PQRS Solidifies PQRI for Years to Come

Big changes to PQRI in 2011 put pay for performance in the spotlight.

By Penny Osmon, BA, CPC, CPCI, CHC, PCS

Updates to the Physician Quality Reporting Initiative (PQRI) signal that the shift from pay for reporting to pay-for-performance has begun. The 2011 Physician Fee Schedule final rule, issued Nov. 2, 2010 by the Centers for Medicare & Medicaid Services (CMS), incorporates key provisions of the Patient Protection and Affordable Care Act (PPACA), and gives PQRI a new name—Physician Quality Reporting System (PQRS)—to reflect its permanence. Quality reporting no longer can be ignored; the time has come for practices to embrace the process.
For 2011, CMS has made the reporting process less cumbersome by reducing the threshold of claims reporting to 50 percent (down from 80 percent in 2010), offering a new group reporting option for entities of fewer than 200 eligible professionals (EPs), and adding a new measure group for asthma. The list of eligible professionals remains the same, and there still is no solution that allows participation of rural health clinics (RHCs), federally qualified health centers (FQHCs), or critical access hospitals (CAHs) to be reimbursed via method II (for additional information on CAH billing standards.

Participation Incentives

PPACA provisions not only extended the incentive payments for successful participation through 2014, but added payment adjustments for unsuccessful reporters beginning in 2015. A 1 percent incentive payment is available in 2011, and a 0.05 percent incentive payment is available for successful reporters from 2012 to 2014. A negative payment adjustment of 1.5 percent will apply for noncompliance in 2015, increasing to 2 percent in 2016.
PQRS incentive payments are based on total allowed, reimbursed charges for services covered under the Medicare Part B Physician Fee Schedule (PFS) during the reporting period. Although the money may provide incentive to participate, don’t forget the future alignment of PQRS with quality improvement programs. This is illustrated in the final rule:
“As the program matures and we phase out the incentives for satisfactory reporting and phase in payment adjustments for failing to satisfactorily report, we envision continuing further refinements aligning PQRS with a more robust role in quality improvement.”
An additional 0.05 percent incentive payment is available from 2011 through 2014 for EPs who provide data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year, submitted through an MOC program, the physician must participate in and successfully complete an MOC program. Board certification status may require more frequent reporting. For physicians to wade through the confusion, CMS must issue further clarification and guidance on the interaction between CMS contractors and the medical boards. This optional incentive may prove too confusing and require duplicate work triggering physicians to ask: “Is it worth the effort?”

Quality Reporting Methods

The four reporting methods from which to choose in 2011 are: (1) claims; (2) CMS qualified registry; (3) CMS qualified electronic health record (EHR); and (4) group reporting, which is divided into sub groups a) GPRO I (>200 EPs) and b) GPRO II (2199–EPs).
In addition to the four reporting methods, EPs can choose to report on either individual quality measures or measure groups. If an EP chooses to report individual quality measures and submit by claims, three measures must be reported on at least 50 percent of all eligible Medicare patients.
If submitting through a registry, there is a threshold of 80 percent of all eligible Medicare patients. If less than two individual quality measures apply to a particular EP, one or two measures may be reported through claims reporting; however, the EP is subject to a measure applicability validation process to verify that additional measures did not apply.
The reporting periods for both registry and claims continue to provide flexibility, with both a six month and 12 month option—with the exception of the 30 patient measure group reporting method, which is a 12 month reporting period for claims and registry. EHR reporting is available only as a 12 month option and requires submission of 20 predetermined quality measures. Quality data recorded through this method will be submitted to CMS in early 2012. A list of certified EHR products for 2011 is online at: www.cms.gov.
To participate in either GPRO option, organizations must make a decision and self-nominate between Jan. 3 and Jan. 31, 2011. The GPRO I option requires the entire group to participate on 26 predetermined measures focused on preventive and chronic conditions. Groups selecting this method will receive a pre-populated collection tool from CMS. Reporting GPRO II is based on group size and requires reporting a combination of individual and group measures. CMS plans to accept approximately 500 groups for GPRO II participation in 2011.

Claims Based vs. Registry Based Reporting

Claims and registry based reporting continue to be the primary methods of choice. In the 2010 PFS final rule, CMS hinted at potential elimination of the claims reporting option. In the 2011 rule, this position is clarified:
“CMS believes it would be premature to eliminate the claims based reporting mechanism for 2011 and by doing so would create a barrier to participation. When there is an adequate number and variety of registries available, a transition may occur.”
CMS recently announced, through an open door forum, the success rate of claims reporting in 2008 and 2009 was 50 percent, while the success rate for registry reporting was 90 percent. Although the statistics might initially guide EPs directly to the registry option, most registries have costs associated with them. Another important aspect is workflow within the clinic. The claims process is built on collection of real time data, while a registry allows EPs to collect the data along the way and report on it later.
Reporting a measure group on 30 Medicare Part B fee-for-service (FFS) patients using the claims method must be initiated by reporting a measure group specific intent G code to indicate the selected reporting method. Claims reporting of measure groups also allow EPs to submit one measure group specific composite G code when all applicable measures within the measure group are completed successfully on a patient. When deciding which option best meets the needs of an EP, there are many components to consider.
Tip: To learn more about PQRS related G codes, go to www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage, select the link labeled “Additional 2011 Physician Quality Reporting System Measure Documents,” and open the 2011 Physician Quality Reporting System (Physician Quality Reporting) Measures Groups Specifications Manual (2011_PhysQualRptg_MeasuresGroups_SpecificationsManual_121510.pdf) file.
The practical first step is to determine which of the 194 measures for 2011 best apply to the EP’s clinic, noting the 44 measures that can be submitted only through a registry. If there are less than two measures that apply, EPs must report via claims.
If EPs identify three or more applicable measures, the next step is to determine whether to use individual or measure group reporting. The 2011 measure groups are:

  • Diabetes Mellitus
  • Chronic Kidney Disease (CKD)
  • Preventive Care
  • Rheumatoid Arthritis
  • Coronary Artery Bypass Graft (CABG)
  • Rheumatoid Arthritis
  • Perioperative Care
  • Back Pain
  • Hepatitis C
  • Heart Failure
  • Coronary Artery Disease (CAD)
  • Ischemic Vascular Disease (IVD)
  • Community Acquired Pneumonia
  • Asthma

Note that measure group specifications may vary from the individual measure specifications that comprise the group. The specifications for both are online at
After determining quality measures for reporting, the EP can identify which method (claims or registry) is most appropriate. Two important changes to registry reporting in 2011 are:

  • If an EP chooses to report a measure group on 30 patients through a registry, all 30 patients must be Medicare Part B FFS patients. In 2010, only two Medicare Part B FFS patients were required.
  • A zero-measure performance rate will not be accepted for registry submission. If reporting on a measure group, this means all individual measures within the measure group must be reported at least once for the 30 Medicare patients. When submitting individual measures through a registry, all three measures must be reported as performed at least once.

A list of CMS approved registries for 2011 will be available in spring 2011 at www.cms.gov/pqri. If an EP chooses the registry option, clinical data collection begins in January 2011, and the data will be entered into the registry tool at a later date. If you select this reporting method, consider how you will capture and track the data for submission at a later date. This could include a spreadsheet, printed summary report, or another alternative that meets the needs of organizations.
When deciding between claims and registry, consider other initiatives or projects occurring in the clinic. Important considerations include: current workload, potential workflow changes, and potential return on investment recognized by staff time gained; less room for errors on claims, and; the ability to submit quality data at your convenience.

Pay for Performance Is Coming

Ultimately, the focus of clinical quality measure data collection will shift to performance improvement. PPACA requires CMS to develop a plan by 2012 outlining how to integrate the PQRS measures with the EHR meaningful use incentive program. The 2011 PFS proposed rule specifically sought comments on how best to align the two incentive programs, and stated:
“In an effort to align PQRI with the EHR incentive program, we propose to include many American Recover and Reinvestment Act (ARRA) core clinical quality measures in the PQRI program to demonstrate meaningful use of EHR and quality of care furnished to individuals. We propose the selection of these measures to meet the requirements of planning the integration of PQRI and EHR reporting.”
Clearly, we are slowly migrating to a pay-for-performance reimbursement system where clinical data will help drive quality improvement in health care.
PQRS Reporting Requirements at a Glance

Measure Group Comparison
Reporting Method Claims Registry
Reporting Period 6 or 12 months 6 or 12 months
Target Sample 30 Part B FFS Medicare patients (12 months) or 50 percent of all Medicare patients for whom the measures apply (minimum of 8 patients for 6 months or 15 for one year) 30 Part B FFS Medicare patients (12 months) or 50 percent of all Medicare patients for whom the measures apply (minimum of 8 patients for 6 months or 15 for one year)
Submission Cost Free Yes, varies by registry
Average Success Rate 50 percent 90 percent
Workflow Considerations Real time data submission on a claim Data submission can occur after the date of service.
Other Notables Must indicate intent to submit a group measure with a G code. Can use a composite G code. Zero performance measures will not be counted.


Individual Measure Comparison
Reporting Method Claims Registry
Reporting Period 6 or 12 months 6 or 12 months
Target Sample 50 percent of all Medicare Part B FFS patients for whom the
measures apply
80 percent of all Medicare Part B FFS patients for whom the measures apply
Submission Cost Free Yes, varies by registry
Average Success Rate 50 percent 90 percent
Workflow Considerations Real time data submission on a claim could impact chart prep. Data submission can occur after the date of service.
Other Notables Submission should begin early in 2011 for the best chance of success. Collection of clinical data should begin early.

Penny Osmon, BA, CPC, CPCI, CHC, PCS, is the director of educational strategies for the Wisconsin Medical Society. She has over 15 years of experience in Medicare compliance, coding, and practice management. She presents educational programs on revenue cycle, risk management, and health information management for physician practices throughout Wisconsin and the Midwest region with an emphasis on reducing waste, mitigating risk, and improving quality. She serves on the Wisconsin Medical Group Management Association Third Party Payer and Medicare and Medicaid Workgroups.

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