UPDATED: What you need to know to achieve Success with PQRS

What you need to know to achieve Success with PQRS

While some of the background about PQRS is a review of preview posts, I have included the material so that you have all the basic information in one place and can use this as an easy reference about PQRS. I will do the same for the elements of Meaningful Use. I will make sure you have access to these as reference materials so that you can share them with your colleagues and your program director if you work in a wound center since you will need to collaborate with your hospital in order to extract the information necessary from the wound center’s Electronic Health Records.

What is PQRS?

The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. By reporting on PQRS quality measures, EPs can quantify how often they are meeting a particular quality metric.

In 2015, the program began applying a negative payment adjustment (meaning, a financial penalty) to EPs who did not satisfactorily report data on quality measures for services covered under the Medicare Part B Physician Fee Schedule (MPFS) in 2013. Those who failed to report in 2014 will see penalties beginning in 2016. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment. (In other words, penalties lag 2 years behind reporting.)

What Are Clinical Quality Measures (CQMs)?

CQMs are tools that are intended to measure health care processes, outcomes, and patient perceptions.

How is PQRS data used?

PQRS data are reported to CMS to determine whether an EP will experience a financial penalty for physician services.

Other than the monetary risk why should I pay attention to this?

  1. CMS requires Physician PQRS data to be publicly reported. Data are reported on the Physician Compare website by provider name. Quality data are increasingly used to establish payment rates by payers, set salary incentives, and even by patients to select doctors. As we discuss measures you might report, ask yourself if you want your salary or expertise to be judged by this particular quality measure.
  2. PQRS data are used to calculate your Value Modifier data. I have talked about the VM in previous posts and will discuss it in detail in the future. The VM is a separate quality program in which practitioners may be subject to as much as a 4% reduction in Medicare payments if PQRS performance is poor and the “resource use” (billed charges) to Medicare patients is high. However, bonus payments are possible if PQRS performance is good and resource use is low.
  3. CMS has previously announced its intention to link 50 to 80% of Medicare payments to a quality basis within 2 years, and recently stated that the number would be 85% by the end of 2016. I would take that as a warning to figure this out now.

How Many PQRS Measures Do Doctors Need to Report in 2015?

In 2015, EPs need to report 9 PQRS measures. Alternatively, you can report the Diabetes Measure Group. I have explained this process already. The problem with the diabetes measures group for wound care clinicians is that while it is easier (at least this year) it is not relevant to wound care and because it is reporting on only diabetic patients, it means that your Quality and Resource Use Utilization Report (QRUR) will be skewed to include ONLY potentially high cost diabetic patients, possibly setting you up for monetary penalties under the Value Modifier. However, the Diabetes Measure Group still remains a better answer than being judged by smoking cessation, BMI, and immunizations.

Which Measures do I report?

The 9 measures an EP reports must cover at least 3 of the 6 National Quality Strategy (NQS) domains. The six NQS domains are:

  1. Patient Safety
  2. Person and Caregiver-Centered Experience and Outcomes
  3. Effective Clinical Care
  4. Community/Population Health
  5. Communication and Care Coordination
  6. Efficiency and Cost Reduction

One of the nine measures you select must come from the new “cross-cutting” measure list.

Where can I find the list of measures for 2015?

There are a total of 255 measures are available in the 2015 PQRS Program. I have summarized them below, but you can read them in detail at CMS’ PQRS website.

  • 63 outcome-based measures
  • 19 “cross-cutting” measures
  • There are no PQRS measures specific to wound care
  • There are 3 PQRS measures relevant to the examination of the diabetic foot.

Your mission is to find 9 of the 255 that a wound care clinician can pass, even if none of them have anything to do with wound care or hyperbaric medicine.

How are measures reported?

Measures can be reported by claims but you would have had to have started this on 1/1/2015 by putting the right billing codes in your charge master, so it is too late now. There is an “EHR-Direct” Reporting Option but only certain measures can be reported this way and they are directed at primary care physicians. Your only realistic option is the Qualified Registry reporting option.

How do I pick the Qualified Registry that I want to work with?

First you pick the measures you want to report and then you select a registry that reports those measures. Read “How to get started”.

What if I don’t think I can pass 9 measures using only the standard PQRS measures?

Then you are in good company with the rest of us. If you practice wound care and hyperbaric medicine full time, you probably can’t be successful with PQRS using only the standard PQRS measures. That’s because there are no relevant PQRS measures in the system.

The Alliance of Wound Care Stakeholders and the U.S. Wound Registry (USWR) tried very hard to get wound care measures into PQRS but weren’t successful at convincing CMS that wound care was a sufficient priority or that data supporting processes like off-loading was strong enough!

Is there a way to report wound care and hyperbaric medicine quality measures?

YES! The USWR has developed 20 wound care and hyperbaric medicine specific quality measures. Many were developed in conjunction with the American Podiatric Medical Association (APMA) and the Undersea and Hyperbaric Medical Association (UHMS).

What is the U.S. Wound Registry (USWR) and what does it do?

The USWR is a Qualified Clinical Data Registry (QCDR) which is a registry recognized by CMS as one that can develop its own measures and report those measures to CMS on behalf of providers.

The mission of a QCDR is to collect medical and/or clinical data for the purpose of patient and disease tracking. It receives quality data from EPs and calculates their performance on quality measures. It submits quality measure data to CMS to demonstrate whether EPs have satisfactorily participated in PQRS. A QCDR must be able to report patient outcome stratified by patient RISK.

What are the rules for QCDR Reporting?

  1. Report at least 9 measures covering 3 National Quality Strategy (NQS) domains
  2. Report on at least 50% of applicable patients seen during the 2015 participation period.
    • All Patients are Eligible, not just Medicare beneficiaries
  3. Report on at least 2 outcome measures.
    • If the QCDR does not possess 2 outcome measures, then the QCDR must possess at least 1 outcome measure (patient outcomes must be risk stratified) and 1 of the following other type of measures:
      • Resource use
      • Patient experience of care
      • Efficiency/appropriate use
      • Patient safety

Where can I find a list of the USWR QCDR Measures?

The USWR collects data and reports on 20 wound care and hyperbaric medicine measures developed by the USWR and 24 standard PQRS measures. All of the details about those measures can be found on the USWR website. Providers may “mix and match” any of these 42 measures in order to find 9 measures that they can pass.


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Caroline Fife, MD

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