PQRS
Contact Melesia Tillman, 404-633-3777, x820 with claims-based questions;
Contact Melissa Francisco, 404-633-3777, x102 with Rheumatology Clinical Registry questions

PQRS Overview

Physician Quality Reporting System: 2013 Measures
There are 19 measures that will affect rheumatology practices. The incentive bonus pay for successfully reporting will be .5% of the allowable 2013 Medicare Part B Fee for Service with no cap. Also, keep in mind if your practice does not report PQRS for 2013 you will receive a 1.5% of the allowable 2013 Medicare Part B Fee for Service penalty that will be applied in 2015.

2013 PQRS – Individual Measure Reporting options

Below are the different reporting methods:

Registry-based -- RCR: (options for mid-year PQRS start)

  • Successfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS patients between January 1 - December 31, 2013.
    - or -
    Successfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS patients between July 1 - December 31, 2013

Claims-based: (January 1 start date)

  • Successfully report three or more measures for a minimum of 50 percent of applicable Medicare Part B FFS patients between January 1 - December 31, 2013.
    - or -

  • Successfully report three or more measures for a minimum of 50 percent of applicable Medicare Part B FFS patients between July 1 - December 31, 2013.

2013 PQRS – Measures group reporting options (including RA)

Registry-based -- RCR: (options for mid-year PQRS start)

  • Successfully report on a minimum of 20 patients with a majority (11) patients must be Medicare Part B FFS patients between January 1 - December 31, 2013

NOTE: For reporting options that include a minimum 80 percent requirement, this means that providers must report successfully for at least 80 percent of their patients to which the measure applies in the given time period. Providers who choose to report on only 80 percent of their patient population for a certain measure must, therefore, report with complete accuracy. Because this would allow no room for error without losing the entire incentive payment, CMS recommends that providers report on more than 80 percent of their patient population for each measure, whenever possible, even up to 100 percent.

Claims-based: (January 1 start date)

  • Successfully report on a minimum of 20 Medicare patients in the group between January 1 - December 31, 2013.

    - or -

    Successfully report on a minimum of 50 percent of patients in the group with a minimum 20 Medicare patients between January 1 - December 31, 2013

Claims-based: (option for mid-year PQRS start)

  • Successfully report on a minimum of 50 percent of patients in the group with a minimum 15 patients between July 1 - December 31, 2013 (Medicare patients only)

Note: The following option is still available for mid-year start:

Successfully report on a minimum of 20 patients in the group whose visits took place at any time in 2013 (Medicare patients only).

Exclusions

Exclusion modifiers may be appended to a CPT II code (on a claim) OR within a registry to indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some measures do not provide for performance exclusions.

Reasons for appending a performance measure exclusion modifier fall into one of four categories:

1P exclusion modifier due to medical reasons
Examples include: not indicated (absence of organ/limb, already received/performed); contraindicated (patient allergic history, potential adverse drug interaction)

2P exclusion modifier due to patient reasons
Examples include: patient declined; economic, social, or religious reasons

3P exclusion modifier due to system reasons
Examples include: resources to perform the services not available; insurance or coverage/payer-elated limitations; other reasons attributable to health care delivery system

8P reporting modifier - action not performed, reason not otherwise specified

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