Physician Quality Reporting System & the Electronic Prescribing (eRx) Incentive Program 2011...

Physician Quality Reporting System & the Electronic

Prescribing (eRx) Incentive Program

2011 Overview

December 9, 2010

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DisclaimersThis presentation was current at the time it was published or uploaded onto the

web. Medicare policy changes frequently so links to the source documents have been provided within the

document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose

obligations. Although every reasonable effort has been made to assure the accuracy of the information

within these pages, the ultimate responsibility for the correct submission of claims and response to any

remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS)

employees, agents, and staff make no representation, warranty, or guarantee that this compilation of

Medicare information is error-free and will bear no responsibility or liability for the results or

consequences of the use of this guide. This publication is a general summary that explains certain

aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions

are contained in the relevant laws, regulations, and rulings.

CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registered

trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to

Government Use. Fee schedules, relative value units, conversion factors and/or related components are

not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA

does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no

liability for data contained or not contained herein.

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2011 Overview

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Toward Value-Based Purchasing

VBP

2007•

TRHCA

• 74 measures

• Claims-based only

2008•

MMSEA

• 119 measures

• Claims

• 4 Measures Groups

• Registry

2009• MIPPA

• 153 measures

• Claims


• Registry

• EHR-testing

• eRx

2010• MIPPA

• 175 individual measures

• Claims


• Registry

• EHRs

• eRx

• Large Groups

2011

• ARRA and ACA

• 190 individual measures

• Claims


• Registry

• EHRs

• eRx

• Large Groups

• Small Groups

• Maintenance of Certification

• Physician Compare Web Site

2011 PFS Final Rule

• Requirements and measures for the 2011 Physician

Quality Reporting System, the 2011 eRx incentive, the

2012 eRx payment adjustment, and 2013 eRx payment

adjustment are described in the 2011 PFS final rule with

comment period

• The 2011 Medicare PFS final rule with comment period

was published in the Federal Register on November 29,

2010.

• To view the entire rule, go to:

http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf

• Public comment period ends January 3, 2011

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http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf

Physician Quality Reporting System

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2011 Physician Quality Reporting System Overview

• 1% Incentive Payment

• Reporting Mechanisms for Individual Eligible Professionals

– Claims

– Qualified Registry

– Qualified EHR

• Reporting Periods for Individual Eligible Professionals

– 12 months - Jan. 1, 2011 - Dec. 31, 2011

– 6 months - Jul. 1, 2011 - Dec. 31, 2011 (claims and registry-based

reporting only)

• Individual eligible professionals may report individual

Physician Quality Reporting System measures or measures

groups

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2011 Criteria for Satisfactory Reporting of Individual Measures

*Eligible professionals who report on fewer than 3 measures may be subject to the Measure Applicability Validation process.

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Reporting Mechanism(s)

Reporting Period(s)

Criteria for Satisfactory Reporting of Individual Measures

Claims Jan 1, 2011- Dec 31, 2011

Report at least 3 Physician Quality Reporting System measures, (or 1-2 measures if fewer than 3 apply*); and

or

Jul 1, 2011- Dec 31, 2011

Report each measure for at least 50% of applicable Medicare Part B FFS patients seen during the reporting period (revised)

2011 Criteria for Satisfactory Reporting Individual Measures (cont)

*Measures with a 0% performance rate will not be counted (new) 8


Reporting Period(s)

Criteria for Satisfactory Reporting of Individual Measures

Registry Jan 1, 2011 - Dec 31, 2011

Report at least 3 Physician Quality Reporting System measures*; and

or Jul 1, 2011- Dec 31, 2011

Report each measure for at least 80% of applicable Medicare Part B FFS patients seen during the reporting period

EHR Jan 1, 2011- Dec 31, 2011

Report at least 3 Physician Quality Reporting System EHR measures*; and

Report each measure for at least 80% of applicable Medicare Part B FFS patients seen during the reporting period

2011 Criteria for Satisfactory Reporting of Measures Groups

*For registry-based reporting, measures groups with a 0% performance rate will not

be counted (new)

**Eligible professionals reporting measures groups using the registry-based reporting

mechanism will no longer be able to report on non-Medicare FFS patients (new)

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Reporting Period(s)

Criteria for Satisfactory Reporting of Measures Groups

Claims or Registry

Jan 1, 2011- Dec 31, 2011

Report at least 1 Physician Quality Reporting System measures group*; and

Report each measures group for at least 30 Medicare FFS patients seen during the reporting period**

2011 Criteria for Satisfactory Reporting of Measures Groups (cont)


Reporting Period


Claims Jan 1, 2011- Dec 31, 2011

Report at least 1 Physician Quality Reporting System measures group;

Report each measures group for at least 50% of applicable Medicare Part B FFS patients seen during the reporting period (revised); and

Report each measures group for at least 15 Medicare Part B FFS patients seen during the reporting period

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Reporting Period


Claims Jul 1, 2011- Dec 31, 2011

Report at least 1 Physician Quality Reporting System measures group;

Report each measures group for at least 50% of applicable Medicare Part B FFS patients seen during the reporting period (revised); and


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Reporting Period(s)


Registry Jan 1,2011- Dec 31, 2011

Report at least 1 Physician Quality Reporting System measures group*;

Report each measures group for at least 80% of applicable Medicare Part B FFS patients seen during the reporting period; and


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*Measures groups with a 0% performance rate will not be counted (new)



Reporting Period(s)


Registry Jul 1, 2011- Dec 31, 2011

Report at least 1 Physician Quality Reporting System measures group*;

Report each measures group for at least 80% of applicable Medicare Part B FFS patients seen during the reporting period; and


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*Measures groups with a 0% performance rate will not be counted (new)

2011 Physician Quality Reporting System Measures

• Retirement of 5 measures: #114, #115, #136, #139, #174

• 194 measures*, including 5 new measures for claims and registry reporting, 11 new registry-only measures, and 4 new measures for EHR-based reporting only

• 20 EHR measures

• 14 measures groups -

– Includes 1 new measures group (asthma)

* This includes the 4 measures in the Back Pain Measures Group, which cannot be reported individually

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2011 Options for Group Practice Reporting- GPRO I

• For self-nominated groups with 200 or more eligible professionals

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Reporting Mechanism

Reporting Period

Criteria for Satisfactory Reporting

Completion of pre-populated data collection tool for an assigned set of Medicare beneficiaries

Jan 1, 2011- Dec 31, 2011

Report on all 26 measures included in tool, which address diabetes, HF, CAD, preventive care, and HTN; and

Complete tool for at least 411 consecutively assigned beneficiaries per disease module and preventive care module

2011 Options for Group Practice Reporting - GPRO II (new)

• Pilot for approx. 500 self-nominated groups

with less than 200 eligible professionals

• Reporting Mechanism - claims (or, if the

only measures groups that apply to the

practice are the registry-only measures

groups, registry)

• Reporting Period- Jan 1, 2011- Dec 31,

2011

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2011 Options for Group Practice Reporting - GPRO II (cont)

Group size (# of eligible professionals)

# of measures groups required to be reported

Min. # of Medicare Part B patients in denominator for satisfactory reporting of measures groups

# of individual measures required to be reported

% of Medicare Part B patients in denominator for satisfactory reporting of individual measures via claims

% of Medicare Part B patients in denominator for satisfactory reporting of individual measures via registries

2-10 1 35 3 50% 80%

11-25 1 50 3 50% 80%

26-50 2 50 4 50% 80%

51-100 3 60 5 50% 80%

101-199 4 100 6 50% 80%

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Additional 0.5% Incentive

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• Under the Affordable Care Act, physicians who satisfactorily report Physician Quality Reporting System measures for the Jan 1, 2011-Dec 31, 2011 reporting period can qualify for an additional 0.5% incentive for 2011, if the physician more frequently than is required to qualify for or maintain board certification status:– Participates in a Maintenance of Certification

Program and– Successfully completes a qualified Maintenance of

Certification Program practice assessment

Informal Review Process

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• The Affordable Care Act requires CMS to establish an informal process for eligible professionals to seek a review of the determination that an eligible professional did not satisfactorily submit data on Physician Quality Reporting System measures.

• Requests for an informal review must be emailed to the QualityNet Help Desk at [email protected] within 90 days of the release of the professional’s 2011 feedback report.

• A written response will be provided within 60 days of receiving the original request.

mailto:[email protected]

Public Reporting of Physician Quality Reporting System Data

• MIPPA requires CMS to post on a website the names of eligible professionals and group practices who have satisfactorily reported under the Physician Quality Reporting System

• This information, for 2011, will be posted on the Physician Compare Website (the Affordable Care Act requires CMS to develop this website by January 1, 2011) after the 2011 incentive payments are made in 2012

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Other Affordable Care Act Provisions

• Physician Quality Reporting System incentives through 2014

– 1% for 2011

– 0.5% for 2012- 2014

• Physician Quality Reporting System payment adjustment

beginning 2015

– 1.5% payment adjustment for 2015

– 2% payment adjustment for 2016 and each subsequent year

• Develop plan to integrate reporting under the Physician Quality

Reporting System and reporting under EHR Incentive Program

by 1/1/2012

• Timely feedback

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Electronic Prescribing (eRx) Incentive Program

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2011 eRx Incentive Program

• An eligible professional or group practice must have a qualified eRx system to participate

• Report the 2011 eRx measure - Numerator - G8553:At least one prescription created during the

encounter was generated and transmitted electronically using a qualified eRx system

- Denominator - 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

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2011 eRx Incentive

• 1% Incentive Payment (not available to professionals receiving 2011 incentive from Medicare EHR Incentive Program)

• Reporting Period– Jan 1, 2011- Dec 31,2011

• Reporting Mechanisms– Claims, qualified registry, qualified EHR

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How Individual Eligible Professionals Can Qualify for the 2011 Incentive

• Become a successful e-prescriber– Report the eRx measure for at least 25

unique eRx events for patients in the denominator of the measure

• At least 10% of eligible professional’s charges based on codes in the denominator of the measure

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How Group Practices Can Qualify for the 2011 Incentive

• Participate in the 2011 Physician Quality Reporting System under GPRO I or GPRO II

• Become a successful e-prescriber– Depending on the group’s size, report the eRx

measure for 75-2,500 unique eRx events for patients in the denominator of the measure

• At least 10% of eligible professional’s charges based on codes in the denominator of the measure

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2012 eRx Payment Adjustment

• The PFS amount for covered professional services furnished by an eligible professional (or group practice) who is not a successful e-prescriber will be reduced by 1% in 2012

• Reporting Period: Jan 1, 2011- Jun 30, 2011• Reporting Mechanism: Claims• Payment adjustment does not apply if <10% of an eligible

professional’s (or group practice’s) allowed charges for the Jan 1, 2011 – Jun 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure

• Earning an EHR incentive for 2011 will not exempt an eligible professional or group practice from the payment adjustment

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How an Individual Eligible Professional Can Avoid the 2012 eRx Payment Adjustment

• The eligible professional– is not a physician (MD, DO, or podiatrist), nurse

practitioner, or physician assistant as of Jun 30, 2011- Based on primary taxonomy code in NPPES or- The eligible professional reports the G-code indicating

that (s)he does not have prescribing privileges once on claims prior to Jun 30, 2011 (G8644)

– does not have at least 100 cases containing an encounter code in the measure denominator

– becomes a successful e-prescriber

– Report the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure

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How a Group Practice Can Avoid the 2012 eRx Payment Adjustment

• For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice must become a successful e-prescriber- Depending on the group’s size, report the eRx

measure for 75-2,500 unique eRx events for patients in the denominator of the measure

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Hardship Exemption for eRx Payment Adjustment

• CMS may, on a case-by-case basis, exempt an eligible professional from the application of the eRx payment adjustment if compliance with the requirement for being a successful e-prescriber would result in a significant hardship.

• This exemption is subject to annual renewal. • For the 2012 eRx payment adjustment, the following

circumstances would constitute a hardship:– The eligible professional practices in rural area with limited

high speed internet access or– The eligible professional practices in an area with limited

available pharmacies for electronic prescribing

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Hardship Exemption for eRx Payment Adjustment (cont)

• G-codes have been created to address the 2 hardship circumstances (G8642 and G8643)

• To request a hardship exemption for the 2012 payment adjustment, – An eligible professional must report the

appropriate G-code on claims prior to Jun 30, 2011

– A group practice must submit this request at the time it self-nominates to participate in eRx GPRO I or GPRO II

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2013 eRx Payment Adjustment

• The PFS amount for covered professional services furnished by an eligible professional (or group practice) who is not a successful e-prescriber will be reduced by 1.5% in 2013

• Reporting Period: Jan 1, 2011- Dec 31, 2011• An eligible professional or group practice that is a

successful e-prescriber for the 2011 eRx incentive will be considered a successful e-prescriber for purposes of the 2013 payment adjustment

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Public Reporting of eRx Data

• MIPPA requires CMS to post on a website the names of eligible professionals and group practices who are successful e-prescribers

• This information for 2011 will be posted on the Physician Compare Website, which CMS is required to develop by Jan 1, 2011 under the Affordable Care Act, after the 2011 incentive payments are made in 2012

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Important Dates

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2010 Submission Deadlines

• January 2, 2011 - January 31, 2011 – Test submission period for registries and eligible professionals utilizing the EHR-based reporting mechanism for the 2010 Physician Quality Reporting System and/or eRx Incentive Program

• February 1, 2011 - March 31, 2011 – Data submission period for registries, GPROs and eligible professionals utilizing the EHR-based reporting mechanism for the 2010 Physician Quality Reporting System and/or eRx Incentive Program

• February 28, 2011 – Date by which 2010 claims must be processed to be included in 2010 Physician Quality Reporting System and eRx Incentive Program analyses

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Self-Nomination Deadlines

• January 31, 2011 – Registry self-nomination deadline for the 2011 Physician Quality Reporting System and eRx Incentive Program

• January 31, 2011 – EHR vendor self-nomination deadline for the 2012 Physician Quality Reporting System and eRx Incentive Program

• January 31, 2011 – GPRO I and II self-nomination deadline for the 2011 Physician Quality Reporting System and eRx Incentive Program

• January 31, 2011 – Maintenance of Certification Program self-nomination deadline for the 2011 Physician Quality Reporting System

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Upcoming Calls/Meetings• December 13, 2010 - National Provider Call (2:30pm-4:00pm)• December 15, 2010 - Special Open Door Forum (1:00pm – 3:00pm). The call will

describe and provide an overview of : – changes to GPRO for the 2011 program year and– the eRx payment adjustment

(Dial 1-800-837-1935 Conference ID 24749053)• February 9, 2011 – 2012 Physician Quality Reporting System Town Hall Meeting

(10:00am-4:00pm) • See the CMS Sponsored Calls page of the Physician Quality Reporting System

website for more information: http://www.cms.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage

• December 17, 2010 – deadline for submitting 2012 measure suggestions, for more information on the 2012 Call for Measures see the CMS Measures Manager website: http://www.cms.gov/MMS/13_Call%20for%20Measures.asp#TopOfPage

• **March 2011 - Special Open Door Forum- We are seeking Eligible Practitioners to present Physician Reporting and eRx Success Stories. Please contact: [email protected] if you would like to present.

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http://www.cms.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage

http://www.cms.gov/MMS/13_Call%20for%20Measures.asp#TopOfPage

mailto:[email protected]

QualityNet Help Desk

Phone: 1-866-288-8912

TTY: 1-877-715-6222

Email: [email protected]

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