Medicare: Quality


The Patient Protection and Affordable Care Act (PPACA) mandated that non-participation or unsuccessful/unsatisfactory reporting in Medicare’s Physician Quality Reporting System (PQRS), formerly referred to as PQRI, will result in negative payment adjustments to Medicare reimbursement beginning in 2015. In the 2012 Medicare Physician Fee Schedule Final Rule, the Centers for Medicare and Medicaid Services (CMS) ruled that providers who did not successfully/satisfactorily participate in PQRS by the 2013 reporting period will have their Medicare reimbursement decreased by 1.5 percent beginning on January 1, 2015. Non-participation or unsuccessful/unsatisfactory reporting during the 2014 performance period will result in a 2% reduction in a provider's 2016 Medicare reimbursement, and further non-participation or unsuccessful/unsatisfactory reporting this year (Jan. 1 -  Dec. 31, 2015) will affect a provider's 2017 Medicare reimbursement by applying a payment reduction of 2%.

If you have never participated in PQRS, you may not know where to begin. For those doctors of chiropractic who are continuing their participation in PQRS in 2015, please be advised that significant updates and revisions have been made to the PQRS Measures applicable to chiropractic practices. For more information, and to get started, review the information/resources below.

*NEW* 2015 Physician Quality Reporting System (PQRS) Measures Applicable to Doctors of Chiropractic

For the 2015 reporting period (January 1 – December 31, 2015), DCs have two (2) PQRS Measures that they are able to report. For more information, click on the links below:

  • Getting Started with PQRS 2015—A Guidebook for Doctors of Chiropractic - The ACA has developed the PQRS Guidebook specifically with the chiropractic practice in mind. We have researched all of the 2015 regulations and measure specifications, identified the information that DCs need to know, and compiled that information into this succinct and efficient resource to assist with the proper implementation of PQRS reporting in your office.

*NEWCMS 2015 Measure Specifications

*NEW* PQRS & EHR Payment Adjustments and the New Format of the Medicare Fee Schedule in 2015

The new format of the 2015 Medicare Fee Schedule is due to the negative payment adjustments that have been implemented and applied to all providers that did not satisfactorily participate PQRS during the 2013 reporting period and/or who were not meaningful  users of Electronic Health Records (EHR) in 2014. The payment adjustments apply to all non-participating/non-satisfactorily reporting providers regardless of whether a provider elected to be “participating” (Par) or “non-participating” (Non-Par) for purposes of Medicare payments.  In preparation for the implementation of the negative payment adjustments beginning on January 1, 2015, all Medicare Administrative Contractors (MACs) were directed by CMS to revise the format of their fee schedules to display the limiting charge amount after applying the EHR and PQRS negative adjustment(s). Specifically, the MACs are required to add the following line items:

•         EHR Limiting Charge;

•         PQRS Limiting Charge;

•         EHR/2014 eRx* Limiting Charge;

•         EHR + PQRS Limiting Charge; and

•         EHR/2014 eRx* + PQRS Limiting Charge.

*Note: DCs are not affected by the Electronic Prescribing (eRx) penalty.

The MACs are only required to post how the negative payment adjustments will specifically affect Non-Par providers because they have the ability to choose either to accept or not accept assignment on Medicare claims on a case-by-case/claim-by-claim basis. In 2015, for cases/claims when a Non-Par provider chooses not to accept assignment, they are required to abide by the limiting charge restrictions when collecting payment from the patient and the limiting charge amounts vary depending upon whether the provider successfully participated in PQRS (in 2013) and/or EHR (in 2014). 

Please Note: It is very important that Non-Par providers select the correct limiting charge amount that applies to them when billing Medicare for claims in which they do not accept assignment. CMS states: “Submission of a non-par, non-assigned Medicare Physician Fee Schedule (MPFS) service with a charge in excess of the Medicare limiting charge amount constitutes a violation of the limiting charge. A physician or supplier who violates the limiting charge is subject to a civil monetary penalty of not more than $10,000, an assessment of not more than 3 times the amount claimed for each item or service, and possible exclusion from the Medicare program. Therefore, it is crucial that EPs are provided with the correct limiting charge they may bill for a MPFS service.

Participating (Par) providers that did not successfully/satisfactorily report data on quality measures for covered professional services during the 2013 PQRS reporting period (Jan. 1 – Dec. 31, 2013) and/or were not meaningful EHR users in 2014 will also receive negative payment adjustments beginning on January 1, 2015.  CMS will take the penalty directly out of the allowed amount for services billed. Because it will apply the penalty to the entire allowed charge, then pay 80 percent of that amount, the beneficiary’s 20 percent coinsurance would be slightly reduced as well.  

For more information on this topic, please refer to MLN Matters® Number MM8667 “Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments”




“Quality” is an increasing concern for healthcare policymakers in Washington, DC. The word dovetails into various areas such as pay-for-performance and health IT. Although this issue and its related areas have been percolating for almost a dozen years (and there is some experience in private pay on the issues), with the development of actual quality measures and the continuing significant reimbursement reform challenges, this is all now on the front-burner where public programs (and specifically, Medicare) are concerned. The Tax Relief and Healthcare Act of 2006 linked reimbursement to reporting on quality measures for the first time; CMS’ Physician Quality Reporting System (PQRS), is the program associated with this. 

The Basics: What is a Quality Measure?

Quality measures, generally, are rooted in evidence-based medicine. They can be “guideline” measures (e.g., you get 12 visits for acute low back pain), “process” measures (e.g., when a patient comes in with a cardiovascular episode and you gave them an aspirin), or “outcome” measures (e.g., "X" condition was resolved). There are also other types of measures, such as “structural,” “efficiency,” or “cost of care” measures.

A few points which are important to keep in mind:

  • There is significant debate on the value of the different types of measures, with the community currently focusing mostly on “process” measures. [Note: “Guideline” measures have generally been discounted as a way to measure quality of care.] Certain groups are also paying close attention to “structural” and “cost of care” measures. The ultimate goal of all parties is to have effective outcomes measures.

  • There is also significant debate about whether certain measures simply demonstrate competency or actually will improve quality. For example, some measures deal with the documentation of care. Many in the community argue that documentation of care should be happening anyway, while others point out that it doesn’t happen 100% of the time, hence there’s room for improvement—a gap in care—with which a measure could help.

  • Measures are not specialty-specific.

What Can Individual DCs Do to Prepare?

Understand the PQRS program and report on the measures.


Feedback Reports