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American Academy of Family Physicians
Thursday Nov 14, 2013

A simple solution to avoid Physician Quality Reporting System penalty

The Centers for Medicare and Medicaid Services (CMS) will soon switch an incentive tool from a carrot to a stick.

The Medicare Part B Physician Quality Reporting System (PQRS) will shift from awarding a 0.5 percent participation bonus for participating entities to levying a 1.5 percent penalty for non-participating entities, beginning in 2015. This hazard is easily avoided, but you must take action before the end of this year.

Quality Data Codes (QDCs) are Current Procedural Terminology (CPT) and Heathcare Common Procedure Coding System (HCPCS) codes that attest compliance with CMS quality measures. One QDC submission by Dec. 31, 2013, is the only requirement for avoidance of the 2015 penalty if the eligible professional hasn’t already met the requirements outlined in the 2013 PQRS measure specifications, elected to participate in the administrative claims-based reporting mechanism, or isn’t reporting one valid measure in a measures group. Every physician should submit one QDC on an eligible Part B claim before Dec. 31, 2013.

An example would be the addition of QDC G8427. G8427 attests that an eligible professional documented the patient’s current medications to the best of his/her knowledge and ability (quality measure No. 130). Medication history updates are best-practice activities. Therefore, G8427 may credit physicians for quality practices already being performed.

Accurately documented QDC submissions can yield an exceptional return on investment. For example, a group practice with $1 million in annual Medicare Part B revenue would avoid $15,000 per year in penalties at little or no cost for complying.

It should be added, however, that while this strategy will help avoid a penalty in 2015, there's no guarantee that it will work to avoid penalties in future years. This blog has written before on the benefits of more thoroughly participating in PQRS.

The PQRS deadline is a preventable health reform headache. Physicians should speak to their billing staff and self-prescribe this simple QDC remedy.

– Matthew T. Johnson, MD, MBA, Department of Family Medicine, University of Illinois at Chicago College of Medicine

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