The Dirty Dozen: 12 Things PTs, OTs, and SLPs Need to Know About PQRS 2016

It’s that time of year again—no, I’m not talking about the proliferation of premature snowflake decorations and holiday-themed retail store soundtracks. Instead, I’m referring to Medicare’s annual gift of regulatory changes and updates, courtesy of the beloved Final Rule. One of the programs wrapped into that package: PQRS. And while the 2016 program doesn’t look much different than the 2015 rendition—kind of like your grandmother’s fruitcake—the Final Rule does allude to some pretty big changes down the road.

Here’s the sampler version of everything you need to know:

  1. Regardless of whether you, as an eligible professional (EP) report via claims or via a registry, you must report on nine measures across three NQS domains for at least 50% of your Medicare Part B fee-for-service patients.
  1. If you can’t meet the nine-measure minimum because there aren’t enough measures that apply to your specialty, then you’ve got to report on all of the measures (up to eight) that do apply to you. You’ll then be subject to Measures Applicability Validation (MAV), a process that allows Medicare to verify that you did, indeed, report on as many measures as you could.
  1. Provided that you see at least one Medicare patient in a billed visit during 2016, you must report on at least one cross-cutting measure—regardless of the total number of measures that apply to you.
  1. If you show a 0% performance rate on any measures, those measures won’t count toward your reporting data.
  1. As in previous years, your PQRS performance in 2016 will impact your reimbursements two years down the road. Specifically, failing to satisfy the reporting requirements for 2016 will land you a 2% negative adjustment to all of your Medicare Part B payments in 2018.
  1. The Group Practice Reporting Option (GPRO) is back again in 2016, and while the majority of the GPRO guidelines for this coming year are the same as those for 2015, Medicare did toss one more log on the fire: CMS now requires review of cross-cutting measure applicability as part of the MAV process for GPRO participants.
  1. All in all, there are 281 PQRS measures available in 2016, up from 225 in 2015.
  1. As of now, there are only a handful of general measures changes that affect rehab therapists, although additional changes could come to light once Medicare releases its updated measures specifications. Here’s what we know at this point:
    1. Measure 431 (unhealthy alcohol use: screening and brief counseling) will replace Measure 173 (screening for unhealthy alcohol use). Note: We aren’t positive yet that this measure will apply to OTs in 2016. We are waiting on official confirmation from CMS.
    2. Measures 154 (falls: risk assessment), 155 (falls: plan of care), and 431 are now cross-cutting measures.
    3. Measure 131 (pain assessment and follow-up) will move from the Community, Population and Public Health NQS domain to the Communication and Care Coordination NQS domain.
  1. Occupational therapists will have the option of completing PQRS using the new Multiple Chronic Conditions Measures Group, which includes measures 128, 130, 131, 134, 154, and 155. The reporting rules are similar to those associated with the Back Pain Measures Group of 2014: each participating EP must report on a minimum of 20 patients, with at least 50% of those patients being Medicare beneficiaries.
  1. After 2016, PQRS—at least in the form we’ve grown accustomed to—could go away forever. That’s because the reporting mechanisms and penalties associated with the current PQRS program eventually will become part of the new Merit-based Incentive Payment System (MIPS), which is set to go into effect in 2019 (with reporting beginning in 2017).
  1. The potential demise of the standalone PQRS program absolutely should not deter you from participating in PQRS in 2016. Here’s why.
  1. Rehab therapy professionals looking to prepare themselves and their practices for all the changes ahead—in 2016 and beyond—should register here for WebPT’s upcoming free webinar, PQRS 2016: Everything PTs, OTs, and SLPs Need to Know.

There you have it—12 tasty morsels of PQRS knowledge. Remember, though, in terms of data-tracking, PQRS is only the first course. I’ll discuss the future role of data in rehab therapy—and how it relates to the shift to a value-based payment environment—in greater depth as more details come to light.

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