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6 PQRS Measures for Physical Therapy

January 15, 2014 12 Comments

There are 6 PQRS measures for physical therapy that outpatient practices should consider for PQRS reporting in 2014.  PQRS Codes for Physical TherapySit back and relax, have a cup of tea:  it won’t be as complicated as it seems.  But first let’s take a step back and explain a few details related to claims based reporting, an easy way to get started with the program:

  • PQRS reporting is only for those physical therapists billing on the CMS 1500 form (rehab agencies, CORFs, SNF and hospital outpatient therapy providers are not eligible).
  • Individual providers (in the group practice) must report on at least 3 measure on 50% of eligible patients to be exempted from the 0.2% penalty (applied in 2016)
  • Individual providers must report on 9 measure (or 1-8 as applicable) on 50% of eligible patient in order to qualify for the 2014 0.5% bonus payment (paid in 2015)

Note there is also the option for reporting PQRS codes for physical therapy via a group registry including an EMR based registry.  Stay tuned for a future post on PQRS reporting via registry.

6 PQRS Measures for Physical Therapy – Choose 3 to Avoid Penalty in 2016

The PQRS measures finalized for physical therapy in 2014 are:

Measure #Measure Description
128Preventive Care and Screening: BMI Screening and Follow-up
130Documentation and Verification of Current Medications in the Medical Record
131Pain Assessment Prior to Initiation of Patient Treatment
154Falls: Risk Assessment
155Falls: Plan of Care
182Functional Outcome Assessment
Select from these codes for claims based reporting. Note that there are 2 additional codes pertaining to wound care only applicable wherein wound care is provided, for sake of simplicity they are not included in this table.


Next Steps

Breathe a sigh of relief, if you have never participated in the PQRS program, participation this year via your submitted claims should be strongly considered (particularly if have a high percentage of Medicare patients).  Claims based reporting on at least 3 measures will stave off the 0.2% reduction in payment in 2016.  The American Medical Association has published great “Measure” guidelines in past years, and this year they are still in the process of updating their website with current measures.  Keep a look out on the AMA site for the measures noted in the table above, or if you have time on your hands you can confuse yourself by reading through everything on the CMS PQRS site.

What measures do you plan to use?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (12)

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  1. Josh Bailey says:

    It appears from reading CMS updates that verification of medication should be billed each time 97110 is billed. This seems excessive from a logical perspective, well as when compared to other measures which are to be reported with billing of 97001 or 97002. Is this an accurate understanding?

  2. Josh – Thanks for your comment, and indeed the specifications for this measure have changed for physical and occupational therapists in 2014. This measure must be reported for every visit and is triggered by the following procedure codes 97001, 97002, 97003, 97004, 97110, 97140, 97532. In 2013 this measure was only reportable when using 97001, 97002, 97003, 97004, 97532. Since 97110 is the most frequently used code in outpatient therapy, there is indeed going to be more attention to detail to ensure not only proper coding on the claim, but therapists documentation in the therapy record per the 2014 measure specification. For therapy providers that are reporting on 6 measures in order to qualify for the 0.5% incentive payment this measure will have to be in the mix. For providers that are reporting on 3 measures (for 50% of eligible patients) this might not be at the top of the selection list due to the attention to detail on documentation and claims. Providers selecting an EMR program should strongly consider how PQRS fits into the mix, as PQRS reporting for physical therapy (private practice) is here to stay.

  3. Davita says:

    I am confused on how to report any of the codes at all. I thought I had a good grasp on it, but we are now getting denials for lacking information from Medicare. I believe the fall risk and assessment and the fall POC are the measures that rea giving us issues. I’m pretty sure there is a combination of codes that need to be submitted with these measures, but I am unclear as to which ones are supposed to be reported and at what time. Any clarity would be greatly appreciated.

  4. Thanks for your comment. You may be correct is your insight as to what is causing the denials. The Falls Risk Assessment and Falls Plan of Care measures require more reporting. There are nine different reporting codes associated with Measures 154-155. Do you have a copy of the 2014 CMS PQRS Measure guide? The definitions of all the reporting codes for these measures will be explained. In a nutshell if the patient is assessed to be at risk for falls in Measure 154, then 2 codes must be reported: 1100F (At risk for future falls) and 3288F (Falls risk assessment was completed). That is likely the culprit. Be sure to check back and let us know!

  5. Davita says:

    The way we have been billing the exmaple that you gave is 1100F, 3288F, and 0518F if they have had a fall. If they haven’t had a fall then we use 1101F only. Then, we also include measures #128-BMI and #131 Pain Assessment on every eval that we submit to Medicare. I do not have the guide that you mentioned. Is there a reference on-line that I could refer to?

  6. Saksham says:

    Hi Nancy,
    I have few questions regarding PQRS 2014 –
    1. If a Physician reports a measure group(Back Pain) having 5 measures and also report 4 individual measures, then should there be one PQRS XML report generated with both individual measures and measure group in it? or there should be 4 xmls for individual measures and one XML for a measure group?

    Kindly help me out with this. Thanks in advance

  7. Thank you for your comment. I suggest you direct your question to the PQRS Help desk, it would appear you are a software vendor and need technical information. Good luck!

  8. Jorge L Narvaez says:

    Hi Nancy, for a physical therapy practice, does the 3 measures minimum apply to each individual Medicare patient (e.g. each of the 50% Medicare patients been reported must have at least 3 codes); or is the minimum of 3 measures for the facility as a whole (e.g. some patients with a Diabetes code, others with a BMI codes and other with a fall code, etc.) as long as 50% of the facility’s Medicare patients is reported?

  9. Hello Jorge, and thank you for your question. In 2015 the PQRS program has changed and 9 measures must be reported. There are 6 measures for physical therapy, so all 6 must be reported for 50% of the eligible Medicare patient visits. Data will be collected and subject to Measure Applicability Validation (MAV) to ensure that all eligible measure were reported. I teamed up with Clinicient to provide a complimentary webinar on February 12th. There is also an opportunity to review the playback and download the slides here.

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