What you should know about PQRS changes in 2016


The Physician Quality Reporting System (PQRS), is a voluntary reporting system designed by Medicare. The system is designed to provide incentives for providers to report that they completed certain tasks during patient visits that improve quality.

For example, getting a list of the patient’s current medications is a best practice that should be performed universally and is incentivized by a PQRS measure. There is another PQRS measure to encourage the inspection of footwear of diabetic patients to prevent pressure ulcers. They both make perfect sense.

Intended- and Unintended- Results

There are over 400 individual claims-based PQRS measures, and they all make perfect sense. The PQRS program has a very logical premise that care will be improved by coupling financial incentives with the use of evidence based best practices. In theory, increasing the use of these best practices will result in measurable benefits in the form of lower costs and better general health for the Medicare population.

So it is a logical program with a laudable goal. The problem is in the complexity: too many measures, different measures depending on clinical specialty, and multiple reporting mechanisms each with its own set of unique requirements. All of the PQRS complexity is layered on top of a hairball of other, non-coordinated, non-related, but stunningly complex requirements. For example, Functional Limitation Reporting, the Therapy Cap, medical necessity requirements, special procedure code aggregation rules, CCI Edits, the multiple procedure payment reduction requirements, and the list goes on.[i]

As I have written before: the goals of PQRS, along with the goals of the other byzantine requirements and regulations are laudable.  But the complexity of these layers of requirements forces all healthcare providers, but particularly therapists, to spend an inordinate amount of time and energy trying to understand and comply with the bureaucratic tangle.

But enough kvetching: PQRS is here, and unless you are willing to take a 2% haircut on your Medicare payments two years from now, we need to make complying with it as easy as possible.

Understanding Concepts and Requirements

I think it is easier to comply with these requirements if one understands some concepts:

  • Each Medicare patient visit is potentially eligible for reporting PQRS measures based on a number of factors, including the patient’s age and other procedures performed during the visit. Some measures require additional factors for eligibility, like the patient’s diagnosis, or the results of other related PQRS measures.
  • There are minimum reporting requirements each therapist must meet over the course of the current year to avoid a financial penalty on Medicare payments for services provided 2 years from now. In other words, you must meet the minimum reporting requirements this year to avoid a future penalty.
  • The minimum reporting requirements are complex, but for PT, OT, and Speech specialties all available measures must be reported on at least 50% of the eligible visits over the course of the year to avoid the future penalty. To use Medicare’s terms, the “denominator” for successful participation is based on the number of visits eligible for reporting on a particular measure. The “numerator” indicates the number of the eligible visits where the measure was successfully reported. So, if 10 of your visits for 2016 are eligible for the Medication Measure, you would need to report that you completed it on at least 5 of those visits, or 50%, to avoid the future financial penalty.

Anatomy of PQRS Measures

Each PQRS measure has a brief description followed by the requirements of the “denominator”, or eligible visits and the “numerator”, or what constitutes successful completion of the measure.  If anyone asks you why a certain patient visit is not eligible for a certain measure, you should be able go to the source documentation and answer the question with a little practice.

I would encourage you to actually review the source documentation for each PQRS measure. After reading through a few of them, you will discover that they are all logically written. And, if you have any questions about the requirements for a particular measure in the future, it becomes very easy to refer directly to the measure specifications for your answer.

Good News, Bad News

So, the bad news for 2016 is that we still have PQRS. The good news is, at least for the claims-based reporting supported by Clinicient, there are few changes.

Changes for 2016

As you can tell, the individual requirements for measure eligibility for a particular visit are complex. To avoid brain damage, make sure that you employ a system that informs you about eligible measures for each visit. Save your brain cells for more important things, like thinking about the most appropriate plan of care for your patient, or whether or not Edgar Martinez belongs in the Hall of Fame.[ii]

Physical Therapy

There are no changes from 2015. The claims-based measures are:

  • 128: Body Mass Index (BMI) Screening and Follow Up Plan
  • 130: Documentation of Current Medications
  • 131: Pain Assessment and Follow Up
  • 154: Falls Risk Assessment
  • 155: Falls Plan of Care
  • 182: Functional Outcome Assessment

Occupational Therapy

There are minimal changes for OT. In addition to the six measures for PT there are additional measures for Elder Maltreatment and Tobacco Use:

  • 128: Body Mass Index (BMI) Screening and Follow Up Plan
  • 130: Documentation of Current Medications
  • 131: Pain Assessment and Follow Up
  • 134: Screening and Follow Up for Clinical Depression
  • 154: Falls Risk Assessment
  • 155: Falls Plan of Care
  • 182: Functional Outcome Assessment
  • 226: Tobacco Use Screening and Cessation Intervention

 Speech Language Pathology

There are 3 claims based measures available for Speech in 2016:

  • 130: Documentation of Current Medications
  • 131: Pain Assessment and Follow Up
  • 226: Tobacco Use Screening and Cessation Intervention

The Future

Medicare is working with the best of intent in a huge bureaucratic system to make sure that the government is getting the value it is paying for and that Medicare beneficiaries are getting the care they deserve.

“Goodbye PQRS, Hello MIPS”

There has been some speculation that PQRS will be going away for therapy specialties in the near future, because Medicare is instituting yet another program called the Merit Based Incentive Payment System or MIPS.  (Yet another opportunity to increase your acronym vocabulary.)

From the CMS website:

“The MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program based on:

  • Quality
  • Resource use
  • Clinical practice improvement
  • Meaningful use of certified EHR technology”

Currently, it is not known whether or not our therapy specialties will be subject to MIPS, because there isn’t a way to apply the value-based modifier and there is no Electronic Health Record standard for PT, OT, or Speech.

At the same time, it is hard for me to believe that PQRS will go away for our professions… Medicare is committed to assuring quality and PQRS is their tool of choice.

Even if PQRS doesn’t exist in its present form, it is here now. You need to make an informed decision on whether or not to participate. If you do participate, you need to have a system in place to navigate all of the complexities.

At Clinicient, we are committed to explaining these requirements to you and making compliance with these requirements as easy as possible. Doing so ensures that you can concentrate on the Great Care that you want to provide and that your patients deserve.

Learn more about PQRS and other compliance change for the year ahead at our upcoming webinar, 2016 Medicare Changes: What Every Therapist Needs to Know. The latest Medicare changes can impact your patients and your bottom line, so you won’t want to miss it!

Join special guest and Medicare Compliance expert Nancy Beckley and Physical Therapist and Clinicient Co-Founder Jerry Henderson to learn the latest Medicare updates and answer your Medicare questions, such as:

  • Updates on 2016 Medicare changes
  • How to avoid future PQRS payment reductions
  • Common Medicare mistakes and where practices can go wrong

Webinar Event Details:

  • Monday, January 11th
  • 10am – 11am Pacific
  • 1pm – 2pm Eastern

[i] What do PQRS and Functional Limitation Reporting have in common?  They are both reported by special procedure codes that begin with the letter “G”.

[ii] The answer is “YES”.

{loadposition Adroll_Blogs_Medicare}


Leave a Reply

Your email address will not be published. Required fields are marked *