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CMS Reductions

PQRS  EHR  VBMQ  Legislative

CMS Reductions are not handled at the contractor level. Providers must contact CMS directly for the below reductions.

PQRS

Beginning on January 1, 2015, Center for Medicare & Medicaid Services (CMS) must apply this negative payment adjustment to any eligible professionals (EPs) who are not satisfactory reporters under the Physician Quality Reporting System (PQRS). The negative payment adjustment in 2015 applies to all of the EP's Medicare Physician Fee Schedule (MPFS) services and will result in the EP receiving 98.5 percent of the MPFS amount that would otherwise apply to such services during 2015. In other words, an EP receiving the negative payment adjustment would be paid 1.5 percent less than the MPFS amount for that service. In 2016 and beyond, the negative payment adjustment increases to 2.0 percent, or payment of 98 percent of MPFS amount for covered professional services furnished in 2016 and subsequent years. If an EP believes that a negative payment adjustment was applied in error, the EP may contact the Quality Net Help Desk to seek an informal review of previously submitted data. Information on how to contact the Help Desk is available on CMS' PQRS websiteExternal Website. If the Help Desk discovers that a negative payment adjustment was applied in error, the Help Desk will notify CMS. If the Help Desk discovers that a negative payment adjustment was applied in error, the Help Desk will notify CMS.

EHR

The Centers for Medicare & Medicaid Services (CMS) handles all EHR request. Please contact the EHR information CenterExternal PDF at 1.888.734.6433 (7:00am-7:00pm CST M-F) for questions. EHR requests are not handled at the Contractor level.

VBMQ

Beginning on January 1, 2015, CMS applied a value-based payment modifier (Value Modifier) to specific groups of physicians. A group is defined as a single Taxpayer Identification Number (TIN). The Value Modifier can be an upward, downward, or no adjustment and applies to the paid amount of physician payments under the Medicare Physician Fee Schedule. Section 1848(p) of the Social Security Act requires CMS to establish a Value Modifier that provides for differential payment under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished compared to cost during a performance period. Section 1848(p) requires that the Value Modifier be applied to specific physicians and groups of physicians the Secretary determines appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, 2017. 

For physician payments made in 2015, the Value Modifier applies to groups of physicians with 100 or more eligible professionals. The Value Modifier applies to previously identified physicians. CMS applies the Value Modifier adjustment at the taxpayer identification number level and applied it to the items and services billed by physicians under the taxpayer identification numbers (TIN), not to other eligible professionals that also may bill under the TIN. CMS applied the Value Modifier adjustment to the Medicare paid amounts for the items and services billed under the PFS so that beneficiary cost-sharing is not affected.

CMS identified the groups of physicians with 100 or more eligible professionals (identified by TINs) and determined each group's Value Modifier adjustment for 2015 based on the group's reporting for the Physician Quality Reporting System (PQRS) in performance period 2013.

If You Think If There is an Error in your Value Modifier

If a physician group believes that CMS has made an error in the calculation of the group's Value Modifier, then the group may request a correction through our informal review process. For the 2016 Value Modifier and beyond, informal review must be requested no later than 60 days after receipt of the QRUR. If, upon review, CMS determines that we have made an error in the calculation of the quality composite and we are unable to recalculate it, then we will classify the TIN as "average quality." For the 2016 Value Modifier and beyond, if we are able to receive and utilize corrected quality data, then we will recalculate the quality composite. If we determine we made an error in the calculation of the cost composite then we will re-compute the cost composite to correct the error.

Who You Can Contact for Further Information?

  • Physician Value Help Desk (for Value Modifier questions): Monday - Friday: 8:00 am - 8:00 pm EST Phone: 888-734-6433, press option 3
  • QualityNet Help Desk (for PQRS questions: 866-288-8912 (TTY 877-715-6222) 7:00 a.m.- 7:00 p.m. CST M-F

You will be asked to provide basic information such as name, practice, address, phone, and e-mail address.

Additional Information

More information about the full implementation of the CMS Physician Feedback/Value-Based Payment Modifier Program is available on the CMS websiteExternal Website. Please refer to a Summary of the 2015 Physician Value-based Payment Modifier PoliciesExternal PDF.

Legislative

As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims on or after April 1, 2013, incur a two percent reduction in Medicare payment. Please refer to MM8378: New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Payment Due to SequestrationExternal PDF

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