The PQRS Survival Guide | Maximizing Reimbursement

January 22nd, 2016 - By Kevin V. Nguyen

On February 26, 2016, the Physician Quality Report System (PQRS) data from Medicare providers who see Medicare Part B patients is due. By understanding the ins-and-outs of the PQRS system, you will save your practice time and money.

PQRS in a Nutshell

The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. By reporting on PQRS quality measures, individual EPs and group practices can also quantify how often they are meeting a particular quality metric.

If you are enrolled as a Medicare provider the data submissions are required. Unfortunately, if the data sent is not satisfactory, there will be a negative payment adjustment. Almost 40% of eligible providers are being penalized for not reporting PQRS in 2013.

Who Is Required to Participate in PQRS?

You must be enrolled as a Medicare provider who sees Medicare Part B patients and has a national provider identifier (NPI) number. As of Jan. 1, 2011, you must also be enrolled in the Medicare PECOS system.

According to the CMS, the professionals eligible to participate are:

  • Medicare physicians: Doctor of Medicine, Osteopathy, Podiatric Medicine, Optometry, Oral Surgery, Dental Medicine, and Chiropractic
  • Practitioners: Physician Assistant, Nurse Practitioner*, Clinical Nurse Specialist*, Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant), Certified Nurse Midwife*, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologists
  • Therapists: Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist

*Includes Advanced Practice Registered Nurse (APRN)

How Do You Report Your PQRS Data?

First, you must determine whether you are participating as an individual EP or group practice:

  • Individual EPs are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN).
  • A group practice under 2015 PQRS is defined as a single Tax Identification Number (TIN) with 2 or more individual EPs who have reassigned their billing rights to the TIN. Group practices can register to participate in PQRS via the group practice reporting option (GPRO) to be analyzed at the group (TIN) level. Note that group practices participating via GPRO are referred to as PQRS group practices.

Then you must choose which reporting mechanism to submit your data through:

PQRS Measure
Source: CMS Website

Providers can submit Medicare Part B claims through PrognoCIS (option 1).

Claims-Based Reporting through PrognoCIS

Individual EPs can use PrognoCIS EHR to submit their Medicare Part B claims.

Step 1: Choosing which Individual Measures to Report

Individual EPs must choose measures from the 2016 Physician Quality Reporting System (PQRS) Measures List on the CMS Measures Codes webpage.

Sample PQRS 2016 Measures

Note: Be aware of each individual column and its purpose, not all individual measures are available via claims-based reporting. Review the measures list and determine which ones may apply.

Step 2: Satisfactory Reporting of the Measures

EPs may satisfactorily report in 2015 PQRS by meeting the following criteria:

  • At least nine (of the 280+) individual measures across 3 National Quality Strategy (NQS) domains or 1 measure group as an option to report on measures to CMS (with the exception of GPRO Web Interface).
  • One cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter.


  • EPs who submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures across less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure-Applicability Validation (MAV).
  • EPs who see 1 Medicare patient (face-to-face encounter), but do not report on 1 cross-cutting measure will be subject to MAV. (See the Analysis and Payment webpage for more information on MAV).
  • Note: Measures with a 0% performance rate will not be counted for either of the options.

Step 3: Establishing Office Workflow

Establishing an office workflow will allow each chosen measure’s denominator-eligible patient to be accurately identified on the Medicare Part B claim. Ensure that:

  • All supporting staff understands the measures selected for reporting.
  • All denominator-eligible claims for the selected measure(s) are identified and captured and reporting frequency of the selected measure(s)) is reviewed and understood.

A comprehensive PDF on claims-reporting is available on the CMS website.

Final Thoughts

The February 26 deadline is fast approaching, and submitting your data as soon as possible is a good idea. Coincidentally, those who are also eligible for the Medicare EHR Incentive Program (Meaningful Use) have the opportunity to submit their data through the PQRS EHR reporting option to fulfill the requirements for both PQRS and the Medicare EHR Incentive Program. PrognoCIS is MU-certified and fully ready for both data submissions for PQRS and Meaningful Use.

PrognoCIS is hosting a webinar for PQRS on February 16, register your spot today.

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