Note: 2016 was the last year for which providers were required submit PQRS data. Medicare's PQRS and Meaningful Use programs were replaced in 2017 and beyond by the new Quality Payment Program. The information below is maintained as a historical reference only.
These guidelines will help you locate PQRS criteria in MacPractice. MacPractice cannot advise how to fulfill requirements or apply and receive incentive payments/avoid payment cuts. Please visit www.cms.gov for more information. There are several different ways to report PQRS to Medicare and 250+ different reportable PQRS measures for 2016. Before MacPractice support can assist you in any way with PQRS, you need to know what measures you are trying to report and what method you are trying to use to report.
CMS has provided several resources that may assist you in the reporting process, which can all be found here.
- As of 2015, there are no longer any incentives associated with submitting PQRS. If you are reporting PQRS going forward now, it is only to avoid the payment cuts to your Medicare payments.
- No other insurance companies besides Medicare currently plan to cut payments for lack of PQRS reporting. You should consider the amount of business you do with Medicare vs the amount of training, work flow changes, and additional effort that reporting PQRS will mean for your practice. In some cases, the effort of reporting is not worth the percentage of Medicare payments lost. In other cases, Medicare is a significant portion of the practice's income and reporting PQRS is well worth the time.
- In 2015, charges billed to Medicare will see a 1.5% cut if you did not report PQRS in 2013. In 2016, charges billed to Medicare will see a 2% cut if you did not report PQRS in 2014. In 2017, charges billed to Medicare will see a 2% cut if you did not report PQRS in 2015. Finally, in 2018, charges billed to Medicare will see a 2% cut if you do not report PQRS in 2016.
- With the recent introduction of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) for Alternative Payment Models (APMs), the payment cuts from Medicare for not reporting PQRS are planned to change in the 2017 reporting year, effecting the 2019 payment year. For more information on MACRA, see CMS' site here.
PQRS Reporting Methods
Claims Based Reporting-
This method of PQRS reporting can be used if you choose to report as individuals, but not as a group. There are around 150 different measures that can be reported via claims. Claims Based Reporting requires that you report on 50% or more of the eligible cases for each measure you choose to report. Below are some helpful suggestions for implementing Claims Based Reporting.
1. Choose the measures you need/want to track. A quick Google search for "PQRS in 2016 for *your specialty*" should be helpful. Since reporting can vary greatly depending on specialty, this is not something that MacPractice can provide advice on, as we are unaware which measures pertain to the diagnoses you treat, the procedures you do, and the patient population you see. Once you know what measures you need to report, we can provide assistance in setting up the codes and alerts below.
2. Add the reporting codes to your fee schedule. These will include CPT II and/or G codes, depending on which measure you're trying to meet. If you have Codes Manager purchased, you can download and import the needed codes into your fee schedule from the HCPCS codes or the CPT codes with Category Two Codes selected for your Fee Type. If you do not have Codes Manager, you can simply add the needed codes to your fee schedule manually.
3. Set up Clinical Decision Rules. PQRS measures need to be reported when a patient meets certain qualifications. You can set up Clinical Decision Rules to trigger when patients meet the necessary age, diagnosis, gender, procedure code, etc. qualifications for the measures you're trying to track. These aren't necessary, but some offices find them helpful as reminders to add the reporting codes to the Medicare claims. You must add the reporting code to the same claim as the qualifying visit CPT code. CMS does not allow for submission of only the reporting codes, so they must be remembered before a claim is submitted.
EHR Based Reporting-
There are 55 Clinical Quality Measures in MacPractice 5.0+ that are able to be used to track and report PQRS. Not every PQRS measure has a CQM report, since there are over 250 measures overall and not all are accepted via this method. CMS did not create reports for software vendors to add to their softwares, which means that if there is not a report for it, it cannot be submitted via this method. For more documentation on each Clinical Quality Measure, see here.
1. Choose the measures that you need/want to track. A quick Google search for "PQRS in 2016 *specialty*" should be helpful. Since reporting can vary greatly depending on specialty, this is not something that MacPractice can provide advice on, as we are unaware which measures pertain to the diagnoses you treat, the procedures you do, and the patient population you see. Once you know what measures you need to report, we can provide assistance in understanding how the reports work in MacPractice.
2. Run the corresponding CQM report for the measure(s) you want to report and make sure you're adding the correct data to the correct patients. Each report has a small question mark at the bottom that will provide documentation on how to add patients to the denominator and numerator of each report.
3. Track your data for the full reporting period, then submit the QRDA files. Each year, you should be collecting PQRS data for the full year. This means that you will not submit anything to CMS until at least January 1 of the next calendar year.
Generating QRDA files-
Once a CQM report has been run, there is an option at the bottom right to export either QRDA Category 1 or QRDA Category 3 files. (Category 1 files make 1 file per patient in the report, so a folder for these is recommended. QRDA Category 3 will generate one file for the overall report.) Depending on where you are submitting the files, they will accept either one format or the other, or both. MacPractice support can only assist with generating the files. Once they exist, it's up to your office to know how and where to submit them.
Registry Based Reporting-
This is not something that MacPractice will be able to assist with. There are many different registries out there depending on state, speciality, etc. so you must locate a registry and work with them to submit whatever data they need.
One option that MacPractice clients have used successfully in the past is pqrswizard.com. There are options on here for reporting what are called Measures Groups. These 22 groups of measures are not applicable to all specialties, so they are not an option for everyone. If you are able to report a measures group from this site, it simply requires collecting information and inputting data onto the site for 20 patients (the majority of which need to be Medicare patients). While there is a charge for this reporting option per provider, many providers find this option much simpler than trying to remember tracking and billing for Claims Based Reporting or ensuring that they are properly coding things for EHR Based Reporting. The data for this option need only be reported once a year.
G-Codes are a set of CMS-defined HCPCS codes used to report quality measures on a claim; these codes are maintained by CMS. G-codes are used to distinguish clinical actions across measures.
If you have purchased the Codes Manager ability, you can import these codes from the HCPCS fee codes. Alternatively, you may obtain G-codes from the CMS here. Manually enter these codes into the fee schedule.
Adding G-codes to a Fee Schedule
To add G-codes to your fee schedule:
- Click the plus button next to the fee schedule name to create a "new record."
- Enter the G-code, as obtained from CMS.
- Enter the description of the G-code.
- Enter an applicable Unit Fee. Typically, G-codes use 0.00 unit fees as they are used primarily for reporting purposes.
- Ensure the PQRS checkbox is checked. The PQRS checkbox is used to flag G-codes so that when using claims manager, it will see these charges as billable.