CMS Provides Guidance on PQRS Feedback Reports and the PQRS Informal Review Process for 2015 Results: What ACG members need to know

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    Whitfield L. Knapple, MD, FACG Chair, ACG National Affairs

    Whitfield L. Knapple, MD, FACG
    Chair, ACG National Affairs

    Each year, physicians and group practices receive “PQRS feedback reports” detailing whether they satisfactorily participated in PQRS, or whether they are subject to the future payment cuts.

    CMS recently announced that these payment adjustment letters are anticipated to be sent later this summer.  CMS also provided further guidance described below.

    Basic Background

    PQRS applies a 2% payment cut to 2017 payments under the Medicare Physician Fee Schedule (MPFS) to individual eligible professionals (EPs) and PQRS group practices who did not satisfactorily report PQRS data in 2015.   Individual EPs and PQRS group practices must have met the criteria for satisfactorily reporting PQRS data in 2015 for covered professional services to avoid the negative payment adjustment in 2017 (2015 program participation affects payment adjustments in 2017).

    Individual EPs are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN).

    Group practices participating in PQRS via the group practice reporting option (GPRO) are referred to as PQRS group practices and are identified by their TIN.

    What is in this feedback report?

    The reports provide information about whether an individual EP satisfactorily reported PQRS measures as well as the payment adjustment status. A report will be generated for each TIN/NPI combination or PQRS group practice if one of the following scenarios apply:

    • Individual EPs or PQRS group practices submitted PQRS quality data through one of the approved reporting mechanisms.
    • EPs submitted MPFS claims that included denominator-eligible instances but did not submit PQRS quality data.

    The data displayed in these PQRS feedback reports include:

    • Provider level data
    • Reporting mechanism level (claims, registry, QCDR, EHR)
    • PQRS Measure level
    • Reporting rate and available supporting data elements for the measure-applicability validation (MAV) process will be reported. MAV eligibility notes and other satisfactorily reporting criteria addendum notes have been added to the reports.

    How do I access this feedback report?

    You can also access the feedback report via CMS’ “Enterprise Identity Management System” (EIDM).  EIDM is accessible from the CMS Enterprise Portal at https://portal.cms.gov.

    After you establish an EIDM account, follow these steps to access your PQRS Feedback Reports:

    1. Log-in to the CMS Enterprise Portal: https://portal.cms.gov
    2. Select “login to CMS Secure Portal”, accept the Terms and Conditions, and enter your EIDM User ID and password to log in.
    3. Select the “PV-PQRS” tab, and the “Feedback Reports” option.

    Quick Reference Guides are available for assistance with roles and EIDM accounts in the Physician and Other Health Care Professionals Quality Reporting Portal.

    Why is this Important? PQRS Informal Review

    If you believe that a 2017 negative PQRS payment adjustment was applied in error, you can submit an informal review request.  An informal review is a process that allows individuals and group practices to request a review of their payment adjustment determination.  With an informal review request, CMS will investigate whether or not the outcome was appropriate.

    If it is determined that satisfactory reporting was achieved, CMS will reverse the application of the negative PQRS payment adjustment.

    Individual EPs or support staff submit a request for an informal review for each TIN/NPI that submitted 2015 PQRS data.  The informal review is at the TIN/NPI level, so a separate request must be submitted for each TIN and NPI in question.

    Important Note: The informal review decision will be final and there will be no further review.

    How to Submit a Review?

    To submit a 2015 PQRS informal review request, go to the Quality Reporting Communication Support Page (CSP) (Note: available fall of 2016).

    For detailed information about submitting an informal review request, please refer to the “2015 Physician Quality Reporting System (PQRS): 2017 Negative Payment Adjustment -Informal Review Made Simple” on the PQRS Payment Adjustment Information webpage

    Are These PQRS Reports Different From QRURs?

    Yes.  Annual Quality Resource and Usage Reports (QRURs) are at the TIN level and show the TIN’s actual performance on all of the quality and cost measures.  These are used to calculate the 2017 Medicare Value-Based Payment Modifier.

    CMS expects these reports to be available in Fall 2016.

    For more information on 2015 PQRS feedback reports and how to request them, visit the How to Obtain a Quality Resource and Usage Report (QRUR) webpage.

    Whitfield L. Knapple, MD, FACG

    Chair, ACG National Affairs Committee

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