Eligibility
Do I have to participate in PQRS?
What makes me an eligible provider?
If you are a healthcare professional
providing services paid under or based on the Medicare Physician Fee Schedule,
then you are eligible to participate in PQRS. So, if you bill under Medicare
Part B for outpatient therapy services—including PT, OT, SLP, and DC—then you
must meet the requirements for satisfactory reporting, regardless of setting.
Otherwise, you will incur a financial penalty in the form of a 2% negative
adjustment of all 2018 Medicare Part B payments.
However, there are some exceptions.
According to CMS, “Some professionals may be eligible to participate per their
specialty, but due to billing method may not be able to participate,” including
“professionals who do not bill Medicare at an individual National Provider
Identifier (NPI) level, where the rendering provider’s individual NPI is
entered on CMS-1500 or CMS-1450 type paper or electronic claims billing,
associated with specific line-item services.”
Do Medicare Part A facilities have
to complete PQRS reporting?
No. PQRS does not apply to
professionals billing under Medicare Part A.
What other factors make someone
ineligible for PQRS?
You are not eligible for PQRS if
you:
- Provide Medicare Part B services, but bill under Part A
(i.e., at a facility or institution).
- Do not bill Medicare at an individual National Provider
Identifier (NPI) level, where the rendering provider’s individual NPI is
entered on CMS-1500 claim form and associated with specific line-item
services.
- Provide services payable under fee schedules or
methodologies other than the Medicare Physician Fee Schedule (this may
include services provided in federally qualified health centers,
independent diagnostic testing facilities, independent laboratories,
hospitals, rural health clinics, ambulance providers, and ambulatory surgery
center facilities).
Can a PTA enter PQRS data?
PTAs do not qualify as eligible
professionals. Thus, they cannot report PQRS. While they can assist in
gathering PQRS data, the PT must supervise/sign off on all quality actions
performed.
Will other payers, besides Medicare,
require PQRS in the future?
While the future of PQRS remains
uncertain, it likely will become part of Medicare’s Merit-based Incentive
Payment System (MIPS), which is set to go into effect in 2019 (with reporting
beginning in 2017). So, while other payers may not adopt PQRS in its current
form, you can expect to see a greater emphasis on quality data across the
entire payer spectrum as the US healthcare system shifts to a more value-based
payment environment.
I don’t use an EMR. Do I still
report PQRS?
Regardless of whether you use an
EMR, if you’re an eligible professional, you must satisfy PQRS requirements in
order to avoid incurring the 2% penalty. If you do not report via a registry
(which is the option most convenient for EMR users), then you can report via
claims. That means you must record the appropriate PQRS quality data codes
directly on the billing claim.
