The payment reduction amount will be increased to 2% in 2016 and subsequent years.  The payment reduction will apply to all physicians who treat Medicare patients, regardless of whether the physician is participating or non-participating and will reduce both the participating fee, the non-participating fee and therefore, the NYS limiting charge. 

The Medicare Physician Quality Reporting System (PQRS), formerly PQRI, is a reporting program that uses a combination of incentive payments and payment reductions to promote reporting of quality information by eligible Medicare professionals.  PQRS is a pay-for-performance initiative that rewards health care providers for meeting certain performance measures for quality and efficiency of care.  

Please note that the goal of this article is to provide NYSPA members with information and the necessary tools to avoid the PQRS payment reduction slated for 2015.  This article is not intended to serve as a primer on the PQRS quality reporting measure in general.  For more information on the PQRS program, please refer to the CMS website (see link below). 


Physicians wishing to avoid the payment reduction should do the following:

Report at least one valid measure on the CMS 1500 claim form for one patient, on one date of service, during the 2013 calendar year.  The measure is to be reported using designated reporting codes and should be listed as a separate line item on the CMS 1500 claim form, with a zero dollar value. 



The PQRS program includes over 200 measures that are available for reporting.  In order to assist members, NYSPA has identified 4 measures that are relevant and appropriate to psychiatry and are expected to be relatively straightforward for use by individual physicians:    

Outpatient Measures (two are diagnosis specific; one is available for any diagnosis)

Measure # 9:  Major Depressive Disorder:  Antidepressant Medication during Acute Phase for Patients with MDD (patients 18 years and older)

Measure # 247: Substance Use Disorders:  Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence (patients 18 years and older)

Measure # 130:  Documentation of Current Medications in the Medical Record (patients 18 years and older)

Inpatient/Nursing Home Measure
Physicians with no outpatient practice who practice only in an inpatient hospital or nursing home may utilize the following measure:

Measure # 47:  Advance Care Plan (patients 65 years and older) 

More detailed information regarding these 4 measures may be accessed here


Although one reported measure for one patient, on one date of service and on one claim form will be sufficient to avoid the 2015 payment reduction, NYSPA strongly advises that all members report at least three measures for three different dates of service on or before December 31, 2013.  The submission of two additional measures should help to ensure that at least one claim form is captured and processed correctly and in a timely manner. 

Physicians working for more than one organization must meet the reporting criteria for each tax identification number (TIN) used by the physician during 2013 to avoid the 2015 payment reduction.  For example, if a physician works in a clinic and also maintains a private practice, the physician must report at least one measure for each of the physician's practice settings.

In order to successfully avoid the payment reduction, the claim form including the reporting code(s) must be submitted to CMS by December 31, 2013 and processed no later than February 28, 2014. 

It is also possible to report the required measure via a participating registry or participating/qualified Electronic Health Record.


The reporting code for each reportable measure should be listed as a separate line item with a zero dollar value immediately following the CPT code(s) for each associated patient and date of service.  To assist members, NYSPA has prepared a sample CMS 1500 claim form, available here


The patient record must also include documentation of the measure to be reported.  For example, if a physician chooses to report Measure #130 (Documentation of Current Medications in the Medical Record), the patient note for that date of service must include a listing of all medications the patient is currently taking, including medications prescribed by the reporting physician, medications prescribed by other physicians, and any over-the-counter medications. 

Finally, it should also be noted that there are two other ways to avoid the PQRS payment reduction.  First, an individual provider may qualify as a successful PQRS reporter by reporting at least three different quality measures for a certain portion of their Medicare Part B patients, depending on the reporting method used.  If you are already participating in the PQRS program and earning an incentive, you do not need to take any action to avoid the payment reduction at this time.  Second, providers may elect to have CMS calculate their quality performance based on administrative claims.  The administrative claims option is available only during the period July 15, 2013 through October 15, 2013.  For more information on these alternatives methods of avoiding the payment reduction, please see the 2013 PQRS: 2015 PQRS Payment Adjustment Tip Sheet 

For additional information:

CMS Website -

PQRS Educational Video -

Prepared by Rachel Fernbach, Esq.