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What Penalties are Associated With Not Submitting PQRS Codes?
psychology and behavioral health pqrs codes

What Are the Penalties Associated With Not Submitting PQRS Codes?

If you accept Medicare Part B Fee for Service (FFS) patients, there are a lot of rules you must follow precisely to avoid penalties in the future. Don’t worry– we’re here to help you each step of the way. In this post, we’ll discuss everything you need to know about PQRS and what penalties, if any, you may face for failing to comply. Let’s jump right into it.

What is PQRS?

Be prepared for plenty of abbreviations. PQRS stands for Physician Quality Reporting System. PQRS was formerly PQRI, or the Physician Quality Reporting Initiative. It’s a voluntary quality program for the Centers of Medicare and Medicaid Services (CMS). When it was first established, PQRS was incentive-based. In 2010, the Affordable Care Act (ACA) brought about changes for the PQRS. It enacted penalties on any eligible provider who did not submit qualifying PQRS data. Also, since 2014, PQRS no longer offers incentives for reporting. Instead, incentives are given under the Physician Value Based Payment Modifier (VBM) program. PQRS is only open to providers who care for those with Medicare insurance. Both individuals and groups are welcome to join. PQRS was created with the hopes of providing the best medical care for Medicare patients. Participating individuals and groups are given scores based on their submitted quality information. This information empowers Medicare patients who use the PQRS to find the best physician for their needs. PQRS reports are used to populate the results in Physician Compare. This tool helps patients make informed decisions about their health care options.

How Do I Participate in PQRS?

You can participate in PQRS as either an individual or a group, if you have more than one person in your practice. Let’s take a look at each:

Individual Reporting

For the year 2016, individual eligible professionals (EP) must report on nine measures across three NQS domains for at least half of all Medicare Part B FFS patients you see. If less than nine measures apply (which is common in therapy practices), don’t stress. Just report on the all of applicable measures for at least half of your Medicare Part B FFS patients. You’ll be subject to the Measure-Applicability Validation (MAV) process which determines whether you must report on more measures. pqrs-reporting-rules-software-for-mental-healthFlow Chart Courtesy of It’s important to note that any measure with a 0% performance rate will not be counted by CMS.

Group Reporting

Groups with at least two eligible professionals can submit reports to PQRS. If you’re working in a practice, it may be easier for your billing and reporting staff to keep track of one set of quality measures for the entire office. It may also help you meet reporting requirements you can’t reach on your own. As with individual reporting, groups need to report on nine measures for at least half of all Medicare Part B FFS patients. These measures should cover at least three NQS domains with at least one measure qualifying as a cross-cutting measure. If your group consists of 100 or more EPs, you may report six measures across two NQS domains for at least half of your Medicare Part B FFS patients. You will also need to conduct a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey using a CMS-certified vendor. CMS will allow you to submit your PQRS data through various submission methods, including claims-based reporting, the Group Practice Reporting Option (GPRO) web interface, or direct submission from an IT system vendor. When submitting data, there are hundreds of quality measures a provider can choose from. Remember, you’ll need to submit data on at least nine quality measures across three National Quality Standard (NQS) health care quality domains. These domains include:
  • Communication and Care Coordination
  • Community/Population Health
  • Effective Clinical Care
  • Efficiency and Cost Reduction
  • Patient Safety
  • Person and Caregiver-Centered Experiences and Outcomes
You will need to do this for at least half of your Medicare Part B FFS patients. One of these quality measures should be cross-cutting. This is any measure that is broadly applicable across multiple clinical settings and eligible professionals or group practices. In therapy practices, you may find the following codes useful: PQRS 130 Documentation of Current Medications in the Medical Record NQS domain: Patient Safety PQRS 134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan NQS domain: Community/Population Health PQRS 182 Functional Outcome Assessment NQS domain: Communication and Care Coordination Here’s a list of all 2016 PQRS cross-cutting measures. pqrs-cross-cutting-measuresImage Courtesy of CMS, 2016 Cross-Cutting Measure Set

Is PQRS participation mandatory?

Although it’s not technically mandatory, you are subject to fees/penalties if you don’t participate in the PQRS while accepting Medicare Part B FFS patients. If you are eligible to participate in PQRS, you should – otherwise you will be fined and see a reduction in your Medicare Part B payments.

What are the Penalties for Not Submitting?

PQRS applies a negative payment adjustment to individual eligible professionals (EPs) and group practices who care for Medicare Part B FFS patients but do not report data on quality measures. If you do not participate in PQRS, your Medicare Part B reimbursement will be negatively adjusted at a set rate. Expect a negative 2% penalty for not participating or unsatisfactory reporting which will be extracted from your payment reimbursement for any Medicare patients.

How Do I Avoid the Penalties?

You can avoid the penalties by participating in the PQRS if you’re eligible. Be careful to report on at least nine measures covering at least three NQS domains for at least half of your Medicare Part B FFS patients.

What Do I Do Now?

As you see by now, PQRS codes can get complicated pretty quickly. If you’d like to avoid the stress of not filing codes correctly or on time, we’ve got you covered. TheraNest can actually track important PQRS updates and do the reporting for you. In fact, you’ll find that TheraNest makes all of your invoicing easier. Try TheraNest free for 21 days– no credit card required. Click here to start your free trial.

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