Skipping Out on Your PQRS Reporting Obligations?

The Physician Quality Reporting System (PQRS) now enforces hundreds of different quality measures for Medicare providers. It can be confusing for specialists such as chiropractors to discern which specific measures will affect their practice and the possible implications of reporting or not reporting on them. Let's address this conundrum and examine some of the ways health care reform is affecting reporting obligations.

The Penalty Timeline

The PQRS has been around since 2006, although it was previously called the Physician Quality Reporting Initiative (PQRI). It's designed to incentivize quality care by offering payouts to doctors who successfully report on key care metrics, which vary by practice. The 2010 Patient Protection and Affordable Care Act (PPACA) announced that PQRS participation would become mandatory by 2015. To enforce this, the Centers for Medicare and Medicaid Services (CMS) will be phasing out incentive payouts and transitioning to payout penalties over the next two years. Here's what the timeline looks like:

• 2013: Jan. 1 – Dec. 31 served as the performance period for 2015 PQRS penalty calculation.
• 2014: Jan. 1 – Dec. 31 served as the performance period for 2016 penalty calculation; it was also the last year to earn incentive payout for PQRS participation (0.5 percent of total Medicare Part B Fee Schedule).
• 2015: Penalties applied for unsatisfactory 2013 PQRS reporting (reimbursement docked 1.5 percent); final Medicaid incentives paid out for satisfactory PQRS participation during previous year.
• 2016: Penalties applied for unsatisfactory 2014 PQRS reporting (reimbursement docked 2 percent).

Three Vital PQRS Measures

As you can see, change is happening fast. That's why it's important for you to develop an understanding of what quality measures your practice needs to report on. In order to fill and file PQRS reports, physicians use "G-codes" indicating their actions on specific measures for each patient. Then, at the end of the year (typically before a February deadline), they must submit claims on paper or digitally to CMS.

There are three measures which specifically apply to doctors of chiropractic. To receive incentive payout and avoid penalties, DCs will need to have satisfactorily reported on these three measures at least 50 percent of the time for Medicare patients, and for every Medicare patient who is at least age 18 and has reported a spinal manipulation code.

1. Measure #131: Pain Assessment and Follow-Up

• Use a standardized tool – Brief Pain Inventory (BPI), Faces Pain Scale (FPS), Numeric Rating Scale (NRS), etc. – to conduct initial pain assessment.
• Enact a follow-up plan involving reassessment of pain.
• Document the follow-up plan if pain assessment is positive.
• Follow-up plan includes follow-up appointment, referral, notification of other providers, or initial treatment plan still in effect.

2. Measure #182: Functional Outcome Assessment

• Use a standardized tool – Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), etc. – to conduct functional outcome assessment.
• Create a treatment plan to address functional deficiencies found.
• Document the treatment plan.
• Use the functional outcome assessment tool at least once every 30 days.

3. Measure #137: Preventative Care and Screening for High Blood Pressure & Follow-Up Documented

• Conduct high blood pressure screening at least once per reporting period (current period: Jan. 1 – Dec. 31, 2015)
• Enact a follow-up plan when blood pressure is above normal.
• See ACA guidebook to 2014 PQRS for specific blood pressure classifications and recommended follow-ups.

The G-codes for each of these measures (used to indicate what actions the physician did or did not take and what documentation was made) are listed in the 2014 PQRS Quality-Data Code List. Condensed versions can be found on trade sites such as the ACA website

Time to Act

On a related note, the window is also closing fast for electronic health record (EHR) conversion. Starting this year, providers who have not adopted meaningful use (MU) certified EHR technology will be penalized 1 percent of their Medicare payouts. So, if you haven't implemented a chiropractic EHR or started recording quality measures, time is of the essence.

If you're in the market for an EHR, there are certified EHR systems that offer integrated quality measure capture and electronic submission. The Office of the National Coordinator for Health Information Technology (ONCHIT) also offers a great online tool for checking the CEHRT status and quality measure reporting abilities of other vendors.

The U.S. health care system is undergoing sweeping compliance changes when it comes to patient care and record-keeping, but with a little research and self-education, specialists in every field can stay ahead of the curve and avoid unnecessary penalties.