PQRS and the Value Modifier – Do you Stay the Course or Change Direction?
Starting in 2013, CMS began to phase in a new program known as the Value-Based Modifier, “VM” for short. Each year, practices are provided with a Quality and Resource Use Report (QRUR). CMS uses the practice’s data reported from the PQRS program in conjunction with the data found on patients’ Medicare claims to score on two metrics:
- Cost (low/medium/high)
- Quality (low/medium/high)
Under this program, all of the PQRS scores are entered into a system that uses an algorithm to add each provider (TIN) or group to a scatterplot. This scatterplot is then overlaid onto a 3×3 matrix grid demonstrating low/medium/high cost and low/medium/high quality grid to determine the VM fee modifier.
Please see the table below on the roadmap of the value modifier in the upcoming years.
| Performance Year | Payment Year | Who it affects |
| 2013 | 2015 | Groups of 100 or more EPs |
| 2014 | 2016 | Groups of 10 or more EPS |
| 2015 | 2017 | Solo and two or more EPs , excludes groups participating in MSSP, Pioneer ACO, or CPCI* |
| 2016 | 2018 | Solo and two or more EPs , excludes groups participating in MSSP, Pioneer ACO, or CPCI* |
| 2017 | 2019 | Solo and two or more EPs, includes groups participating in MSSP, Pioneer ACO, or CPCI* |
| 2018 | 2020 | All plus Medicare PFS payments to non-physician EPs included |
*MSSP: Medicare Shared Savings Program
*ACO: Accountable Care Organization
*CPCI: Comprehensive Primary Care Initiative
Would you like to get reacquainted with the latest information for the Value Modifier, QRUR, or PQRS? Join us on March 9th for a free webinar or stop by our booth at HIMSS #3273. Find out not only how to avoid penalty payments, but also how to actually increase your fee for service (FFS) claim payments for Medicare Professional Fee Services (MPFS) by +2-4% per claim!
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