PQRS Informal Reviews, Feedback Reports, and Performance vs. Reporting Rates

04 Dec 2015

As the PQRS informal review request deadline has now been extended through December 16th, many providers who received notification letters indicating they would be subject to the negative payment adjustment in 2016 have been trying to access their annual feedback reports to determine exactly how and why they missed the successful reporting threshold.   To recap, an informal review may be requested if the individual eligible professional or group practice disagrees with the analysis of satisfactory reporting to avoid the negative payment adjustment.  Unfortunately, many providers who reported via claims have been struggling with finding the necessary information to include in their informal review.

One area of confusion among providers has been in regard to differentiating between their performance rate and their reporting rate.  The Annual Quality and Resource Use Reports (QRURs) and Supplementary Exhibits  that can be run on the CMS Enterprise Portal only reference the performance rate, which is the percentage of eligible patient encounters that were reported for which the provider indicated the performance was met for the measure.  It is the reporting rate, though, that determines whether or not the eligible professional is subject to the payment adjustment.  The reporting rate is the number of QDCs and CPT II codes that were submitted divided by the number of eligible patient encounters.

For example, let’s say Susan had 500 patient encounters that would have qualified for PQRS reporting for Measure 131 in 2014.  Of those 500 encounters, she reported successfully on 300 of those.  Her reporting rate for Measure 131 would be 60%.  Of those 300 encounters, she reported a numerator QDC that described the performance as being met for that measure 275 times and a numerator QDC indicating the performance was not met 25 times.  Her performance rate would then be 91.7%.  So if the reporting rate was met, why does performance rate matter?  First, the performance rate cannot be 0% in order for the measure to count toward the number of successfully reported measures.  Secondly, it is the performance rate which will be available on the Physician Compare website in 2016.

So, how do you go about finding that all-important reporting rate?  Per the QualityNet Help Desk, the reporting rate information for 2014 is not viewable on any reports that can be run on the Enterprise Portal.  Instead, a request must be submitted through the QualityNet Help Desk to have this report run and forwarded.  This request can be submitted by a security official for the practice or by the provider.  (You’ll need to provide your NPI and TIN.)  This report will show both the reporting rate (the number of instances you reported the measure divided by the number of instances in which you could have reported the measure) as well as the performance rate (the number of times the performance for the measure was met divided by the reported instances).  For more information on annual feedback reports, visit the QualityNet Help Desk at https://www.qualitynet.org/portal/server.pt/community/pqri_home/212 or call 866-288-8912.

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