The Right Incentives from Feds: Pay for Performance

March 2011 Reimbursement Corner: PQRS: CMS Pay for Performance Program

By: James M. Fox, M.D., M.B.A., F.A.C.E.P. and Sandra A. Steele, C.P.C., C.E.D.C. Recent updates to the Physician Quality Reporting Initiative (PQRI) indicate that the shift from pay for reporting to pay for performance has begun.  PQRI has been assigned a new name – Physician Quality Reporting System (PQRS) to reflect its permanence. For those physicians that reported PQRI measures in 2010, a 2% bonus can be expected this fall. For 2011, CMS has made the reporting process less cumbersome by reducing the number of claims with accurate reporting to 50% (down from 80 percent in 2010).   Incentive payments have been extended through 2014; 1% incentive payment in 2011, and a 0.05 % incentive payment is available in 2012 to 2014.  A negative payment adjustment of 1.5% will apply for noncompliance in 2015, increasing to 2% in 2016.  PQRS incentive payments are based on the total allowed, reimbursed charge for services covered under the Medicare Part B fee schedule.  As we found in the PQRI program, the amount of incentive payment, or future negative payment adjustment, can be significant. Emergency physicians typically report on 7 measures (under PQRS you will need to successfully report at least 3 measures on 50% of your eligible claims).  There have been important changes to the documentation requirements for some of the measures: Vital Signs for CAP – All four vital signs must be documented and the provider must document all vital signs or document “vital signs reviewed”. Oxygen Saturation for CAP – providers should document the oxygen saturation within their portion of the record “02 sat 96%”. Mental Status and Empiric Antibiotic Therapy for CAP – the provider should continue to document the mental status and antibiotic therapy in their record. Aspirin at Arrival for Acute Myocardial Infarction – providers should make sure all AMI patients have their aspirin status documented in the record. 12-Lead ECG performed for Non-Traumatic Chest Pain (age 40+) & 12-Lead ECG performed for Syncope (age 60+) – if these patients do not require an ECG, document the medical reason the ECG is not required.  CMS is developing a “Physician Compare” website which will publicize data on providers who satisfactorily participate in the 2011 PQRS program.  Quality reporting can no longer be ignored; if you have not yet embraced the process, it is now time to start