Important changes to 2012 Medicare quality reporting program

29 December 2011

Several important changes in the Medicare quality reporting program for physicians take effect in 2012. Through the Physician Quality and Reporting System (PQRS), physicians and non-physician providers who participate in the program transmit data to the Centers for Medicare and Medicaid Services (CMS) regarding quality measures related to care provided to their Medicare patients. Physician quality reporting through PQRS is voluntary but the Affordable Care Act mandates PQRS participation in future years.

CMS recently finalized regulations requiring that 2015 program penalties be based on 2013 quality reporting. Therefore, those physicians who elect not to participate or do not successfully participate in PQRS during the 2013 program year will receive a 1.5 percent payment penalty in 2015, which increases to 2 percent in subsequent years. Physicians who participate between 2011 and 2014 are eligible for incentive payments.

The following changes will also take place within PQRS in 2012:

• Individual reporting: Individual physicians and non-physician providers do not need to sign up or pre-register to participate in the 2012 PQRS. Submission of quality data codes for the 2012 PQRS quality measures to CMS through claims, a qualified registry or electronic health record (EHR) will indicate intent to participate in the 2012 program.
• Group practice reporting option: Previously there were two classes of group practices that could use the group practice reporting option (GPRO): groups with 199 or fewer physicians and groups of 200 or more physicians. In 2012, there is now only a single GPRO for practices comprised of 25 or more eligible professionals. Group practices are required to submit a self-nomination letter indicating their interest in participation.
  
  Group practices will report 29 quality measures on a certain number of consecutive patients in 2012. A group practice with 25–99 professionals is required to report 218 consecutive patients, and a group practice with 100 or more professionals is required to report 411 consecutive patients.
• PQRS measures and measure groups: There will be 210 quality measures available for claims and/or registry reporting, including 26 new quality measures. There are an additional 51 measures available for EHR-based reporting, which includes all 44 of the Medicare EHR Incentive Program measures, five PQRS measures that were available in the 2011 EHR reporting option and two new measures CMS developed. CMS eliminated the six-month reporting period for claims and registry reporting for individual measures via registry, but a six-month reporting period remains for reporting on measures groups via a registry.
  
  CMS also added eight measures groups, bringing the total number of reportable PQRS measures groups to 22. These include: diabetes mellitus, adult kidney disease, preventive care, coronary artery bypass graft, rheumatoid arthritis, perioperative care, back pain, coronary artery disease, heart failure, ischemic vascular disease, hepatitis C, HIV/AIDS, community-acquired pneumonia, asthma, chronic obstructive pulmonary disease, inflammatory bowel disease, sleep apnea, dementia, Parkinson's disease, elevated blood pressure, cardiovascular prevention and cataracts. Because of the limitations of claims-based reporting, some measures groups are only reportable through registries.
  
  Measures contained in the following measure groups will be available for reporting as individual measures: diabetes mellitus, adult kidney disease, preventive care, coronary artery bypass graft, rheumatoid arthritis, perioperative care, coronary artery disease, heart failure, ischemic vascular disease, hepatitis C, HIV/AIDS, community-acquired pneumonia and asthma.
• Alignment of the Medicare PQRS and EHR Incentive Program: To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reporting under the Medicare EHR Incentive Program will be included in the 2012 PQRS. This will allow physicians to report data on quality measures under the EHR-based reporting option.
• Reporting threshold: CMS decreased the threshold for successful PQRS claims-based reporting from 80 percent to 50 percent starting in 2011, which will continue in 2012.
• Informal appeals process: An eligible professional electing to utilize the informal appeals process must request an informal review within 90 days of the release of his or her feedback report, regardless of when the participant actually accesses his or her feedback report. CMS has extended the time the agency has to respond to the request for an informal review from 60 days in 2011 to 90 days for 2012.
• PQRS payment adjustment: CMS designated 2013 as the reporting period for the 2015 PQRS payment penalty. If CMS determines that an eligible professional or group practice has not satisfactorily reported data on quality measures for the Jan. 1–Dec. 31, 2013 reporting period for purposes of the 2015 payment penalty, then the fee schedule amount for services furnished by the participating professional or group practice during 2015 would be 98.5 percent of the fee schedule amount that would otherwise apply to such services.

Refer to CMS's Web site for additional information on PQRS, including measures, measures groups, reporting options and periods.