Is PQRS Really Worth It?

Older couple holding hands

As the nearly 77 million Baby Boomers (born 1946 – 1964) continue to age, the population age 65 and over is projected to double to 71.5 million by 2030 and grow to 86.7 million by 2050. That means that more than 80 million people will be eligible to be on Medicare and Social Security. To help cut down on the costs of health care in Medicare, the government is enacting programs to enhance the value of its purchasing dollars in health care. It is time for us to evaluate if chiropractors really want to be in the program.

At a recent Medicare conference, National Government Services reported that Medicare expenditures rose from $408 billion for 43.2 million beneficiaries in 2006 to $582 billion for 52.3 million beneficiaries in 2013. Every 8 seconds, someone becomes Medicare eligible. Due to the sheer numbers, expenditures will continue to rise, even if spending rates slow down. Governmental programs have been formed to ensure quality care is “medically necessary” and is available to all Medicare beneficiaries. In the midst of growing compliance demands, many physicians, including chiropractors, are evaluating whether they wish to participate in the program.


In January 2004, the Centers for Medicare and Medicaid Services (CMS) declared that a medical doctor or doctor of osteopathy can opt out of Medicare, but still see a Medicare patient. Chiropractors, physical therapists in independent practice and occupational therapists in independent practice cannot opt out of Medicare and still see Medicare patients. This seems to be a contradiction we have to live with. Your participation in Medicare is either as a participating physician (in-network) or non-participating physician (out of network). However, whether you are a participating (par) physician or non-participating physician (non-par), you still must file a claim for all covered active services. Not seeing a Medicare patient is to exclude 20% of the population from the services you provide, creating an ethical dilemma within this business decision.

In its quest to determine what constitutes quality medically necessary care, the government has initiated several programs. Among those programs is the Physician Quality Reporting System (PQRS). By declaring certain measures or groups, Medicare is gathering information to determine the most effective treatment to aid in or decrease the effects of certain conditions. The eligibility for measure group participation is determined by the CPT® code for service associated with the measure. Since chiropractors are limited to 98940, 98941 and 98942 by our scope of practice in Medicare Part B, the measures in which we may participate are therefore limited. In past years, we were eligible for two measures and in 2014, for three measures. In 2015, we are back to two measures: Pain Assessment and Functional Capacity of ADL (Functional Outcomes). Reporting on just two measures makes it an easy enough procedure to accomplish [???].

On October 31, 2014, CMS News released final rules pertaining to care for Medicare beneficiaries. According to the release, “The rules reflect a broader Administration-wide strategy to move our health care system to one that values quality over quantity and spends taxpayer dollars more wisely by finding better ways to deliver care, pay providers, and distribute information.”

Included among the rules are the following:

  • Better coordination of care for beneficiaries with multiple chronic conditions. Under this year’s rulemaking, the Medicare Physician Fee Schedule will include a new chronic care management fee in 2015. If chiropractors are eligible for this program, our role in taking care of chronic conditions may finally be realized.
  • Paying providers for quality care, not quantity of care. Fees will be increased on a case management system, rather than a fee-for-services reimbursement model. Medicare will continue to phase in the Value-Based Modifier (VBM). The VBM will be individually assigned to each provider. The VBM amount will be determined in part by whether or not you participated in the PQRS program. Initial indications are that other insurance companies may utilize the VBM as a basis for increasing or decreasing their reimbursement individual rates. In other words, Medicare PQRS involvement will enhance your reimbursement in other insurance programs, not just Medicare. Payments will be adjusted to physicians and other eligible providers based on the quality of care and cost of care furnished by that provider.
  • Better information is now available through the Physician Feedback Program and the Quality and Resource Use Reports (QRURs).
  • The Physician Feedback Program provides comparative performance information to Medicare Fee-For-Service physicians. This program helps CMS provide meaningful and actionable information to physicians so they can improve the care they furnish to Medicare patients. The Physician Resource Use Measurement and Reporting Program was created by the Medicare Improvements for Patients and Providers Act of 2008. The Affordable Care Act of 2010 extended and enhanced the Program – now called the Physician Feedback Program.
  • The QRURs provide comparative information so that physicians can view data analysis of the clinical care their patients receive in relation to the average care and costs of other physicians’ Medicare patients. The reports are confidential and show physicians how their patients use various tests and services and how the care and cost of the physician’s care compares to others.
  • The Value-Based modifier will be based on information gathered through the PQRS program, the QRURs and the Physician Feedback Program. The Value-Based Modifier is expected to be implemented for all physicians no later than 2017.
  • Finally, CMS will expand and finalize new measures to the “Physician Compare” website. CMS has now finalized policies to expand the quality measures available on its website to be accessed by the public to compare their doctor to others. This will include public reporting, including patient experience measures for satisfaction and qualified data registries.

Through the programs CMS has instituted, Medicare, other insurance companies and the public will be able to not only access information about each physician, but will be able to adjust payment to that physician. Thus, quality care will be rewarded.

In my opinion, the government programs may be worth your involvement by increasing awareness of the care we provide; expanding patient access to care provided by the chiropractic profession, and rewarding quality care that each physician provides. This information may then be accessed by patients in choosing their doctors. Many doctors utilize marketing in their practice. While we cannot hold ourselves out to be better than other physicians, the government programs may actually accomplish it for us.

Dr. Fucinari will be presenting several classes and webinars to aid the doctor and staff in correct compliance procedures. For an updated schedule of classes and locations, go to and Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. For further information on chart audits, compliance audits, manuals or consulting, please contact Dr. Fucinari at

Editor’s Note: The Illinois Chiropractic Society will have a PQRS course available online in February with the 2015 updates. ICS Members will have access to that course and many others at no additional charge as a part of your membership benefits.

About Author

Mario Fucinari DC, CCSP, APMP, MCS-P, CPCO

Dr. Mario Fucinari has helped train doctors and staff over the last 20 years. He received his bachelor's degree from Wayne State University in Detroit and his Doctor of Chiropractic degree from Palmer College of Chiropractic in 1986. Dr. Fucinari was the recipient of the 1998 and the 2003 President's Award from the Illinois Chiropractic Society (ICS) for his work with education and training and most recently received the 2012 Chiropractor of the Year award from the ICS. Dr. Fucinari was the first chiropractic physician to attain the Certified Medical Compliance degree. Two years later he earned his degree as a Certified Instructor for the Certified Medical Compliance Program. He is now the Chairman of the Chiropractic division of the national medical compliance program. He has produced classes and publications on HIPAA, Clinical Documentation, Medicare, and Stroke and Cervical Manipulation. He is a worldwide speaker for NCMIC, Foot Levelers, ChiroHealthUSA and several state associations and a Certified Chiropractic Sports Physician [CCSP].Online CME CoursesConnect

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