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Payment Adjustment Information

Physician Quality Reporting System (PQRS) Payment Adjustment Information

Eligible professionals who do not satisfactorily report data on quality measures for covered professional services will be subject to a payment adjustment under PQRS beginning in 2015.

The PQRS payment adjustment applies to all of the eligible professional’s Part B covered professional services under the Medicare Physician Fee Schedule (PFS).

Accordingly, eligible professionals receiving a payment adjustment in 2015 will be paid 1.5% less than the MPFS amount for that service. For 2016 and subsequent years, the payment adjustment is 2.0%.

2016 PQRS Payment Adjustment

In 2014, if an eligible professional or group practice does not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% payment adjustment will apply in 2016.

The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an eligible professional or group practice during 2016.

If reporting for PQRS through another CMS program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to earn a PQRS incentive and/or avoid the PQRS payment adjustment.  Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, eligible professionals should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier (VBM), etc. requirements of each of these programs.

Avoiding 2016 PQRS Payment Adjustments

For Individual Eligible Professionals

Eligible professionals can avoid the 2016 payment adjustment by meeting one of the following criteria during the 2014 PQRS program year:

1. Meet the requirements to satisfactorily report or satisfactorily participate for incentive eligibility as defined in the 2014 PQRS measure specifications (same criteria as 2014 PQRS incentive eligibility)

2. Report at least 3 measures covering one NQS domain for at least 50 percent of the eligible professional’s Medicare Part B FFS patients via claims or qualified registry

• An eligible professional that reports fewer than 3 measures covering at least 1 NQS domain via claims or qualified registry- reporting will be subject to the Measure-Applicability Validation (MAV) process, which will allow CMS to determine whether additional measures domains should have been reported.

3. Participate via a qualified clinical data registry (QCDR) that selects measures for the eligible professional, of which at least 3 measures covering a minimum of 1 NQS domain AND submits measures for at least 50% of applicable patients seen during the participation period to which the measure applies

For Group Practices

Group practices participating in the Group Practice Reporting Option (GPRO) can avoid 2016 payment adjustments by meeting one of the following criteria during the 2014 PQRS program year:

1. Meet the requirements for satisfactorily reporting for incentive eligibility as defined in the applicable 2014 PQRS measure specifications

2. Report at least 3 measures covering one NQS domain for at least 50 percent of the group practice’s Medicare Part B FFS patients via qualified registry

• Report 1-8 measures covering 1-3 NQS domains for which there is Medicare patient data (subjecting the group practice to the MAV process*), AND report each measure for at least 50% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

*A group practice who reports fewer than 3 measures covering 1 NQS domain via the registry-based reporting mechanism will be subject to the MAV process, which would allow CMS to determine whether a group practice should have reported on additional measures.

Payment Adjustment Resources

2014 Physician Quality Reporting System (PQRS):  2016 PQRS Payment Adjustment  - This tip sheet provides information on the 2016 PQRS payment adjustment and guidance on how individual eligible professionals and group practices can avoid the 2016 PQRS payment adjustment. Information provided in this tip sheet is based on the 2014 Medicare PFS Final Rule.

PQRS: What’s New for 2014 - This tip sheet provides information on the 2016 PQRS payment adjustment and guidance on how individual eligible professionals and group practices can avoid the 2016 PQRS payment adjustment (Appendix 3). Information provided in this tip sheet is based on the 2014 Medicare PFS Final Rule.

Payment Adjustment Regulation

The criteria for satisfactorily reporting data on quality measures in 2014 to avoid the 2016 PQRS payment adjustment are detailed in the 2014 Medicare Physician Fee Schedule Final Rule.