08. April 2014 · Comments Off on Understanding PQRS and Negative Payment Adjustments: · Categories: Uncategorized

Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of  incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs) and group practices1. The program provides an incentive payment to practices  with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who successfully report clinical quality data for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer). 1

Voluntary reporting program with Negative Payment Adjustments:

PQRS allows Eligible Providers to “voluntarily report” quality reporting measures, it will start enforcing negative payment adjustments starting in 2015.  As per Section 1848(a)(8) of the Social Security Act, Centers for Medicare & Medicaid is required to subject eligible professionals (EPs) and group practices who do not report data on Physician Quality Reporting System (PQRS) quality measures for covered professional services during the 2013 program year for a payment adjustment beginning in 2015.2

1.5%  negative payment adjustment will occur in 2015 (EP or group practices participating in GPRO will receive 98.5% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services).2

In calendar year 2013, medical practice groups of 100 or more EPs (all of whom file Medicare PFS claims using a single tax identification number) must register and participate in PQRS as a group in order to avoid an additional negative 1.0% payment adjustment in 2015 under the Value-based Payment Modifier. 2

Just as 2015, Section 1848(a)(8) of the Social Security Act, requires the CMS to subject EPs and group practices to a payment adjustment in 2016. EPs and group practices receiving a PQRS payment adjustment in 2016 will be paid 2.0% less than the PFS amount for services rendered January 1- December 31, 2016 (or receive 98% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services). The reporting period for the 2016 PQRS payment adjustment is the 2014 program year. 3

Avoid 2016 Negative Payment Adjustment: 3

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Sources:

1:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

2:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf

3:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014PQRS__Avoiding2016PQRS-PaymentAdjustment_F03-27-2014.pdf

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