MIPS|PQRS|PQRI - Articles

Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
November 7th, 2018 - Wyn Staheli, Director of Research
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
Risky Business The CMS HCC Risk Model
July 27th, 2018 - Terry Ketchersid, MD, MBA
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
The Money in MIPS
June 15th, 2018 - Diana Strubler
Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), recently announced that 91% participated in the first year of the Quality Payment Program (QPP), barely squeaking by their goal of 90%....
New Modifiers Released in 2018
February 13th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There were 13 new modifiers released in 2018, be sure you are using them if appropriate.     FY X-ray taken using computed radiography technology/cassette-based imaging    JG Drug or biological acquired with 340b drug pricing program discount    QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was ...
Using a 2015 Certified EHR in MIPS Year 2
February 1st, 2018 - Diana Strubler
The following information is from BC Advantage. As of Dec 31, 2017, Acumen EHR v8.0 achieved Office of the National Coordinator for Health Information Technology (ONC-Health IT) 2015 edition certification! What's a 2015 CEHRT?A CEHRT (Certified EHR Technology) is defined by CMS specifically for their incentive payment programs such as...
MIPS - To Participate or Not Participate - That is the Question
January 10th, 2018 - Wyn Staheli, Director of Research
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
New MIPS Reporting Option for 2017 Data
January 10th, 2018 - Wyn Staheli, Director of Research
On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated: Data can be submitted and updated any time from January 2, 2018 to March ...

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New Payment Rulings Could Affect You
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
Payment Rulings and Small Provider Practices
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
CMS Overpaid Providers $729 Million in Incentive Payments
June 16th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements according to the OIG.  The OIG estimated CMS inappropriately paid $729,424,395 to EPs who did not meet the requirements for meaningful use. Eligible professional’s (EP’s) are physicians, dentists, podiatrists, optometrists or chiropractors, if ...
The Quality Payment Programs
April 24th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medicare has given the option for participation in the Quality Payment Program offering two tracks you can choose from as well as the option to pick your pace. You can choose to start anytime between January 1 and October 2, 2017: Advanced Alternative Payment Models (APMs) or The Merit-based Incentive Payment System ...
Quality Reporting is not Just for CMS
February 6th, 2017 - Wyn Staheli
If you thought that quality reporting is just for CMS, you are wrong. Other payers recognize the need to establish quality metrics.
Virtual Groups and MIPS
January 23rd, 2017 - Wyn Staheli
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations. The following statements are from the MIPS Final ...
Alternative Payment Models (APMs) and Advanced APMs
January 16th, 2017 - Wyn Staheli
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?  According to a fact sheet ...
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
December 15th, 2016 - Brittney Murdock, CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
International Classification of Diseases (ICD)-10 Code Updates and Impact to 4th Quarter 2016 Eligible Professional Medicare Quality Programs
December 15th, 2016 - CMS.gov
On October 1, 2016, new International Classification of Diseases (ICD)-10-CM and ICD-10-PCS code sets went into effect. Updating of these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support...
Don’t expect beneficiaries to pick up the slack for PQRS, EHR cuts
December 4th, 2014 - Scott Kraft
2015 is a big year for payment adjustments for providers who’ve failed to take part in CMS incentive programs for electronic health records (EHR) meaningful use, e-prescribing and the Physician Quality Reporting System (PQRS). It’s the year that CMS goes from dangling the carrot...
e-Prescribing UPDATE from CMS Final Rule for Jan 1 2010
November 25th, 2009 - Codapedia Editor
CMS released its Physician Final Rule 10-30-09! They made e-prescribing easier. Starting Jan 1 2010, physicians can show that they have and are using a qualified e-Prescribing program by reporting on 25 claims only, (per eligible professional, not per practice) for the entire year. In addition,...
E-Prescribing and Medicare Bonus Payments
April 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE Question Our doctors want to begin e-prescribing in order to get the Medicare bonus payment. How much is the bonus payment, and how do we let Medicare know that we are e-prescribing? Answer The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...
PQRI reporting period options for 2009
March 18th, 2009 - Betsy Nicoletti
Each year, CMS has different reporting options and periods for PQRI. The incentive payment--bonus--is based on 2% of allowed Medicare charges for the reporting period. The reporting period options for 2009 are the entire year, or the second half of the year. The attached pdf file is from CMS, and...
Is the PQRI bonus based only on the charges with measures?
March 13th, 2009 - Betsy Nicoletti
The PQRI bonus is 2% of total allowed Medicare charges for services paid under the Medicare Fee Schedule. This includes the 80% paid by Medicare and the 20% the practice collects from the patient or co-insurance. The services included are E/M services, procedures, drug administration Excluded...
Quality Data Codes and diagnosis listing
March 5th, 2009 - Betsy Nicoletti
Do I have to link my Quality Data Codes to a specific diagnosis code? Yes! This was a source of error for physicians who reported in 2007. If the measure defines a specific diagnosis (chronic kidney disease, fracture, osteoporosis) then you must link your PQRI Quality Data Code (QDC) to the...
What are PQRI numerators and denominators?
March 5th, 2009 - Betsy Nicoletti
What does it mean when PQRI talks about the numerator and the denominator for measures? I avoided PQRI, because I hate that math talk! However, after I got over my math fear, I found it was fairly simple. If you think about a fraction, the numerator is the number on top, and denominator is on the...
Why did so few physicians receive a PQRI bonus in 2007
March 5th, 2009 - Betsy Nicoletti
Why did so few physicians receive a PQRI bonus for 2007? CMS released a report describing the common errors in claims submission, that resulted in physicians not receiving a bonus. Before we discuss these, keep in mind that there is no appeal in the PQRI program for practices that believe they...
Do all physicians in a group need to use the same PQRI measures
March 5th, 2009 - Betsy Nicoletti
Do all of the physicians in the group need to use the same measures? No, each individual physician or other health care professional can select whichever three measures are most relevant to their practice. This is true whether the group is a single or multi-specialty group.
Do all physicians in a group need to participate in PQRI
March 5th, 2009 - Betsy Nicoletti
Two of our three doctors are interested in participating in PQRI, but the third doesn’t want to. How will that work? Successful PQRI reporting is measured based on NPI, that is, by the individual physician or other eligible professional. The bonus is paid to the practice, based on the...
Where are the PQRI worksheets
March 5th, 2009 - Betsy Nicoletti
Where are the PQRI Worksheets? The PQRI Worksheets are on the AMA’s website this year. Last year, they were published in a folder on the CMS website, downloadable in a group. This year, they are available individually on the AMA’s website. You can search by disease to find the...
Registry reporting for PQRI
March 5th, 2009 - Betsy Nicoletti
Registry reporting • Certain measures may be reported by a registry at the end of the year, rather than ongoing, claims based • These are indicated by an R in the list • Some measures may only be reported by registry reporting, not claims based on as part of a measures...
How to get started with PQRI
March 5th, 2009 - Betsy Nicoletti
How to get started with PQRI Select the measure or measures group you intend to report on. How? First, check your specialty website for help in selecting measures Medicare had two recent Open Door Forum calls with specialty societies...
What patients are eligible for PQRI reporting
March 5th, 2009 - Betsy Nicoletti
What patients are eligible? • Fee for service Medicare • Railroad Medicare • Patient for whom Medicare is the secondary payer • Not Medicare Advantage For claims based and measures group reporting, these are eligible patients.
PQRI Physician Quality Reporting Initiative: an Overview
March 5th, 2009 - Betsy Nicoletti
PQRI The briefest of historical reviews 2007: 1.5% potential payment with cap on total payment • Half year reporting period • Bonus payment subject to cap • 1.5% of total allowed Medicare Fee Schedule payments • Includes Railroad Retirement Board charges • ...

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