Medicare and PQRS Updates for 2016

15 Dec 2015

As 2015 comes to a close, it isn’t too soon to start looking ahead to next year.  From a Medicare standpoint, there aren’t many changes in store for 2016 which may be good news or bad news depending on whether you are a glass half-empty or a glass half-full kind of person.  While therapists would certainly welcome any changes that would reduce the amount of reporting that they’re currently doing for initiatives like PQRS and Functional Limitation Reporting, the fact that there aren’t many new hoops to jump through next year is encouraging.   In today’s blog post, we’ll take a look at a few Medicare updates and reminders for 2016 with an emphasis on some of the changes in store for PQRS reporting.

General Medicare Updates

  • Therapy cap: The final 2016 Medicare Physician Fee Schedule Rule released by CMS set the 2016 therapy cap at $1,960 for PT and speech therapy combined and a separate $1,960 cap for OT.
  • Exceptions process: The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 extended the therapy caps exceptions process through December 31st, 2017. Therapists may continue to use the KX modifier for services above the therapy cap which meet medical necessity requirements
  • Manual medical review: MACRA also modified the requirement for manual medical review of services over the $3,700 thresholds for OT and PT/speech combined.   CMS is still finalizing the process for targeted manual medical review for services that exceed the $3,700 thresholds.
  • The Medicare deductible amount for 2016 is $166. Medicare beneficiaries have a 20% co-insurance once the deductible has been met.

PQRS Reporting in 2016

In 2016, eligible providers who bill under the physician fee schedule must report successfully under PQRS to avoid a ‐2.0% reduction in their 2018 fee schedule.  To avoid the negative payment adjustment, eligible professionals must once again report nine measures covering at least three National Quality Strategy (NQS) domains on at least 50% or more of their eligible Medicare patient encounters.  If nine measures covering at least three NQS domains are not available to a particular provider group, they must report all available measures covering two or fewer NQS domains to avoid the payment penalty.  Providers who report fewer than nine measures will be subject to the Measure-Applicability Validation (MAV) process which CMS uses to confirm that you qualified to report fewer measures and NQS domains.

For PTs reporting via claims, the same six measures that were available in 2015 are available for reporting in 2016 and include Measures 128, 130, 131, 154, 155, and 182.

For OTs reporting via claims, the same nine measures that were available in 2015 are again available in 2016, all of which must be reported.  These include Measures 128, 130, 131, 134, 154, 155, 181, 182, and 226.

For PTs reporting via registry, there are eight measures available (Measures 126, 127, 128, 130, 131, 154, 155, and 182) unless the therapist is also using FOTO in which case Measures 217, 218, 219, 220, 221, 222, and 223 are also available.

OTs reporting via registry have more than nine measures available from which they can choose their nine to report.  The available measures include 126, 127, 128, 130, 131, 134, 154, 155, 181, 182, 226, 402, and 431.  (One noticeable change is the removal of Measure 173 and the addition of 431.  More info is provided below.)  Additional measures are available for OTs using FOTO including Measures 217, 218, 219, 220, 221, 222, and 223.

PQRS Measure Updates

Several of the measures available to PTs and/or OTs have had some minor modifications for 2016.  Most of these include updated rationale and clinical recommendation statements which have no bearing on the instructions for reporting the measure or the codes to report.  Below is a summary of the primary changes to measures that are commonly reported by therapy providers.  (Changes to denominator codes that are not relevant to therapists are not included in the changes summarized below.)

Measure 126 – No updates (ICD-9 codes removed from denominator)

Measure 127 – No updates (ICD-9 codes removed from denominator)

Measure 128 – No updates

Measure 130 – Updated Rationale, Clinical Recommendation Statements

Measure 131 – Updated NQS Domain, Rationale, Clinical Recommendation Statements

Measure 134 – No updates

Measure 154 – Includes updated Numerator definitions.  These updates provide clarification on the requirements for documenting the quality actions performed in addressing this measure.  Specifically:

  • Balance/gait Assessment – Medical record must include documentation of observed transfer and walking or use of a standardized scale (e.g., Get Up & Go, Berg, Tinetti) or documentation of referral for assessment of balance/gait
  • Postural blood pressure – Documentation of blood pressure values in supine and then standing positions
  • Vision Assessment – Medical record must include documentation that patient is functioning well with vision or not functioning well with vision based on discussion with the patient or use of a standardized scale or assessment tool (e.g., Snellen) or documentation of referral for assessment of vision
  • Home fall hazards Assessment – Medical record must include documentation of counseling on home falls hazards or documentation of inquiry of home fall hazards or referral for evaluation of home fall hazards
  • Medications Assessment- Medical record must include documentation of whether the patient’s current medications may or may not contribute to falls

Measure 155 – Added Denominator coding (no relevant changes for therapists)

Measure 173 – Removed from PQRS

Measure 181 – Includes updates to the Instructions, Numerator definitions for “Psychological Abuse” and “Follow-Up Plan”).  Also includes updates to the Rationale.

Measure 182 – Updated Rationale, Clinical Recommendation Statements; Added NQF Number

Measure 226 – Minor changes to the wording for the Numerator Definition for “Tobacco Cessation Intervention” and the Numerator Note.  These changes do not affect the reporting instructions for this measure.

Measure 402 – Minor change to the Numerator QDC G9460.  (Wording changed from “Tobacco assessment OR tobacco cessation intervention not performed, reason not otherwise specified,” to “….not performed, reason not given”.

Measure 431 – This is a new measure available to OTs reporting via claims.  It takes the place of Measure 173 which was a screening for unhealthy alcohol use.  Measure 431 also includes a screening for alcohol use but this measure also requires brief counseling (a minimum of 5-15 minutes) for unhealthy alcohol use.  Furthermore, this measure requires two denominator eligible visits.  These factors may have an impact on whether or not an OT chooses Measure 431 as one of their nine measures to report.

For more information on the measure changes noted above or on the measure specifications including instructions, numerator and denominator notes, etc., check out CMS’s “Measures Codes” page at  Here, you can download the measure specifications for each individual measure (instead of the entire list of measures, a nice change from years’ past).  CMS has also added very handy measure flow charts for each measure which help guide the provider through the process for each measure.

I hope everyone has a peaceful and safe holiday season and a great start to the new year.  Until then, thanks for reading and Happy Holidays!

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