Understanding PQRS

PQRS (Physician Quality Reporting System) is an extremely complicated system of reporting quality care for Medicare patients.  Originally it started as PQRI (Physician Quality Reporting Initiative), an initiative which paid an incentive to providers for using the reporting system.  It is now going to penalize providers who do not use the system by applying payment adjustments to physicians who do not satisfactorily report the quality measures.  PQRS applies to most providers who bill services for Medicare patients.
CMS states that the first step is to determine if the provider is eligible to participate in PQRS.  A list of PQRS eligible providers can be found at:

Next determine which reporting method best fits their practice.  There are four methods:

    Claims based
    Registry Reporting
    EHR Based Reporting
    Group Practice Reporting Option (GPRO)

Claims based reporting is the traditional reporting option.  It involves submitting CPT-II or G Codes on the Medicare claims for the patients being reported.  In order to qualify using the claims based option, an eligible provider must satisfactorily report on at least 50 percent of eligible instances.  (We are going to cover the claims based reporting option and the G codes in depth in our next newsletter.)

Registry Reporting is done through qualified registries.   Qualified registries are vendors that submit quality measure data to CMS using a source other than an EHR.  Providers would manually input or upload the patient data into the qualified registry.  The qualified registry then calculates the PQRS and submits those calculations to CMS.

EHR Based Reporting is done through an Electronic Health Record system.  Providers may submit PQRS measures through a qualified EHR system.  The qualified EHR system vendor would forward that data on to CMS.

Group Practice Reporting Option is done when a group of providers opts to participate in PQRS as a group practice.  The members of a group who opts into the Group Practice Reporting Option (GPRO) relinquish their right to participate in PQRS as an individual provider.  The PQRS incentive is then calculated based on the group’s total estimated Medicare Part B charges for the year.

Once the method is determined it is important to set up an office workflow to make sure the reporting is completed.  If using the traditional reporting option, or claims based reporting, then the codes used to report PQRS could be added to the encounter form.  If a paper encounter form is used then that would be fairly easy.  The provider can simply check off the appropriate reporting codes and the biller would simply add them to the claim when it is billed.  If the provider uses an electronic system then the codes need to be added to that system so that they can be reported on the claims.  The important thing is to establish a system to ensure that the PQRS reporting is done.

Providers do not need to notify CMS or their Medicare regional carrier prior to beginning reporting.  Simply add the codes to the claims and submit.  Many providers and billers are avoiding figuring out what PQRS is because it seems too complicated.   But avoiding it will end up costing the provider money.  How much money is lost will depend on how many Medicare patients the provider sees.

(Next newsletter will cover the claims based reporting method including the codes used in greater detail.)


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