PQRS
Contact , 404-633-3777, x820 with claims-based questions;
Contact , 404-633-3777, x819 with RCR questions

Physician Quality Reporting System: 2012 Measures

There are 21 measures that will affect rheumatology practices. The incentive bonus pay for successfully reporting will be .5% of the allowable 2012 Medicare Part B Fee for Service with no cap.

2012 PQRS – Individual Measure Reporting options

Below are the different reporting methods:

Registry-based -- RCR: (options for mid-year PQRS start)

  • Successfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS patients between January 1 - December 31, 2012.
    - or -

    Successfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS patients between July 1 - December 31, 2012

Claims-based: (January 1 start date)

  • Successfully report three or more measures for a minimum of 50 percent of applicable Medicare Part B FFS patients between January 1 - December 31, 2012.
    - or -

  • Successfully report three or more measures for a minimum of 50 percent of applicable Medicare Part B FFS patients between July 1 - December 31, 2012.

2012 PQRS – Measures group reporting options (including RA)

Registry-based -- RCR: (options for mid-year PQRS start)

  • Successfully report on a minimum of 30 Medicare patients in the group between January 1 - December 31, 2012 (Medicare patients only)

    - or choose one of the following 2 options -

  • Successfully report on a minimum of 80 percent of patients in the group with a minimum of 30 Medicare patients January 1 - December 31, 2012 (Medicare patients only)

    - or -

  • Successfully report on a minimum of 80 percent of patients in the group with a minimum of 8 patients between July 1 - December 31, 2012 (Medicare patients only)

NOTE: For reporting options that include a minimum 80 percent requirement, this means that providers must report successfully for at least 80 percent of their patients to which the measure applies in the given time period. Providers who choose to report on only 80 percent of their patient population for a certain measure must, therefore, report with complete accuracy. Because this would allow no room for error without losing the entire incentive payment, CMS recommends that providers report on more than 80 percent of their patient population for each measure, whenever possible, even up to 100 percent.

Claims-based: (January 1 start date)

  • Successfully report on a minimum of 30 Medicare patients in the group between January 1 - December 31, 2012.

    - or -

    Successfully report on a minimum of 50 percent of patients in the group with a minimum 30 Medicare patients between January 1 - December 31, 2012

Claims-based: (option for mid-year PQRS start)

  • Successfully report on a minimum of 50 percent of patients in the group with a minimum 15 patients between July 1 - December 31, 2012 (Medicare patients only)

Note: The following option is still available for mid-year start:

Successfully report on a minimum of 30 patients in the group whose visits took place at any time in 2012 (Medicare patients only).

Exclusions

Exclusion modifiers may be appended to a CPT II code (on a claim) OR within a registry to indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some measures do not provide for performance exclusions.

Reasons for appending a performance measure exclusion modifier fall into one of four categories:

1P exclusion modifier due to medical reasons
Examples include: not indicated (absence of organ/limb, already received/performed); contraindicated (patient allergic history, potential adverse drug interaction)

2P exclusion modifier due to patient reasons
Examples include: patient declined; economic, social, or religious reasons

3P exclusion modifier due to system reasons
Examples include: resources to perform the services not available; insurance or coverage/payer-elated limitations; other reasons attributable to health care delivery system

8P reporting modifier - action not performed, reason not otherwise specified

Getting Started With PQRS Reporting

  1. Decide which reporting method is best suited for your practice:

    • Claim-Based
      1. Individual measures
      2. Measure Group
    • Registry
      1. Individual measures
      2. Measure Group

  2. Decide if you are going to report for the whole year or for 6 months (July 1 – December 31, 2012).

    • Whole year reporting successfully = .5% bonus incentive will be based on a whole year of the allowable 2012 Medicare Part B Fee for Service with no cap

    • Six months reporting successfully = .5% bonus incentive will be based on 6 months of the allowable 2012 Medicare Part B Fee For Service with no cap

  3. Inform your billing staff which method your practice will be using.

  4. Make sure all super bills and charge slips reflect the new PQRS codes.

  5. Start reporting as soon as possible to ensure that your practice will meet the goal of whichever reporting option you choose.

    • No registration is needed - a practice can participate in PQRS as long as the physician is a participating Medicare provider.

Click here a pdf file for full measure descriptions in a printable PDF format.

Measures

Note: Click a measure link to see more information; click again to hide the information.
 Click here to expand all measures.

Measure Groups**

There are two measure groups, the RA Measure Group, and the Back Pain Measure Group

RA Measure Group

When reporting the RA measure group you must alert Medicare that you are reporting PQRS as the RA measure group by billing G8490 on the very first Medicare patient that the RA measures apply to. Also, Medicare has developed a short cut to billing the measures in the measure group; if all six of the measures are completed at one time it permissible to bill a "catch all code of G8499". The RA measure group, which includes six measures which are:

Back Pain Measure Group

When reporting the Back Pain measure group you must alert Medicare that you are reporting PQRS as the Back Pain measure group by billing G8493 on the very first Medicare patient that the Back Pain measures apply to. An additional reporting option for rheumatologists to report is the back pain measures group, which includes 4 measures which are:

** If you choose to report a measure group keep in mind that all the measures in the group must be reported to qualify.**

Contact Melesia Tillman at (404) 633 – 3777 ext 820 or by email with questions.

CMS PQRI informational / Q&A conference calls

CMS provides informational conference calls on PQRI from time to time. Information about these calls is posted on the CMS Web site as it becomes available. To receive call-in information, you must register for the calls. For those unable to attend, a replay option will be available shortly following the end of each call. This replay will be accessible for several days following each of the calls.

In addition, PowerPoint slides from recent calls are archived on the CMS Web site and can be accessed at:

http://www.cms.hhs.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage.

Other resource links

For each of the 131 measures in the program, the tools are available online on the AMA website.

For each of the 6 measures groups eligible for claims-based reporting in the 2011 PQRS, the tools are available online on the AMA website.

AMA PQRS 2011 Worksheets, Measure Descriptions, and Measure Specifications: ONLY FOR CLAIMS SUBMISSION

AMA PQRI 2009 Worksheets, Measure Descriptions, and Measure Specifications

#24. Communication with the physician managing ongoing care post-fracture

#39. Screening or therapy for osteoporosis for women aged 65 years and older

#40. Management following fracture

#41. Pharmacologic therapy

#108. Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis

#109. Patients with osteoarthritis who have an assessment of their pain and function

#124. Adoption/use of health information technology (electronic health records)

#131. Pain assessment prior to initiation of patient therapy and follow-up

#142. Assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications

#154. Risk assessment

#155. Plan of care

#176. Tuberculosis screening

#177. Periodic assessment of disease activity

#178. Functional status assessment

#179. Assessment and classification of disease prognosis

#180. Glucocorticoid management

Quality Measures Group: Back Pain

  • #148. Initial Visit
  • #149. Physical Exam
  • #150. Advice for Normal Activities
  • #151. Advice Against Bed Rest

Quality Measures Group: Rheumatoid Arthritis

  • #108. Disease modifying anti-rheumatic drug therapy (DMARD)
  • #176. Tuberculosis screening
  • #177. Periodic assessment of disease activity
  • #178. Functional status assessment
  • #179. Assessment and classification of disease prognosis
  • #180. Glucocorticoid management