Physician Quality Reporting System (PQRS) 2011 Fact Sheet
The Physician Quality Reporting System (PQRS, formerly PQRI) is a voluntary reporting program established by the Centers for Medicare & Medicaid Services (CMS) in 2007. The program creates a financial incentive for eligible professionals to satisfactorily report data on certain quality measures for Medicare Part B services paid under the physician fee schedule.
PQRS is part of a broader CMS initiative aimed at advancing quality and efficiency in health care and moving toward a system in which CMS purchases services based on value rather than volume.
Who is Eligible
Occupational therapists who are independent practitioners or who work in private practice are eligible to report on PQRS measures, as long as they have an individual-level National Provider Identifier (NPI) and use their NPI on Medicare claims billed through their carrier. Occupational therapists working in hospitals or skilled nursing facilities whose employers bill for their services through a Fiscal Intermediary (FI) cannot participate in PQRS because these clinicians do not bill for their services through their own NPI. No special registration is necessary to participate in PQRS. CMS Guide to Getting Started.
Only occupational therapists working in private practice are currently eligible to participate in PQRS. AOTA is advocating for an expansion of the program to include occupational therapists in other settings.
How PQRS Works
Eligible professionals select the quality measures on which they will report quality data during the course of a calendar year. Because the underlying goal of PQRS is to advance data-informed process improvements within individual practices, Medicare requires that practitioners meet certain quality reporting thresholds and collect enough data to assess trends and performance. Only practitioners who have reported quality data on at least 80% of appropriate patients are consequently eligible for the PQRS incentive payment. For example, occupational therapists must report on three measures per patient for 80% of patients covered by Medicare Part B in a given reporting period.
To increase the likelihood that they will meet the 80% requirement for successful reporting, occupational therapists may wish to consider selecting total population measures for quality reporting.
Participating eligible professionals must incorporate selected quality-related enhancements into their routine and customary services (such as assessing pain before initiating therapy) for Medicare patients and document as such. Claims submitted to Medicare for a given occupational therapy session include the CPT II or G code specific to the quality-related service enhancement provided.
CPT II codes are supplemental CPT codes that are used to report quality measures on a Medicare claim. G codes are a set of temporary HCPCS codes that are used to define quality measures on a Medicare claim if there are no CPT II codes yet available.
Although not a current requirement, CMS expects that in addition to reporting quality data, eligible professionals are also tracking and using quality data to make service and practice improvements—the primary aim of PQRS.
PQRS Quality Data Reporting Systems
Eligible professionals may participate in PQRS by reporting quality information (1) to CMS on their Medicare Part B claims, (2) to a qualified PQRS registry, or (3) to CMS by means of a qualified electronic health record (EHR) product.
For claims-based reporting, professionals simply report using Medicare Part B claim form CMS-1500, as per usual. The cost of using this method is the time it takes to input measure specifications and establish reporting protocols for your offices. The only disadvantage is that some measures are not reportable using this method.
For registry reporting, eligible professionals must use a CMS-approved registry, which then captures and stores the data. The registry is responsible for submitting the measure information to CMS and calculating performance rates on behalf of the eligible professional. Providers may submit data to the registry at any time during the reporting period or up to one month afterward. Reporting may done retrospectively or even in batches rather than in real time. Registries have annual fees averaging around $600. List of Approved Registries for 2010 (the list for 2011 is expected to be the same).
For EHR-based reporting, providers may submit quality reports through their office/facility’s EHR if it is on the list approved by CMS: List of Qualified EHRs for 2011.
To select and establish reporting protocols, occupational therapists are advised to confer and partner with personnel within their private practice settings who are responsible for coding and Medicare billing.
Reporting Periods for 2011
For 2011, there are both six-month and 12-month reporting periods available. For claims-based and registry-based reporting, providers may either report from January 1 through December 31, or July 1 through December 31. For EHR-based reporting, providers must report over the course of the 2011 calendar year, that is, January 1 through December 31.
Once claims have been submitted, CMS will analyze them to verify satisfactory reporting during the entire reporting period. If an eligible professional is deemed to have reported successfully, CMS will calculate the appropriate incentive payment and distribute bonus payment checks in the spring of 2012.
Eligible professionals who successfully report will receive an incentive bonus of 1% of all the practitioner’s charges for Medicare Part B covered professional services (not just claims for which quality data were submitted) for the 2011 reporting period. An incentive payment of 0.5% will be paid for successful participation in PQRS for 2012, 2013, and 2014. Beginning in 2015, eligible professionals who fail to report will have their Medicare payments reduced. CMS will address these financial disincentives in future rulemaking. CMS Incentive Payment Timeline.
2011 Quality Measures Reportable for Occupational Therapists
Some PQRS measures are diagnosis-specific or condition-specific (e.g., patients with diabetes and patients with coronary artery disease), whereas others apply to all Medicare patients. Occupational therapists are able to report quality data on those quality measures for which there are occupational therapy CPT service codes. For example, CPT codes 97003 (OT evaluation), 97004 (OT reevaluation), and 97535 (self care/home management) are some of the CPT codes linked to measures reportable by occupational therapists.
For the 2011 calendar year, the following 17 PQRS process measures incorporate occupational therapy CPT codes are thus reportable by occupational therapists for all Medicare beneficiaries:
#124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)
#128 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
#130 Documentation and Verification of Current Medications in the Medical Record
#131 Pain Assessment Prior to Initiation of Therapy and Follow-Up
#134 Screening for Clinical Depression and Follow-Up Plan
#154 Falls: Risk Assessment
#155 Falls: Plan of Care
#173 Preventative Care and Screening: Unhealthy Alcohol Use – Screening
#181 Elder Maltreatment Screen and Follow-Up Plan
#217 Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
#218 Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
#219 Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments
#220 Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
#221 Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
#222 Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments
#223 Change in Risk-Adjusted Functional Status for Patients with a Functional Deficit of the Neck, Cranium, Mandible, Thoracic Spine, Ribs or Other General Orthopedic Impairment
#226 Preventive Care and Screening: Tobacco Use: Screening and CessationIntervention
In addition to these 17 OT-eligible measures, CMS has released a Complete Catalog of 2011 Measure Specifications.
Please review the detailed descriptions of each 2011 quality measure (accessible through the link on each measure number). These specifications outline the exact requirements that must be met to successfully report on a measure.
Continuing AOTA Advocacy
AOTA continually works with other disciplines and organizations to develop new quality measures and to ensure that eligible occupational therapists can report on appropriate existing measures. AOTA also has asked that eligibility requirements be expanded to include occupational therapists in settings other than private practice.
Volunteer to Work on Quality Measure Development
AOTA has periodic opportunities to nominate AOTA members to work in coalition with other disciplines to develop new PQRS measures. As part of the measurement development process, new measures are also piloted in practice settings.
If you are interested in volunteering your expertise by participating in an expert work group or helping to pilot-test new measures as they are developed, please e-mail firstname.lastname@example.org.
Share Your PQRS Experiences with AOTA
We would like to hear from occupational therapists who are participating in PQRS. Please email AOTA at email@example.com to share your feedback, experiences, and pass along tips and suggestions to other AOTA members.
MLN Matters Article SE0922 - Alternative Process for Individual Eligible Professionals to Access Physician Quality Reporting System and Electronic Prescribing (eRx) Feedback Reports
MLN Matters Article SE0830 - Steps for Eligible Professionals to Access Their Physician Quality Reporting System Feedback Reports
MLN Matters Article SE0831 - Steps for IACS Defined "Organizations" to Access Their Physician Quality Reporting System Feedback Reports
Template Letter to Share with Your Patients
American Medical Association Guide to 2011 PQRS
CMS QualityNet Help Desk
1 (866) 288-8912
7:00am – 7:00pm CT
Last updated: February 22, 2011