2015 PQRS Payment Adjustment and Providers who Rendered Services at RHCs/FQHCs

On November 10, 2014, CMS began distributing letters to Physician Quality Reporting System (PQRS) eligible professionals (EPs) regarding the 2015 PQRS negative payment adjustment. The letter indicated that either an individual EP or the group practice that registered for the 2013 PQRS group practice reporting option (GPRO) did not satisfactorily report 2013 PQRS quality measures in order to avoid the 2015 PQRS negative adjustment and, therefore; all of their 2015 Medicare Part B Physician Fee Schedule (MPFS) reimbursements will be subject to a 1.5% reduction.

CMS has received questions from Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who received PQRS negative payment adjustment letters for services furnished during the 2013 calendar year. As stated in the PQRS eligible medical care professionals list, PQRS covered professional services are those that are paid under or based on the MPFS. To the extent that EPs or group practices are providing services which get paid under or based on the MPFS, those services are eligible for PQRS incentive payments and/or payment adjustments. Services payable under fee schedules or methodologies other than the MPFS are not included in PQRS. Therefore, if an EP rendered services under the MPFS in 2013 and did not meet the 2013 PQRS satisfactory reporting requirements, he/she was sent this letter to indicate that he/she will be subject to the 2015 PQRS payment adjustment.

The 2015 PQRS payment adjustment letter includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination; the adjustment applies only to the provider associated with the TIN/NPI noted within the letter and not the clinic or facility. The EP’s contact information used to send the 2015 PQRS negative payment adjustment letters was gathered from the Provider Enrollment, Chain, and Ownership System. Therefore, an EP who worked at an organization that participated in RHC/FQHC methodologies and non-RHC/FQHC methodologies, but under the same TIN, would have only had one address available in PECOS.

Below is an example of how an EP who worked at an RHC/FQHC may also have been eligible to participate in 2013 PQRS:

An EP works at a RHC or FQHC and also works at a non-RHC/FQHC which is under the same TIN. As the EP bills services under the MPFS via a 1500 claim form, s/he may be subject to the 2015 PQRS payment adjustment if s/he does not report quality data under PQRS.

In sum, all EPs or PQRS group practices who billed services under the MPFS for Medicare Part B patients in 2013 must have satisfactorily reported PQRS in order to avoid the 2015 negative payment adjustment. CMS would also like to remind individual EPs and group practices that there are no hardship or low-volume exemptions for the PQRS payment adjustment. As outlined in the 2015 PQRS payment adjustment letter, if you believe that the 2015 PQRS payment adjustment is being applied in error, you can submit an informal review request. All informal review requests must be submitted via a web-based tool, the Quality Reporting Communication Support Page, during the informal review period, January 1, 2015 through February 28, 2015.

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