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Payment Adjustment Information

Individual eligible professionals (EPs) and group practices who do not satisfactorily report data on quality measures for covered professional services will be subject to a negative payment adjustment under the Physician Quality Reporting System (PQRS) beginning in 2015. Note that program participation during a calendar year will affect payments after two years (i.e. 2015 program participation will affect 2017 payments).

The PQRS negative payment adjustment applies to all of the individual EP’s or group practice’s Part B covered professional services under the Medicare Physician Fee Schedule (MPFS).

Accordingly, individual EPs and group practices receiving a negative payment adjustment in 2015 (based on participation in 2013) will be paid 1.5% less than the MPFS amount for that service. For 2016 (based on participation in 2014) and subsequent years, the negative payment adjustment is 2.0%.

2017 PQRS Payment Adjustment

In 2015, if an individual EP or group practice does not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% negative payment adjustment will apply in 2017.

The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual EP or group practice during 2017.

Disclaimer: If a group is reporting for PQRS through another Centers for Medicare & Medicaid Services (CMS) program (such as the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, or Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to avoid the PQRS payment adjustment.

Please note: Although CMS has attempted to align or adopt similar reporting requirements across quality programs, individual EPs should look to the respective quality program to ensure they satisfy the requirements for each program (such as PQRS, EHR Incentive Program, Value-based Payment Modifier (Value Modifier), etc.) in which they participate.

Avoiding 2017 PQRS Payment Adjustments

For Individual EPs

Individual EPs can avoid the 2017 negative payment adjustment by meeting the following criteria during the 2015 PQRS program year:

  • Meet the requirements to satisfactorily report or satisfactorily participate in PQRS as defined in the 2015 PQRS measure specifications. Refer to the 2015 PQRS Implementation Guide - Appendix B: Decision Tree - Avoiding the 2017 PQRS Negative Payment Adjustment for the Decision Trees designed to help participants select among the multiple reporting mechanisms available in PQRS.

Note: An individual EP reporting fewer than 9 measures covering at least 3 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.

For Group Practices

Group practices participating in PQRS GPRO can avoid the 2017 payment adjustment by meeting the following criteria during the 2015 PQRS program year:

  • Meet the requirements to satisfactorily report as defined in the applicable 2015 PQRS measure specifications. Refer to the 2015 PQRS Implementation Guide - Appendix B: Decision Tree - Avoiding the 2017 PQRS Negative Payment Adjustment for the Decision Trees designed to help participants select among the multiple reporting mechanisms available in PQRS.

Note: A PQRS group practice reporting fewer than 9 measures covering 3 NQS domain via the registry-based reporting mechanism will be subject to the MAV process, which will allow CMS to determine whether a group practice should have reported on additional measures.

2016 PQRS Payment Adjustment

In 2014, if an individual EP or group practice did not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% negative 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 individual EP or group practice during 2016.

Disclaimer: If a group is reporting for PQRS through another Centers for Medicare & Medicaid Services (CMS) program (such as the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, or Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to avoid the PQRS payment adjustment. Please note: Although CMS has attempted to align or adopt similar reporting requirements across programs, individual EPs should look to the respective quality program to ensure they satisfy the requirements for each program (such as PQRS, EHR Incentive Program, Value Modifier, etc.) in which they participate.

Avoiding 2016 PQRS Payment Adjustments

For Individual EPs

Individual EPs could have avoided the 2016 negative payment adjustment by meeting one of the following criteria during the 2014 PQRS program year:

  1. Met 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. Reported at least 3 measures covering 1 NQS domain for at least 50% of the individual EP’s Medicare Part B fee-for-service (FFS) patients via claims or qualified registry.
  3. Participated via a qualified clinical data registry (QCDR) that selects measures for the individual EP, including at least 3 measures covering a minimum of 1 NQS domain AND submitted measures for at least 50% of applicable patients seen during the participation period in which the measure applies.

*An individual EP that reported fewer than 3 measures covering at least 1 NQS domain via claims or qualified registry-reporting will be subject to the MAV process, which will allow CMS to determine whether additional measures domains should have been reported.

For Group Practices

Group practices participating in the PQRS Group Practice Reporting Option (GPRO) could have avoided the 2016 negative payment adjustment by meeting one of the following criteria during the 2014 PQRS program year:

  1. Met the requirements for satisfactorily reporting for incentive eligibility as defined in the applicable 2014 PQRS measure specifications.
  2. Reported at least 3 measures covering 1 NQS domain for at least 50% of the group practice’s Medicare Part B FFS patients via qualified registry.
  3. Reported 1-8 measures covering 1-3 NQS domains for which there is Medicare patient data (subjecting the group practice to the MAV process*), AND reported each measure for at least 50% of the group practice’s Medicare Part B FFS patients seen during the reporting period in which the measure applies.

*A group practice who reported 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

How to Report Once for 2015 Medicare Quality Reporting Programs – This beginner-level document offers guidance on aligned reporting mechanisms for both individual EPs and group practices reporting across PQRS, EHR Incentive Program, Value Modifier, and Accountable Care Organizations in order to avoid the 2017 negative payment adjustment. Please note: this document only includes aligned options and does not contain all PQRS reporting options.

How Do I Avoid the 2016 Medicare Quality Reporting Payment Adjustments – This intermediate-level document guide provides a general overview of the 2016 payment adjustments for CMS Medicare quality reporting programs, including PQRS, the Medicare EHR Incentive Program, and Value Modifier.

Understanding the 2015 Medicare Payment Adjustments – This beginner-level document provides a general overview of the 2015 payment adjustments for CMS Medicare quality reporting, including PQRS, Medicare EHR Incentive Program, and Value Modifier.  

Payment Adjustment Regulation

The criteria for satisfactorily reporting data on quality measures in 2015 to avoid the 2017 PQRS payment adjustment are detailed in the 2015 Medicare Physician Fee Schedule Final Rule.

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.