A Guidebook to the 2012 Physician Quality Reporting System

Transcription

1 A Guidebook to the 2012 Physician Quality Reporting System Last Updated: February 2, 2012

2 Getting Started With PQRS The Patient Protection and Affordable Care Act made participation in Medicare s Physician Quality Reporting System (PQRS) program mandatory beginning in Providers who participate in the PQRS program between 2011 and 2014 are eligible for incentive payments if they successfully and satisfactorily transmit data to the Centers for Medicare and Medicaid Services (CMS) regarding quality measures related to their Medicare patients. Conversely, providers who are not successfully/satisfactorily participating in PQRS by the 2013 reporting period (Jan. 1 Dec. 31, 2013) and beyond will face a penalty of having their Medicare reimbursement decreased by 1.5% (98.5% of the fee schedule amount that would otherwise apply to such services) beginning in In 2016, the payment decrease will be 2% (98.0% of the fee schedule amount that would otherwise apply to such services). In other words, the 2012 reporting period (Jan. 1 Dec. 31, 2012) is the last opportunity providers have to voluntarily participate in PQRS and learn how to report successfully/satisfactorily while incentives are still being offered and penalties are not being enforced. If you have never participated in PQRS you may not know where to begin. To get started, follow the steps laid out below: 1) First, you should know that no registration is required to begin participating in PQRS. 2) It is best to start by familiarizing yourself with the quality measures that doctors of chiropractic can report on. These measures include: Measure #124. Health Information Technology: Adoption/Use of Electronic Health Records (EHR) Measure #131. Pain Assessment and Follow Up Measure#182. Functional Outcome Assessment 3) To receive an incentive bonus for participating in PQRS you must report on all measures applicable to DCs. This means you must report on Measure #124, #131 and #182 to receive a bonus. The only exception is if you do NOT have a certified, PQRS qualified or other acceptable electronic health record (EHR) system in your office. If you do not have a qualified/certified EHR, you only have to report on two (2) measures Measure #131 and #182. 4) To participate in PQRS you will be asked to place a G code on your claim form. The G code will correlate to an action that was taken by the provider. 5) For Measures 131 and 182, you will report these measures on every visit for every Medicare patient that you have who is older than 18 and who you have treated with CMT and reported CPT code 98940, or For Measure #124, you will only report this measure if you have adopted and are using a certified, PQRS qualified or other acceptable EHR system. If you DO have an acceptable EHR system in your office you will report this measure on every patient at every visit. In 2012, you must successfully report on all applicable measures on at least 50% of your Medicare patients to qualify for an incentive bonus. 6) Provided below are charts to assist you in reporting the appropriate G code for each visit for each quality measure. Page 2 of 10

3 Measure #124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) The purpose of this measure is for CMS to collect data on whether providers are using qualified electronic health records (EHR). Providers are asked to report whether they are using an EHR system that has been certified by an Authorized Testing and Certification Body (ATCB) or an EHR system that is PQRS qualified. If a provider does not have a qualified EHR, the provider does not have to report on this measure. The provider should report one of the G codes below on line 24 D of a paper claim or on service line 24 of an electronic claim. The following chart depicts the situations in which each G code should be reported for Measure #124: Provider Action Encounter Documented Using a ATCB Certified EHR System The provider documented the patient encounter using an EHR system that has been certified by an Authorized Testing and Certification Body (ATCB). Encounter Documented Using a PQRS Qualified or Other Acceptable EHR System The provider documented the patient encounter using an EHR that is a qualified PQRS EHR or another acceptable system. Code Reported G 8447 G 8448 For a list of qualified PQRS EHRs visit: nganderx pdf Page 3 of 10

4 Measure #131 Pain Assessment and Follow Up The purpose of this measure is for CMS to collect data on when pain assessments are conducted. Examples of pain assessments include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS). Providers are asked to report whether they provided a pain assessment to the patient and if they documented a follow up plan related to that assessment. A follow up plan must include a planned time to reassess the patient for pain and may also include documentation of future appointments, education, referrals, or notification of other care providers, as applicable. The provider should report one of the G codes below on line 24 D of a paper claim or on service line 24 of an electronic claim. The following chart depicts the situations in which each G code should be reported for Measure #131: Provider Action Pain Assessment Documented as Positive AND Follow Up Plan Documented The provider assessed the patient for pain using a standardized tool, documented a positive assessment (pain was present), and also documented a follow up plan that specifically stated a planned reassessment of pain (future appointments, education, referrals, or notification of other care providers as applicable. Pain Assessment Documented as Negative, No Follow Up Plan Required The provider assessed the patient for pain, documented a negative assessment (absence of pain), and no additional documentation was required. Patient not Eligible for Pain Assessment for Documented Reasons The provider documented that patient was not eligible for a pain assessment. Patients are not eligible for pain assessments for the following reasons: Patient refuses to participate; Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others; Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Pain Assessment not Documented, Reason not Specified The provider did not assess the patient for pain and there is no documented reason why the provider did not perform the assessment. Pain Assessment Documented as Positive, Follow Up Plan not Documented, Reason not Specified. The provider assessed the patient for pain, documented positive a positive assessment (pain was present), but did not document a follow up plan and did not document a valid reason why a follow up plan was not drafted. Code Reported G 8730 G 8731 G 8442 G 8732 G 8509 Page 4 of 10

5 Measure #182 Functional Outcome Assessment The purpose of this measure is for CMS to collect data on when functional assessments are conducted. Examples of standardized functional assessments tools include Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI) and Physical Mobility Scale (PMS). Documentation of a current functional outcomes assessment must include identification of the standardized tool used. o Please Note: The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool. Providers are asked to report whether they conducted a functional outcome assessment of the patient and if they documented a care plan. A care plan would include goals based on the deficiencies found in the assessment, future appointments, future procedures, and other information that would describe the next steps for treating the patient s condition. The provider should report one of the G codes below on line 24 D of a paper claim or on service line 24 of an electronic claim. The intent of the measure is for the functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required each visit due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality data code (G 8540: Current Functional Outcome Assessment not documented, Patient not Eligible) should be used for reporting purposes. The following chart depicts the situations in which each G code should be reported for Measure #182: Provider Action Current Functional Outcome Assessment and Care Plan Documented A functional assessment was performed and the provider documented a care plan, including goals based on deficiencies found. Current Functional Outcome Assessment Documented, no Functional Deficiencies Identified, Care Plan not Required A functional assessment was performed but the provider did not document a care plan for a valid documented reason. One example why a provider may not document a care plan in response to the functional assessment might be if the patient had no functional deficiencies. Current Functional Outcome Assessment not Documented, Patient not Eligible A functional assessment was not performed and the provider documented a valid reason why. A patient is not eligible if the following reason(s) exist: The patient refuses to participate The patient is unable to complete the questionnaire The provider has a current functional assessment on file for the patient that was completed within the previous thirty (30) days. Current Functional Outcome Assessment not Documented, Reason not Specified A functional outcome was not performed and the provider did not document a reason why it was not performed. Current Functional Outcome Assessment Documented, Care Plan not Documented, Reason not Specified A functional assessment was performed but the provider did not document a care plan and did not document a reason why a care plan was not devised. Code Reported G 8539 G 8542 G 8540 G 8541 G 8543 Page 5 of 10

6 2012 Criteria for Satisfactory Reporting Individual Quality Measures, by Reporting Mechanism and Reporting Period Reporting Mechanism Claims based reporting Registry based reporting Reporting Criteria Report at least 3 PQRS measures, or 1 2 measures* if less than 3 measures apply to the eligible professional; AND Report each measure for at least 50% of the eligible professional s Medicare Part B FFS patients seen during the reporting period to whom the measure applies. Measures with a 0% performance rate will not be counted. Report at least 3 PQRS measures; AND Report each measure for at least 80% of the eligible professional s Medicare Part B FFS patients seen during the reporting period to whom the measure applies. Measures with a 0% performance rate will not be counted. Reporting Period January 1, 2012 December 31, 2012 January 1, 2012 December 31, 2012 EHR based reporting aligning with the Medicare EHR Incentive Program Report on ALL three Medicare EHR Incentive Program core measures. If the denominator of one or more of the Medicare EHR Incentive Program core measures is 0, report on up to three Medicare EHR Incentive Program alternate core measures (as identified in Table 48 of the 2012 Medicare Physician Fee Schedule Final Rule) January 1, 2012 December 31, 2012 Report on three (of the 38) additional measures available for the Medicare EHR Incentive Program. EHR Direct EHRbased reporting & EHR data submission vendor Report at least 3 PQRS measures AND Report each measure for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate will not be counted. January 1, 2012 December 31, 2012 * Eligible professionals who report on fewer than 3 measures may be subject to the CMS Measure Applicability Validation process. To view the table above and additional PQRS information, visit the American Medical Association s Physician Quality Measure Reporting webpage at: assn.org/ama/pub/physician resources/clinical practice improvement/clinicalquality/physician quality reporting system.page?. Page 6 of 10

7 How to Find Out if You Successfully Participated in PQRS The Centers for Medicare and Medicaid Services (CMS) will provide PQRS feedback reports to doctors. The feedback report will include statistics on the number of quality data codes submitted and success rates in reporting. CMS makes feedback reports available in the fall of the year following the PQRS reporting year. For example, the 2011 feedback reports will be available in October Incentive bonuses are released following the release of the feedback reports usually in the month of November. How to Access your Feedback Report If a PQRS feedback report is available for your organization s Taxpayer Identification Number (TIN) or National Provider Identifier (NPI), there are two (2) ways to access it. 1. A provider can simply call their carrier or A/B MAC to request the PQRS feedback report, which will contain information based on their individual NPI. If the provider is part of a group practice, each provider in the group practice must individually. To obtain a list of carrier/mac Provider Contact Centers, visit the CMS website at: In addition to PQRS information, these reports will provide individual EPs with information on their Medicare Part B Physician Fee Schedule allowed charges upon which the incentive payment is based. 2. Providers can logon to the secure PQRS Portal on QualityNet at: to access their feedback report. 3. Users who have questions or need assistance should contact the Quality Net Help Desk at (Monday Friday 7:00 a.m. 7:00 p.m. CST) or qnetsupport@sdps.org. Incentive Payments For 2012, providers are eligible for a 0.5% bonus, based on all Medicare allowed charges for dates of service January 1, 2012 through December 31, 2012 (this includes deductibles and co insurance). Additionally, where Medicare is the secondary insurance, PQRS payments would not be limited just to the portion paid by Medicare, but to the entire allowed fee. Timeline of Incentives/Disincentives % incentive bonus % incentive bonus % incentive bonus % incentive bonus * % incentive bonus * % payment decrease * % payment decrease * *Providers must be successfully participating in PQRS to avoid payment decreases that will begin in Page 7 of 10

8 Frequently Asked Questions Q. What is the Physician Quality Reporting System? A. The Physician Quality Reporting System (PQRS) represents CMS effort to implement a quality measure reporting program for Medicare providers. It was first mandated by Congress as part of the Tax Relief and Health Care Act of 2006 (TRHCA). Q. Is participation in PQRS mandatory? A. The Patient Protection and Affordable Care Act made participation in PQRS mandatory, beginning in However, CMS ruled in 2012 that if a provider is not successfully participating in PQRS by the 2013 reporting period (Jan.1 Dec. 31, 2013) their reimbursement will be decreased by 1.5% in In 2016 and beyond, reimbursement will be decreased by 2%. Although, until 2015, participation is not mandatory, it is advisable to begin participating as soon as possible (to learn how to report successfully while incentives are still being offered). Q. To which Medicare providers does PQRS apply? A. The program applies to: Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists (as of 1/1/2009) Physical Therapist Occupational Therapist Qualified Speech Language Therapist (as of 7/1/2009) Q. When does the 2012 PQRS reporting period begin and end? A. For 2012, the program begins on January 1, 2012 and concludes December 31, In 2012, eligible providers no longer have the option to report during a six month period. Q. What are the requirements for participating in the PQRS program? A. It is not necessary to register to participate in the PQRS program, but participants must have a National Provider Identifier (NPI) number in order to participate. Q. How does the incentive bonus payment work? A. You can receive up to a 0.5% bonus, based on all Medicare allowed charges for dates of service January 1, 2012 through December 31, This includes deductibles and coinsurance. Additionally, where Medicare is the secondary insurance, PQRS payments will Page 8 of 10

9 not be limited just to the portion paid by Medicare. Q. Is the bonus payment expected to cover the expenses of participating in the program? A. It is difficult to answer this question with any certainty, as the answer is dependent on the practice s ability to utilize current staff and data resources, as well the practice s commitment to reporting on the measures applicable to doctors of chiropractic. It is important to point out that participation in the program demonstrates to CMS, and the rest of the healthcare community, that the chiropractic community is serious about quality care improvement. Q. How will CMS validate whether eligible professionals have successfully reported the minimum number of applicable measures under the Physician Quality Reporting System (PQRS)? A. CMS is required by law to validate, using sampling or other means, whether quality measures applicable to covered services of a participating eligible professional have been reported. CMS will focus on situations where eligible professionals have successfully reported fewer than three quality measures. If CMS finds that eligible professionals who have reported fewer than three quality measures have not reported additional measures that are also applicable to the professional services they furnished to Medicare beneficiaries during the reporting period, then CMS cannot pay those eligible professionals the bonus incentive payment. Please Note: For doctors of chiropractic, there are only three (3) measures currently applicable. However, not all doctors of chiropractic have HIT, so they cannot be required to report on that measure (#124). Therefore, some chiropractic offices will only be able to report on two (2) quality measures (#131 and #182), not three, which will meet CMS validation for successful reporting. Q. Do I need to change my practice management system to participate in the Physician Quality Reporting System (PQRS)? A. If your practice management software does not allow for submission of zero dollar line items, you will need to change this edit for the Medicare claims on which you submit quality data codes. A nominal non zero charge ($0.01) can be associated with the PQRS codes for submission. Q. How do I select which measures are most appropriate to report? A. That information is included in this chapter and online at: Q. What are considered appropriate assessment tools for Measure #131, the pain assessment measure? A. An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment which address location and/or intensity and/or description, include, but are not limited to, Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS). Q. What are considered appropriate assessment tools for Measure #182, the functional assessment measure? A. An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for functional outcome assessment include, but are not limited to, Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), and Neck Disability Index (NDI) and Physical Mobility Scale (PMS). Page 9 of 10

10 Please Note: The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool. Additional Resources ACA webpage dedicated to PQRS: CMS webpage dedicated to PQRS: ACA s Government Relations Department: Phone GR@acatoday.org CMS PQRS Helpdesk: Phone: Qnetsupport@sdps.org In addition, CMS regularly holds calls dedicated to PQRS and allows for open question and answer sessions. Look for announcements of these calls on the website under CMS Sponsored Calls and in ACA publications. Glossary of Terms Centers for Medicare and Medicaid Services (CMS) The nation s federal agency which administers Medicare, Medicaid, and the State Children's Health Insurance Program. Outcome Measure A measure that provides information on how health care affects patients. Pay for Performance (PFP) A model based on rewarding quality health care by setting different payment levels for health care providers based on how well they meet benchmarks of quality and efficiency. Physician Quality Reporting Initiative (PQRI) Mandated by Congress through the Tax Relief and Health Care Act of 2006 (TRHCA), CMS developed the Physician Quality Reporting Initiative (PQRI). PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. To recognize that the PQRI was no longer an initiative and the program was made permanent, in 2011 CMS renamed the program the Physician Quality Reporting System (PQRS). Process Measure A measure associated with the practice of health care or the furnishing of a service that is known to be effective. Structural Quality Measure A measure that reflects the organizational, technological, and human resources infrastructure of a system necessary for the delivery of quality health care (such as the use of health information technology for the submission of measures). Page 10 of 10