Using the American College of Surgeons’ Surgeon Specific Registry (SSR) for CMS Physician Quality Reporting System

The Centers for Medicare & Medicaid Services Physician Quality Reporting System (CMS PQRS) is a program where eligible professionals (EPs) currently submit quality data for physician incentive payment and to avoid penalties. Payments and avoidance of penalties are based on successful participation. EPs submit data on quality measures for covered Physician Fee Schedule services to Medicare Part B beneficiaries.

PQRS Incentive Payments & Penalties

For the 2014 reporting year, the incentive payment is 0.5 percent of the total allowed charges for Medicare Part B services covered in the Physician Fee Schedule (PFS) and completed during the reporting period. Beginning in 2015, there are 1.5 percent penalties for nonparticipation or unsatisfactory reporting based on the two years following a calendar year of participation. For example, eligible professionals who were unsuccessful PQRS participants in 2013 will be subject to a penalty in 2015. Two percent penalties will begin in 2016 and are based on 2014 data.

Reporting Year Incentive Penalty
2014 0.5%
2015 1.5%
2016 and beyond 2.0%

PQRS Reporting through SSR

Physician Quality Reporting System (PQRS) reporting can be done through three different methods: registry-based, claims-based, and electronic health records-based. The ACS Surgeon Specific Registry (SSR) can meet registry-based PQRS measures groups reporting in either full-year or half-year periods. Eligible professionals (EPs) must report on one measures group for at least 20 Medicare Part B Fee for Service (FFS) patients, a majority of whom should be Medicare patients (at least 11 Medicare patients). Eligible professionals will have until January 31, 2015, to submit PQRS 2014 data. If you have questions regarding PQRS participation in the SSR, please e-mail SSR@facs.org.

How Does a Surgeon Comply with PQRS by Using the SSR?

  1. The surgeon electronically signs a required consent for PQRS participation and is then provided access to PQRS measures and variables through the SSR.
  2. The surgeon completes the required variables for PQRS participation.
  3. Once the quality data has been entered, a surgeon signs an electronic attestation for submission and sends the data. The software vendor receives this data and sends all PQRS data to Centers for Medicare & Medicaid Services (CMS) by the submission deadline.
For more information about participating in PQRS, educational resources, and changes to the PQRS program in 2014, please visit the ACS PQRS website. The American College of Surgeons’ SSR also supports Part 4 of Maintenance of Certification (MOC) and provides for electronic transmittal of cases to the American Board of Surgery for recertification.