In short, MIPS is the new Medicare payment incentive/penalty system which will begin in 2019. The Medicare Access and CHIP Reauthorization Act of 2015 (also known as the SGR repeal or 'doc fix') included the creation of a new pay-for-performance program called the Merit-Based Incentive Payment System (MIPS). In 2019, MIPS will replace the current PQRS, EHR, and VBM as we know it now.

Due to an error found in the logic, The Centers for Medicare & Medicaid Services (CMS) is providing guidance relating to measure CMS122 (Diabetes: Hemoglobin A1c Poor Control) included in the 2014 measure set for the Electronic Health Record (EHR) Incentive Program for Eligible Professionals. Version CMS122v3 of the measure was posted on CMS’s website on May 30, 2014. A subsequent posting of this measure in 2015 (CMS122v4) resolved this issue for the 2016 program year. 


CMS is extending the 2014 Informal Review period. Individual eligible professionals (EPs), Comprehensive Primary Care (CPC) practice sites, PQRS group practices, and Accountable Care Organizations (ACOs) that believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment now have until 11:59 p.m. Eastern Time on December 11, 2015 to submit an informal review requesting CMS investigate incentive eligibility and/or payment adjustment determination. This is an extension from the previous deadline of November 23, 2015.  

As you know, the PQRS (Physician Quality Reporting System) includes the reporting of particular G codes to communicate with Medicare, details of the Functional Outcome Assessment and Pain Assessment and Follow-Up measures. These measures must be completed on at least 50% of an eligible professional's active patients to avoid penalty.

Recently, letters have been sent out to practices informing practices that they have not satisfactorily reported those PQRS measures and therefore, a negative payment adjustment (penalty) will be assessed from 2016 Medicare reimbursements.

CMS will begin to apply a negaitive payment for 2014 PQRS

By:  Chris Woolstenhulme, CMRS
Published: September 29th, 2015

Here we go, CMS will begin to apply a negative payment adjustment to EP’s (Eligible Professionals) that did not participate and satisfactorily report Physician Quality Reporting System (PQRS) in 2014. Remember, the program participation during a calendar year will affect your payments in two years. Therefore; if you do to successfully report in the year 2015 you will be penalized in 2017.  

PQRS Information

It is essential for healthcare providers to understand how the Physician Quality Reporting System (PQRS) affects their practice. All Eligible Professionals (EPs) who did not satisfactorily reported data on quality measures for covered professional services in 2014 your CMS payment will incur a 2% PQRS penalty (payment cut) om 2016. This PQRS non-participation payment penalty of 2% continues (based on PQRS participation two years ago) for as long as you do not participate in the PQRS program.

In an effort to improve quality of care in nursing home, CMS has been reviewing PQRS quality measures and offering provider training through a variety of mediums. Antipsychotic drug use is just one of the measures being reviewed. The MLN Connects Provider eNews for February 12, 2015 included the following notice about the trends in antipsychotic drug use and the results are promising:

Antipsychotic Drug use in Nursing Homes: Trend Update

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the 2014 PQRS data submission timeframes. 

2015 PQRS Quality Measures

Measures Codes

Measures codes contain information about Physician Quality Reporting System (PQRS) quality measures, including detailed specifications and related release notes for the individual PQRS quality measures and measures groups and other measures-related documentation needed by individual eligible professionals for reporting the PQRS measures through claims or qualified registry-based reporting.

PQRS FAQ (resource 321)

PQRS participation is important for healthcare providers. Several types of payment adjustments may be applied depending on how well providers meet PQRS criteria. To avoid negative payment adjustments or even gain postitive payment adjustments (Value Based Modifier) by CMS, healthcare providers need to successfully participate in the CMS Physician Quality Reporting System (PQRS).

For detailed information about this program, please refer to Chapter 2.5 of the Behavioral Health DeskBook.


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