ALERT: Please note to avoid the 2015 1.5% penalty a psychiatrist has only to report on one measure for one Medicare patient by the end of 2013.
The Physician Quality Reporting System (PQRS), a CMS (Centers for Medicare and Medicaid Services) quality improvement program continuing in 2013 provides the opportunity for incentives for participation (incentive: up to 0.5% of total Medicare allowed charges in 2013 and 2014) and a penalty beginning in 2015 based on 2013 reporting (penalty: up to 1.5% of total Medicare allowed charges). PQRS, first established in 2006, offers incentives to Medicare providers who report on quality performance measures and assesses penalties to those providers who fail to report. Participation in the program involves the reporting of designated administrative codes on billing claims. Physicians who successfully participate in this program in 2013 will be listed on the new public Physician Compare Website. Actual performance on the measures, versus successful reporting, is expected to be reported on the website beginning in 2015. Detailed specifications for this program, which change annually, are on the CMS PQRS Page.
Current Year’s Performance Measures
The PQRS program continues in 2013 with 259 measures for claims-based reporting. More information is available on the CMS website about other methods of reporting (registries, measures groups, group practice, and electronic health records) which may be an option in certain circumstances. Several measures are pertinent to psychiatrists, including five measures on depressive disorder, four measures on screening for unhealthy substance use, and one measure on medication reconciliation. In addition, a dementia measure set is available for use as a group, meaning if used, all nine measures within the set must be reported. One measure, PQRS # 238 Drugs to be Avoided in the Elderly, is only reportable through an electronic health record.
Physicians who report on at least 3 measures applicable to their practice between January 1 and December 31, 2013 will receive a bonus of up to 0.5% of their total Medicare allowed charges for that period. If less than 3 measures apply to the eligible psychiatrist, 1-2 measures must be reported in at least 50% of encounters where a measure applies. The incentive is awarded for reporting on applicable measures, however, measures with a 0% performance rate will not be counted. No incentive payments are scheduled after 2014. Starting in 2015, there will be a 1.5% payment adjustment (financial penalty) for physicians who do not participate; the tracking for those who receive the 2015 penalty begins this year (2013). For 2015 only, the payment adjustment can be avoided by reporting one PQRS measure for at least one applicable patient using the claims, registry, or EHR reporting. Reporting requirements to avoid the penalty are expected to increase in future years.
Because there are different payment adjustments (penalties) tied to the mutiple eHealth programs, CMS developed a Payment Adjustment Tool to show what payment adjustments to expect based on clinicians’ past, current, and expected future participation.
Mechanisms for Participation
Preregistration is not a requirement to participate in the 2013 PQRS: submission of quality data codes for the 2013 PQRS quality measures to CMS through claims, a qualified registry or electronic health record (EHR) will indicate intent to participate in the 2013 program. To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reporting under the Medicare EHR Incentive Program are included in the 2013 PQRS. This allows physicians to report data on quality measures under the EHR-based reporting option. The mechanisms to report are provided within each measure’s specification section (e.g. for a given measure, review the specifications, identify the G-code (defined), and then submit that code with a billing claim). Additionally, measures identified as pertinent to psychiatrists (along with their designated codes) may be found in this table. Please see the sample CMS-1500 Claim provided by CMS or the mental-health-specific-1500 Claim. The majority of these measures are reportable using alternative methods (qualified registry or electronic health record), please review each measure’s detailed specifications to learn more.
A step-wise example of how to use the appropriate codes for claims-based reporting to PQRS: Measure #9: Major Depressive Disorder: Antidepressant Medication During Acute Phase for Patients with Major Depressive Disorder
- A patient is treated for major depressive disorder (MDD) Measure #9 is utilized.
- The provider lists the appropriate code (G8126) below the CPT code when submitting a claim to Medicare to indicate that the patient is being treating with antidepressant medication during the entire twelve- week acute treatment phase.
- If the patient was not a candidate for treatment with an antidepressant for whatever reason, or was not being seen for a new episode of MDD, the code would be G8128.
Links pertaining to 2013 PQRS Program:
CMS PQRS Website
CMS PQRS Help Desk Contact Information
CMS PQRS 2013 Measure Specifications
CMS PQRS 2013 Implementation Guide
2013 PQRS Participation Tools (AMA)
PQRS Educational Video Presentation
CMS-1500 Claims PQRS Example