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Physician Quality Reporting System for Speech-Language Pathologists

Reporting Quality Measures for Medicare Part B Services

The Centers for Medicare and Medicaid Services (CMS) designed the Physician Quality Reporting System (PQRS) to improve the quality of care for Medicare beneficiaries by tracking practice patterns. The Patient Protection and Affordable Care Act made participation in Medicare's PQRS program mandatory beginning in 2015; penalties are assessed for non-participation and CMS has issued the 2016 2% penalties based on non-participation in 2014. Likewise, providers who did not participate in 2015 will see a 2% penalty on all claims in 2017. If PQRS reporting benchmarks are not met in 2016, a 2% penalty will apply to all 2018 Medicare claims submitted by the provider.

Please note that PQRS participation is a separate initiative from the claims-based outcomes reporting requirement for Medicare Part B therapy services. To receive payment for Medicare Part B services, speech-language pathologists (SLPs) must provide functional outcomes on the claim. Participation in PQRS prevents a 2% reduction in payment from being assessed in 2018.The various non-payable G-codes used by CMS are program specific. Reporting in the mandatory claims-based outcomes reporting system does not exempt SLPs from PQRS participation

Who Must Participate? 

SLPs who provide services to Medicare Part B patients in:

  • Independent private practices
  • Group practices
  • University clinics not associated with a hospital medical center
  • Outpatient clinics not associated with a hospital medical center
  • Critical access hospitals (CAHs) that have elected Method II billing (check with hospital administration)

Claims are submitted on the CMS 1500 Health Insurance Claim Form [PDF], electronically or on paper, with the SLP's individual National Provider Identifier (NPI) number listed as the rendering provider of the service.

Exemptions

SLPs who provide services to less than 15 Medicare beneficiaries in the calendar year are exempt from reporting.

The Group Practice Reporting Option (GPRO) may also exempt SLPs from the penalties if the practice includes physicians, has enrolled in the GPRO option, and whose participating physicians meet all of the requirements for the GPRO measures. SLPs in practices with physicians should consult with their administrators regarding their participation in the PQRS program.

What is Required for 2016 Reporting?

Please note that PQRS participation starts over each calendar year. If you did not participate in 2015, you can participate in 2016 and avoid penalties on 2018 claims. For 2016, SLPs must report on the following measures:

  • #130: Documentation of Current Medications in the Medical Record
  • #131: Pain Assessment and Follow-Up
  • #226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

Participation in PQRS requires adding specified PQRS codes to claims for every qualifying visit. When a claim for a Medicare Part B beneficiary is submitted for fluency evaluation, voice evaluation, or speech-language evaluation a PQRS G-code related to measure #226 must be appended to the claim. Claims for speech-language treatment, aural rehabilitation, swallowing treatment, or cognitive therapy will require a PQRS G-code related to the documentation of medication and pain assessment. For specific instructions regarding the each of these claim-based measures, see PQRS Measures Available for SLPs to Report on Claims.

How Does the Penalty Apply?

If benchmarks are not met in 2016, a 2% payment reduction will be applied on all 2018 Medicare claims submitted for services provided by the individual provider who did not meet the requirements.

PQRS is tracked by the Taxpayer Identification Number (TIN) of the clinic/practice that submitted the claim with the National Provider Identifier (NPI) of the SLP listed on the claim as the "rendering provider."  This means:

  • The SLP must meet benchmark requirements in every practice that uses their NPI on the claim as the rendering provider.
  • A practice must ensure every individual meets benchmarks. Only claims submitted with the rendering SLPs that met benchmark requirements in 2016 will be paid in full in 2018; claims with rendering SLPs who did not meet the benchmarks within the practice for that billing year will be reduced by 2%. If the SLP is new to the practice, there will not be a penalty assessed.
  • If a positive action is not reported for a minimum of 50% of the qualifying patient visits, then the benchmark is not reached. The requirements of the measure must be met and reported.

Reporting is Easy!

All you have to do is:

  1. Know the CPT codes in the measures. If the applicable CPT code is billed on the date of service, a positive action PQRS G-code is needed on the claim to meet benchmark requirements.
  2. Perform the actions of the measure.
  3. Put the appropriate code on the claim form.
For specific instructions for each measure, see PQRS Measures Available for SLPs to Report on Claims.

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