Final Rule for PQRS 2011: What Pain Physicians Can Expect
By: Justin Vaughn, CPC, M.Div
Director of Compliance

12/16/2010

As with all things “healthcare” these days, changes are in store for the Physician Quality Reporting System, or PQRS.  For example, physicians can no longer expect a 2% bonus for successfully reporting their applicable “quality measures.”  The final rule, as found in 42 CFR 414.90, stipulates that successful reporting during the 2011 reporting period will instead yield a 1% bonus—that is, an amount equal to 1% of a physician’s total allowed charges relative to all his/her Medicare claims for that period. 

It gets worse.  Beginning with the 2012 reporting period, the bonus will only be 0.5% of a doctor’s Medicare allowable charges; and starting in 2015, it appears there will be no bonus at all.  Instead, a 1.5% penalty will be assessed for failure to successfully report!

However, it’s not all doom and gloom.  One of the positive changes for the 2011 reporting period is that the 80% reporting threshold doctors have had to meet over the years has been lowered to 50% in the final rule.  In other words, a participating physician need only successfully report on 50% of the cases where his/her PQRS measures would apply.  This obviously increases physicians’ chances for earning the bonus—though that bonus will be half the amount made available for 2010 reporting.

Other elements of interest in the 2011 version of PQRS include:

•    The reporting periods will be the same as in 2010, i.e., Jan-Dec or Jul-Dec.
•    The reporting mechanisms will be the same as in 2010, i.e., via claims, registry or EHR.
•    Claims must be in by Feb 28, 2012.
•    13 of the “measures groups” will be retained from 2010, including the “back pain” measures group.

If you wish to participate in the 2011 PQRS reporting period, you may want to consider reporting on the following measures:

Back Pain Measures Group
Measure 148 – Back Pain: Initial Visit
Measure 149 – Back Pain: Physical Exam
Measure 150 – Back Pain: Advice for Normal Activities
Measure 151 – Back Pain: Advice Against Bed Rest

NOTE:  If you choose to report on any of the four measures found in the Back Pain Measures Group, you must report on all four measures in that group for each applicable patient.

Cluster 32 - Falls
Measure 154 – Falls: Risk Assessment
Measure 155 – Falls: Plan of Care

NOTE:  If either one of the above measures is reported, the provider is required to also report the other, as providers must report every measure within the verification cluster that contains any measure reported.  Measure 154 and 155 are part of Cluster 32, “Falls.”

More information regarding PQRS participation can be found by reviewing the links and downloads at: http://www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.