Physician Quality Reporting System (PQRS)


The Physician Quality Reporting System (PQRS), a CMS (Centers for Medicare and Medicaid Services) quality improvement program continuing in 2014 provides the opportunity for incentives for participation (incentive: up to 0.5% of total Medicare allowed charges in 2014) and a penalty beginning in 2015 based on 2013 reporting (penalty: up to 1.5% of total Medicare allowed charges).  PQRS, first established in 2006, offers incentives to Medicare providers who report on quality performance measures and assesses penalties to those providers who fail to report.  Participation in the program involves the reporting of designated administrative codes on billing claims. Physicians who successfully participate in this program in 2014 will be listed on the new public Physician Compare Website.  Actual performance on the measures, versus successful reporting, is expected to be reported on the website beginning in 2015. Detailed specifications for this program, which change annually, are on the CMS PQRS Page.

Current Year’s Performance Measures
The PQRS program continues in 2014 with 287 individual measures and 25 measures 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 utilization as a measure group.

Financial Implications
Physicians who report on one measure group (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.) 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 patient population between January 1 and December 31, 2014, will receive a bonus of up to 0.5% of their total Medicare allowed charges for that period. Each measure lists the domain of which it is assigned.  If fewer than 9 measures apply to the eligible psychiatrist, 1-8 measures must be reported on for at least 50% of the patients where a measure applies.  The incentive is awarded for reporting on applicable measures, however, measures with a 0% performance rate will not be counted.  No incentive payments are scheduled after 2014.  Starting in 2015, there will be a 1.5% downward payment adjustment (financial penalty) on all Medicare payments for physicians who do not participate; the tracking for those who receive the 2015 penalty began in 2013.  2014 will serve as the performance year for the 2016 penalty adjustment of 2%.  To avoid the PQRS penalty adjustment of 2% for 2016, physicians must report on 3 measures for 50% of their applicable patients.

Due to various payment adjustments (upward payment adjustments in 2014 and downward payment adjustments in years beyond) tied to the multiple eHealth programs, not just the PQRS, CMS has developed a Payment Adjustment Tool showing the payment adjustments clinicians can anticipate as a consequence of their past, current, and expected future participation.

Mechanisms for Participation
Registration is not required to participate in the 2014 PQRS, rather, submission of quality data codes for the 2014 PQRS quality measures to CMS through claims, a qualified registry, or an electronic health record (EHR) satisfies participation in the 2014 program.  To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reporting under the Medicare EHR Incentive Program are included in the 2014 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 an option 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

A patient is seen for depressive symptomatology, and consequently, measure #134 is utilized.

1.     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.  

2.     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:
CMS PQRS Website 
CMS PQRS Help Desk Contact Information
CMS PQRS 2014 Measure Specifications
CMS PQRS 2014 Implementation Guide
2014 PQRS Participation Tools (AMA)
PQRS Educational Video Presentation
CMS-1500 Claims PQRS Example