Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) - established in 2006 - is a Centers for Medicare and Medicaid Services (CMS) quality reporting program. Originally offering payment incentives to Medicare providers who reported quality performance measures, 2015 will mark the inaugural reporting year in which penalties will be assessed to providers who fail to report. Eligible professionals (EP) will receive this downward payment adjustment in 2017. Participation in the program involves the reporting of designated administrative codes on billing claims, through a certified electronic health record (EHR), or qualified registry. Physicians who successfully participate in this program in 2015 will be listed on the new public Physician Compare web page. Specifications for this program, which change annually, are on the CMS PQRS Page.

Current Year’s Performance Measures
The PQRS program continues in 2015 with 260 individual measures and 21 measure groups available for reporting. Several pertinent to psychiatrists include measures on depressive disorder, screening for unhealthy substance use and medication reconciliation. Additionally, the dementia measure set is available for use as a measure group.

Financial Implications
To avoid a penalty, physicians must report on one measure group, or at least 9 individual measures which encompass 3 of the 10 National Quality Strategy domains, applicable to their practice for at least 50% of their eligible patients between Jan. 1 and Dec. 31, 2015. The penalty for this reporting period is 2% of the total Medicare allowed charges for the period. Each measure lists the domain to which it is assigned. If fewer than 9 measures apply to the eligible psychiatrist, 1-8 measures must be reported for at least 50% of the patients where a measure applies. If an EP determines that 9 measures cannot be reported on, and would like to avoid the penalty in 2017, the clinician may volunteer to participate in the Measures Applicability Validation (MAV) process. The MAV process is completed by CMS upon request by the EP. This process allows CMS to designate the appropriate measures for the EP.

Measures with a 0 percent performance rate will not be counted. (Please note a measure group must be reported on as a whole. To report on a group, CMS’s requirements for “measures groups” reporting must be followed.)

Mechanisms for Participation
Registration is not required to participate in the 2015 PQRS. Rather, submission of quality data codes for the 2015 PQRS quality measures to CMS through claims, a qualified registry, or an electronic health record (EHR) satisfies participation in the 2015 program. To align the PQRS with the Medicare EHR Incentive Program (“Meaningful Use”), all clinical quality measures available for reporting under the Medicare EHR Incentive Program are included in the 2015 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). 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 of the measure’s detailed specifications to learn more. While it is expected that most psychiatrists in private practice will use claims reporting to participate in the PQRS, more information is available on the CMS website about other reporting methods (registries, measures groups, group practice, and electronic health records), which may be options in certain circumstances.

A step-wise example of how to use the appropriate codes for claims-based reporting to PQRS:

Measure #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

  1. A patient presents with distressing psychiatric symptoms, and measure #134 is used.
  2. The provider lists the appropriate code (G8431) below the CPT code when submitting a claim to Medicare to indicate that the patient was screened for clinical depression, was documented as positive, AND a follow-up plan was documented.
  3. If the patient was not a candidate for a depression screening for any of the identified reasons found within the measure specifications, the code would be G8433.

Links pertaining to 2014 PQRS Program: