month period of 1/1/16-12/31/16.
Answer: No, at this time the state Medicaid EHR Incentive Program does not send CQM data to CMS for the purpose of PQRS reporting.
Answer: No, 2016 Certified EHR Technology is not a requirement for participation in PQRS.
Answer: No, PQRS reporting applies to all EPs regardless of their participation in the Medicaid or Medicare EHR Incentive Payment programs.
Answer: The reporting period for 2016 PQRS is January 1, 2016 – December 31, 2016.
Answer: For 2016, EPs reporting a Measures Group must report all applicable measures for 20 eligible patients (11+ Medicare FFS patients) in order to avoid the 2018 PQRS payment adjustment. If an EP does not have enough patients to achieve this with a certain Measures Group, the EP can choose another Measures Group that can be reported for 20 patients (11+ Medicare FFS patients). Otherwise the EP will need to report individual measures using all 2016 Medicare patients.
Answer: The Physician Quality Reporting analysis will ignore line items with POS 50 (Federally Qualified Health Center or FQHC) or 72 (Rural Health Center or RHC). However, if you are an eligible professional who works at these facilities and gets paid based on the Medicare Professional Fee Schedule (MPFS), those services are subjected to the payment adjustment.

Please note, if an EP works at a RHC or FQHC and also works at a non-RHC/FQHC which is under the same TIN, they may be subject to the 2018 PQRS payment adjustment if they do not report quality data under PQRS for the eligible services rendered.

Answer: When reporting PQRS via Registry, no additional Quality Data Codes (QDCs) or “G-codes” need to be included in your claims to Medicare.
Answer: The patient must be a Medicare Part B beneficiary on the date of the service of the eligible encounter in order to be used to meet the 11 patient minimum.
Answer: Yes, any patient who meets the denominator criteria for whom you have billed for qualifying services can be included as one of your patients.
Answer: A patient may be counted only once during the reporting period for a single provider, as the data submitted must be for 20 unique, separate and distinct eligible encounters. If you are in a group and a patient is seen on more than 1 occasion by different providers, each provider may include the patient in his or her respective count.
Answer: Inverse Measures are measures where a lower performance rate is better. Lower performance indicates better quality and/or control. For example, Measure #165, Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate. The fewer patients (lower performance/percentage) who developed a wound infection would indicate better quality.

For inverse measures a 0% performance rate would be considered satisfactorily reporting and 100% performance rate will not be counted as satisfactorily reporting.

Answer: The last day to submit 2016 PQRS data to the Registry will be Friday, March 10, 2017 by 5pm.
Answer: Yes, failure to report PQRS in 2016 will result in both a PQRS payment penalty and the automatic value modifier payment adjustments below.

  • PQRS payment penalty for failure to report: -2.0%
  • Automatic Value Modifier payment adjustments for failure to report:
    • Solo practitioners and groups of 2-9 providers: -2.0%
    • Groups of 10 or more providers: -4.0%

Payment adjustments for reporting year 2016 apply to Medicare reimbursements in 2018.

Answer: CMS’s Value Modifier program assesses the performance of measures reported via PQRS. Both cost and quality data are to be included in calculating payment adjustments. All physicians, including solo practitioners, will be subject to an automatic Value Modifier payment adjustment in 2018 if they fail to report PQRS measures for 2016. In addition, all physicians who do participate in PQRS reporting for 2016 will be subject to the 2018 quality-based Value Modifier (an upward or neutral adjustment for solo practitioners and groups of 2-9; an upward, neutral or downward adjustment for groups of 10 or more) based on their PQRS performance in calendar year 2016.

For question about the contents of the QRUR, please contact the CMS Physician Value Help Desk:

  • Monday – Friday; 8:00 am – 8:00 pm EST
  • (888) 734-6433, Press option 3
  • Fax: (469) 372-8023

For more information on the Value Modifier please visit:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

Answer: The automatic Value Modifier payment adjustments for failure to report in 2016 are:

  • -2.0% for solo practitioners and groups of 2-9
  • -4.0% for groups of 10 or more

Quality-tiering is the analysis used to determine the type of adjustment (upward, downward or neutral) and the range of adjustment based on performance on quality and cost measures. Quality-tiering will determine if a group practice’s performance is statistically better than, the same as, or worse than the national mean.

Quality-based payment adjustments to Medicare Part B billing for those who do report PQRS for 2016 are as follows:

  • Upward or neutral adjustment (solo practitioners and groups of 2-9)
  • Upward, neutral, or downward adjustment (groups of 10 or more)
Answer: Under the Value-Based Payment Modifier Program, Quality and Resource Use Reports (QRURs) provide information about the resources used and the quality of care furnished to a groups or solo practitioners Medicare Fee-for Service beneficiaries.

The 2015 QRURs will be generated for all solo practitioners and groups of practitioners nationwide, as identified by their Taxpayer Identification Number (TIN), that have at least one eligible case for at least one quality or cost measure, regardless of whether the 2016 Value Modifier will apply to them. TINs can use their QRURs to see how they compare with other TINs caring for Medicare beneficiaries. 2015 QRURs will be generated for reporting use in fall of 2016.

2015 Mid-Year QRURs will not reflect a practices Value-Modifier quality tiering details for the 2016 payment adjustments. Practices should review their Annual QRURs for 2015 by logging in to https://portal.cms.gov with their EIDM username and password to review detailed information on their Value-Based Payment Modifier quality-tiering scores and adjusted reimbursement for 2016 (upward, neutral, or downward).

Answer: Setting up an EIDM account to access a groups QRUR:

  • A group is defined as a TIN with 2 or more eligible professionals (EPs), as identified by their National Provider Identifier (NPI), that bill under the TIN.
  • To access a group’s QRUR, one person from the group must first sign up for an EIDM account with the Security Official role.
    • If additional persons are needed to access the group’s QRUR, then they can also request the Security Official role or the Group Representative role in EIDM.
  • If you do not have an IACS or EIDM account, then follow the instructions provided here to sign up for an EIDM account with the correct role
  • If you have an IACS account that you previously used to access QRURs or register for the PQRS GPRO, then follow the instructions provided here to sign up for an EIDM account. You will be allowed to perform the same tasks using your EIDM account that you were able to perform with your IACS account
  • If you already have an EIDM account, then follow the instructions provided here to sign up for the correct role in EIDM

For questions about setting up an EIDM account, please contact the CMS QualityNet Help Desk:

  • Monday – Friday: 8:00 am-8:00 pm EST
  • Phone: 1 (866) 288-8912 (TTY 1-877-715-6222)
  • Fax: (888) 329-7377
  • Email: qnetsupport@hcqis.org
Answer: CMS has transitioned all Individuals Authorized Access to CMS Computer Services (IACS) accounts to the Enterprise Identity Management System (EIDM). Please reference the below guide for setting up an EIDM account for existing IACS users: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Completing-EIDM-Account-setup-for-Migrating-IACS-Users.pdf

Beginning on July 13, 2015, an IACS account can no longer be used to access Quality and Resource Use Reports (QRURs); instead, an EIDM account will be required to access QRURs.

Answer: If you fail to report PQRS data in 2016, you will incur the -2.0% PQRS penalty in 2018. However, if more than 50% of the eligible providers within your group successfully report measures individually, you can avoid the 2018 Value Modifier penalty.

If less than 50% of your group reports, you will be subject to the Value Modifier penalties which range from -2.0% to -4.0% based off of the group size, in addition to the -2.0% PQRS penalty above.

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