• Compliance Matters

    PQRS and MIPS: A Quality Reporting Update

    Reporting requirements for PTs in private practice are the same this year as last. Change is coming, however.

    The Physician Quality Reporting System (PQRS) began in 2007 as the Physician Quality Reporting Initiative, a voluntary, incentive-based program for practitioners—including PTs in the private practice setting—that was designed to better ensure high-quality health care services for Medicare beneficiaries.

    The program as we know it today will sunset on December 31 of this year, as required under the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA). A new quality program, the Merit-Based Incentive Payment System (MIPS), will replace PQRS on January 1, 2017.

    Physical therapists (PTs) will not be part of MIPS in its first years, but they may be added to the program in 2019. In the meantime, here's some information about PQRS in 2016, and what we know about MIPS.

    Program Requirements and Measures

    As was the case in 2015,1 private practice PTs who don't participate in PQRS this year, or don't do so successfully, will be subject to a 2.0% reduction in their fee schedule amount in 2 years—so, in 2018.

    Once again, to participate in PQRS you must report individual measures data in 1 of 2 ways—on your claims forms or by submitting the data to a registry approved by the Centers for Medicare and Medicaid Services (CMS). For 2016, PTs again must report at least 9 measures, covering at least 3 National Quality Strategy (NQS) domains, on at least 50% of Medicare Part B fee-for-service patients seen during the reporting period or calendar year. The 9 reported measures must include 1 "crosscutting" measure. (Such measures are broadly applicable and allow Medicare to assess quality of care across disciplines, as well as quality of individual providers in the PQRS program.)

    If 9 measures covering at least 3 NQS domains are not available to you, you must report all available measures (8 or fewer) covering 3 or fewer NQS domains to avoid the penalty. If you report fewer than 9 measures, CMS will confirm that you're eligible to do so using a process called Measure-Applicability Validation (MAV).

    In the 2016 reporting year, as in 2015, PTs have 15 measures in the PQRS program, with all 15 reportable via registry (you must report at least 9), 6 reportable via claims, and 6 considered crosscutting. If you used claims forms to report measures data, you must report on all 6 measures.

    Of the 2 reporting options, most PTs participate via the claims-based reporting mechanism, but registry reporting is growing in popularity due to increases in reporting requirements. A current list of PQRS registries can be found on the CMS webpage: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html.

    Successful Reporting

    To report successfully in PQRS, you must understand not only the overall reporting requirements and measures selected, but also how well you're meeting the requirements throughout the year. To help participants assess their reporting performance, CMS provides claims-based participants with interim feedback reports through Quality Net, the Medicare contractor for PQRS, via an Enterprise Identity Management System (EIDM) account. These are simplified versions of the annual feedback report that are available quarterly. The first-quarter interim feedback report, for example, includes claims for dates of service starting on January 1 of this year and processed by March 31. This way, you can make changes in your reporting process if you're falling below the successful reporting threshold.

    CMS also will provide, in fall 2017, annual finalized feedback reports for 2016. These can be obtained through Quality Net. Providers can access their feedback report through the "PQRS Portal" portion of the CMS Enterprise Portal at http://portal.cms.gov.

    PTs with questions about creating or accessing their feedback reports should contact Quality Net. Its help desk is available Monday through Friday, 8:00 am–8:00 pm ET, at 866/288-8912, or at qnetsupport@sdps.org.

    The Future and MIPS

    In early 2015, the US Department of Health and Human Services (HHS) released its first definitive set of timelines for a transition away from fee-for-service payment models in Medicare. HHS established milestones to create payment systems based on outcomes rather than services provided. This includes plans to link 85% of fee-for-service payments to outcome measures by the end of this year, and to increase that to 90% by the end of 2018. The aforementioned MIPS is 1 vehicle HHS will use to achieve these goals.

    Again, MIPS will start in 2017, with a first payment-adjustment year of 2019. PTs and several other nonphysician groups are excluded in the first years, but PTs may be added to the program beginning in 2019 for the 2021 payment-adjustment year.

    MIPS will align several quality reporting programs under Medicare Part B, including PQRS, the value-based modifier program, and meaningful use of electronic health records technology. Unlike PQRS, MIPS will be performance-based; the provider's performance will be scored, using performance benchmarks.

    Among MIPS' several performance categories will be quality measures, resource use measures, clinical improvement activities, and meaningful use.

    The quality measures categories will include clinical process and outcome measures similar to those currently included in PQRS. The cost measures based on a specific condition or disease will be included in the resource use category. While it is true that resource use measures have most typically been attributed to primary care providers, CMS is working on measures that will be meaningful for specialty providers, including PTs. The clinical improvement activities category is new to the Medicare quality program. It will encompass such activities as practice access, population management, care coordination, and beneficiary engagement. The meaningful use category, finally, will be a redesign of the current program.

    Each of the 4 categories in the program will be weighted, and a total score of 0-100 will be calculated and compared with the performance thresholds set forth by CMS annually. As with PQRS, the payment-adjustment year will be 2 years after the data-collection year. Under MIPS, providers with composite scores below the performance threshold will be subject to MIPS penalties on a sliding scale, with maximum penalties of up to 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond.

    Providers exceeding the performance threshold can earn substantial MIPS bonuses, also on a sliding scale, with the highest bonus at least as high as the highest penalty for that year (eg, 4% in 2019). Bonuses under MIPS may be even higher—up to 3 times the maximum penalty levels. The total of the bonuses and penalties must essentially balance each other, however, because MIPS is budget-neutral.

    CMS has not yet issued details on MIPS, but will do so in the proposed physician fee schedule rule this summer. Included will be information about measures and scoring methodology. We encourage PTs to monitor these developments through APTA's website (see box above).

    Smith, Heather 75x110

    Heather L. Smith, PT, MPH, is program director of quality at APTA.  


    1. Smith H. Update on the physician quality reporting system. PT in Motion. 2015;7(3):8-12.


    APTA has redesigned its PQRS webpage (www.apta.org/pqrs), with new resources to facilitate PT participation. The association will continue developing PQRS resources throughout the 2016 reporting year.

    The association strongly encourages eligible PTs to participate in PQRS as part of the move to value-based payment and better patient outcomes—as well as to avoid penalties in 2018. Direct questions to 800/999-2782, ext. 8511, or email advocacy@apta.org.


    Just read Heather's comments "Program Requirements and Measures" and "Successful Reporting". The summarized instructions alone sound like a trainwreck. Heather, no reflection on you intended. Its just a mess. Who would put together such a crisscrossed mess of a reporting system? And though I know some believe this PQRS will help prove our worth, I will ask again (b/c I have never gotten a satisfactory answer), WHAT important information are they going to get from these report statistics. I believe their intent is simply to see who can and will play their game of report and get included, or be cast out.
    Posted by John on 5/3/2016 4:46:34 PM
    Thanks Heather for helping to make sense out of this. I would like to know if the cost to taxpayers for the development and implementation of this program and the metrics that will be used to determine if any savings generated by the program equal the costs to implement it. (cost/benefit ratio). I suspect this could off set the cost of repealing the therapy cap and then some...
    Posted by Marsha Lawrence -> ?GQ_? on 5/9/2016 4:26:36 PM
    There are programs already available to PT's that report clinical outcomes. How is this data of any use to a therapist ? List of Medications, weight etc.... really. When is the APTA going to ever step up and take the lead. When you think about it, it's amazing that the APTA has never passed a piece of legislation in Washington. However, with so few of our colleagues actually members it's not surprising. We need to be standing up to Medicare and pushing back to shape our practice. Come on APTA you can do better than this.
    Posted by Jeff Sirabian PT, OCS, MHS, Cert MDT, FAFS on 4/22/2017 8:01:34 PM
    The existing process measures are basic to practice (ie recognizing medications that impact function, or the impact of a high BMI on function), however, they remain of fundamental clinical importance. At the time these measures were created consistent documentation of these fundamentals was low in practice, however, today, documentation has improved and in the future these measures will be retired. The future goal of the MIPS program is to move towards more outcomes measures. APTA is working to develop measures that are meaningful to PT practice and more focused on outcomes.
    Posted by Heather Smith -> =KV`@L on 4/26/2017 3:19:37 PM

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