PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs) including Clinical Social Workers.
The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).
Beginning in 2015, the program also applies a payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services. This website serves as the primary and authoritative source for all publicly available information and CMS-supported educational and implementation support materials for PQRS.
Stay informed about the latest PQRS news by subscribing to the PQRS Listserv.
Using Medicare PQRS 2014 Individual Measures in Clinical Practice (PDF)
PQRS Frequently Asked Questions by Clinical Social Workers
During 2014, clinical social workers who are Medicare providers should demonstrate quality care by reporting the Physician Quality Reporting System (PQRS) or receive a two percent penalty in 2016 for not using PQRS. The penalty increases each year PQRS is not used. PQRS identifies measures that may be used by clinical social workers to improve the quality of care provided to Medicare beneficiaries. To assist clinical social workers in reporting PQRS, NASW has developed the following document, Using Medicare PQRS 2014 Individual Measures in Clinical Practice, which is available online at the following link:
NASW has compiled a list of frequently asked questions by its members from “An Hour With Private Practice: Questions and Answers,” to help other clinical social workers in private practice understand how the PQRS program works.
Q: What is a quality data code?
A: A quality data code (QDC) identifies a measure used by a Medicare provider to submit PQRS data via a claims-based or other reporting method.
Q: How is the quality data code reported?
A: On the second line following the documentation of psychotherapy services on the CMS-1500 form, the quality data code is reported under the heading of CPT/HCPCS on item line 24D.
Q: Is there a reporting alternative available to clinical social workers who have less than nine PQRS measures available to report?
A: For clinical social workers, 1-8 measures covering 1-3 domains may be reported.
Q: What are domains?
A: Domains are identified by the National Quality Strategy as a list 6 priorities that address the most common health concerns that Americans face: They are:
- Patient Safety
- Person and Caregiver-Centered
- Experience and Outcomes
- Communication and Care Coordination
- Effective Clinical Care
- Community/Population Health
- Efficiency and Cost Reduction
Q: Where are the domains reported?
A: The domains are reported in the patient’s clinical record when using PQRS.
Q: How do clinical social workers know if their PQRS information was accepted on the claim form?
A: On the Explanation of Benefits, denial code N365 is indication that the quality data code was received into the Centers for Medicare and Medicaid Services (CMS) claims database. N365 reads, “This procedure code not payable. It is for reporting/information purposes only.” Effective July 1, 2014, N365 will be replaced by N620.
Q: What is reported for charges when using PQRS?
A: For 2014 charges, report $0.01. This is a non-chargeable fee provided to help ensure quality data codes are processed in the CMS claims database.
Q: Is PQRS reported on all patients?
A: PQRS reporting is required on at least 50 percent of the Medicare Part B fee-for-service patients in your caseload.
Q: When is the last day to report PQRS?
A: For 2014, PQRS must be filed by February 27, 2015.
Q: Are there pediatric PQRS measures available for use by clinical social workers?
A: For clinical social workers, Measure Number 134 is available for use with children 12 years and older. It reads: Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan.
Q: Is Measure Number 131, Pain Assessment and Follow-Up, available for use by clinical social workers?
A: In 2014, the Pain Assessment and Follow-Up measure is problematic for clinical social workers because only the psychiatric diagnostic assessment code is listed for use in the numerator. This measure is to be reported for each psychiatric service which cannot be done by reporting a diagnostic assessment code for each therapeutic session.
Q: How many PQRS measures are available for use by clinical social workers?
A: Of the 110 PQRS claim measures, 8 measures are available for use by clinical social workers.
Q: How often does one report a PQRS measure?
A: Each measure specification lists the reporting criteria which may vary. The NASW PQRS document describes the reporting criteria for each measure available for use by clinical social workers.
Q: Can a claim be resubmitted to correct PQRS information?
A: A claim cannot be resubmitted to correct PQRS information.
Q: Is PQRS also used with a Medicare Advantage Plan?
A: No, PQRS is reported with Medicare Fee-for-Service, Medicare Secondary Payer Program, and the Railroad Retirement Board.
Q: Are clinical social workers able to report Measure Number 247: Substance Use Disorder Counseling Regarding Psychosocial and Pharmacologic Options for Alcohol Dependence?
A: Measure Number 247 is not recommended for use by clinical social workers because pharmacologic treatment is not within the scope of practice for clinical social workers.
Q: What happens if clinical social workers who are Medicare providers do not report PQRS?
A: In 2014, clinical social workers who do not report PQRS, will be penalized two percent of their Medicare allowable charges in 2016.
Q: Is there a PQRS hotline available to call for assistance?
A: To assist clinical social workers and other Medicare providers, CMS offers assistance from the Quality Net Help Desk, Monday – Friday, 7:00 am – 7:00 pm CST. The phone numbers are 866.288.8912 and TTY: 877.715.6222. The email address is Qnetsupport@sdps.org
Physician Quality Reporting System (PQRS) Overview
The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals (EPs) to report on specific quality measures.
PQRS gives participating EPs the opportunity to assess the quality of care they are providing to their patients, helping to ensure that patients get the right care at the right time. By reporting PQRS quality measures, providers also can quantify how often they are meeting a particular quality metric. Using the feedback report provided by CMS, EPs can compare their performance on a given measure with their peers.
Choosing How to Participate
The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]), or group practices participating in the group practice reporting option (GPRO) who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).
To participate in the 2014 PQRS program, individual EPs may choose to report quality information through one of the following methods:
- Medicare Part B claims
- Qualified PQRS registry
- Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT)
- CEHRT via Data Submission Vendor
- Qualified clinical data registry (QCDR)
EPs should consider which PQRS reporting method best fits their practice when making this decision.
Group practices participating through the Group Practice Reporting Option (GPRO) in the 2014 PQRS program year can participate through one of the following methods:
- Qualified PQRS registry
- Web interface (for groups of 25+ only)
- Direct EHR using CEHRT
- CEHRT via Data Submission Vendor
- CG CAHPS CMS-certified survey vendor (for groups of 25+ only)
For more information about participating in PQRS as a group, visit the Group Practice Reporting Option webpage.
Quality measures are developed by provider associations, quality groups, and CMS and are used to assign a quantity, based on a standard set by the developers, to the quality of care provided by the EP or group practice.
The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method.
When selecting measures for reporting, eligible professionals should consider factors such as:
- Clinical conditions commonly treated
- Types of care delivered frequently – e.g., preventive, chronic, acute
- Settings where care is often delivered – e.g., office, emergency department (ED), surgical suite
- Quality improvement goals for 2014
- Other quality reporting programs in use or being considered
For more information on selecting measures, review the Measures Codes webpage.
Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms above for services furnished during the 2014 reporting period will qualify to earn an incentive payment. If they qualify, they will receive an incentive payment equal to 0.5% of their total estimated Medicare Part B PFS allowed charges for covered professional services furnished during that same reporting period. For more information about PQRS incentive payments visit the Analysis and Payment webpage.
EPs who do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2% payment adjustment to their Medicare PFS amount for services provided in 2016.
For more information about PQRS payment adjustments visit the Payment Adjustment Information webpage.
EPs who report PQRS quality measures data can request to receive National Provider Identifier (NPI)-level Physician Quality Reporting Feedback Reports.
The reports include information on reporting rates, clinical performance, and incentives earned by participating individual professionals, with summary information on reporting success and incentives earned at the practice level. The feedback reports can be accessed through the Web portal in the fall of the year following the reporting (e.g. 2013 feedback reports will be available in the fall of 2014).
Maintenance of Certification Program
In 2014, EPs have the opportunity to earn the PQRS incentive and an additional incentive of 0.5% by working with a Maintenance of Certification entity. Here is what is required:
- Satisfactorily submitting data, without regard to method, on quality measures under PQRS, for a 12-month reporting period either as an individual physician or as a member of a selected group practice
- More frequently than is required to qualify for or maintain board certification:
- Participate in a Maintenance of Certification Program and
- Successfully complete a qualified Maintenance of Certification Program practice
For more information about the program, visit the Maintenance of Certification Program Incentive webpage.
Value-Based Payment Modifier Program
The Value-Based Payment Modifier (VM) Program will provide comparative performance information to physicians as part of Medicare's efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.
In 2016, groups with 10 or more EPs who submit claims to Medicare under a single tax identification number will be subject to the value modifier, based on their performance in 2014. These groups will need to register and choose one of the PQRS GPRO quality reporting methods.
If a group does not choose to report quality measures as a group, and at least 50% of the EPs within the group report PQRS measures individually, CMS will calculate a group quality score based on their reporting. Failing to report will result in a negative 2% value modifier adjustment to 2016 payment under the PFS. The VM adjustment is in addition to the PQRS payment adjustment.
EPs who have questions or need assistance with PQRS reporting should contact the QualityNet Help Desk. The help desk is available Monday–Friday; 7:00 AM–7:00 PM CST:
Step-by-Step Instruction in Getting Started with the Physician Quality Reporting System (PQRS)
2014 – 2016 PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) TIMELINE
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