Thank You to Our Sponsors! Game Plan. CMS EHR Incentive Programs. Where to go for Help, Handouts, and Future Updates

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1 Thank You to Our Sponsors! Incentive Programs Update, Quality Reporting and Information Exchange Dr. Henry and Dr. Gross are affiliated with and have lectured for numerous companies including Topcon, First Insight, RevolutionEHR, FoxFire, VisionWeb, SolutionReach, and the AOA. Philip J. Gross, O.D. Jay W. Henry, O.D., M.S. Where to go for Help, Handouts, and Future Updates Game Plan CMS EHR Incentive Programs Quality Reporting Clinical requirements and Quality of Care PQRS Incentive Program E-Prescribing Clinical requirements, implications, and exemptions E-Prescribing Incentive Program Security and HIPAA compliance ehealth Exchange A critical clinical part! ICD-10 CMS EHR Incentive Programs CMS EHR Incentive Programs The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program 1

2 CMS EHR Incentive Programs Government wants to encourage quick movement to EHRs Largest payments early in program Under Medicare Incentive payments began in 2011 Penalties begin in 2015 Under Medicaid Incentive payments began in 2010 CMS EHR Incentive Programs Two programs are available Choose only one Medicare EHR Incentive Program (Non-hospital based providers only) - - OR - - Medicaid EHR Incentive Program (At least 30% of all your patient encounters must be paid by Medicaid) This includes Medicaid managed care programs: MCOs, prepaid inpatient health plans (PIHPs), or prepaid ambulatory health plans (PAHPs) (ODs approved under Medicaid program in: AL, IL, KY, LA, NJ, OH, MI, SC, MD, VA, MS) Certified EHR Software Certified EHR Software To get an incentive payment for CMS EHR Incentive Programs, you must use an EHR that is certified specifically for the EHR Incentive Programs EHR software is certified by version number Verify your EHR is certified by visiting the ONC CHPL website at: Certified Health IT Product Website Certified Health IT Product Website 2

3 Medicare EHR Incentive Program MEDICARE EHR Incentive Program OVERVIEW In order to participate in the Medicare EHR Incentive Program you MUST be: A Medicare Provider Be listed in PECOS What is PECOS? Provider Enrollment, Chain and Ownership System (PECOS) PECOS is a database of physicians who have enrolled or re-enrolled in Medicare since November 2003 You can verify your listing in PECOS at: Enrollment-and- Certification/MedicareProviderSupEnroll/Downloa ds/orderingreferringfile-pdf.zip IF YOU ARE NOT LISTED IN PECOS THEN START THE ENROLLMENT PROCESS IMMEDIATELY! Provider Enrollment, Chain and Ownership System (PECOS) To enroll get listed in PECOS, you must enroll or re-enroll in Medicare using either paper (855 form) or online via PECOS: You will need all of the following information on the PECOS CHECKLIST to complete the online process. Please gather all of this information prior to starting the online application process PECOS CHECKLIST An active NPI NPPES User ID and password Internet-based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES For help in establishing an NPPES User ID and password or assistance in changing an NPPES password, contact the NPI Enumerator at or send an to [email protected] Personal identifying information. This includes: Legal name on file with the Social Security Administration and date of birth Social Security Number 3

4 PECOS CHECKLIST Schooling information. This includes: Name of school and graduation year Professional license/certification information. This includes: Medical license number Certification number Original effective date(s) Renewal date(s) State(s) where issued PECOS CHECKLIST Specialty/secondary specialty information Drug Enforcement Agency (DEA) number If applicable, information regarding any final adverse actions. A final adverse action includes: A Medicare-imposed revocation of any Medicare billing privileges Suspension or revocation of a license to provide health care by any State licensing authority Revocation or suspension by an accreditation organization; A conviction of a Federal or State felony offense within the last ten years preceding enrollment or revalidation Or an exclusion or debarment from participation in a Federal or State health care program PECOS CHECKLIST Practice location information. This information includes: Practitioner's medical practice location Special Payment Information Medical Record Storage Information Billing Agency Information (if applicable) Any professional licenses, certifications and/or registrations specifically required to operate as a health care physician or non-physician practitioner Electronic Funds Transfer documentation Medicare EHR Incentive Program Can earn up to $44,000 over 5 years per NPI Incentives based on the Individual, not the practice If Multiple ODs in your office each can participate Must be consecutive years once you start Health provider shortage area may get 10% bonus Based on submitted allowable Medicare charges 75% of allowable charges up to a maximum annual cap Does not include Medicare Advantage Payments Example of Year 1 Calculation (If you Started in 2011 or 2012) $18,000 was year one maximum incentive payment for 2011 and 2012 If your total Medicare Allowable charges for the year, were at least $24,000 the calculation is: 75% of $24,000 = $18,000 In other words, you needed to bill $24,000 in Medicare allowable charges to have received the maximum incentive payment for Medicare if your first year was 2011 or 2012 If you only billed out $10,000 then you would get 75% of 10K = $7500 Example of Year 1 Calculation (If you start in 2013) $15,000 is year one maximum incentive payment if 2013 is your first year of participation If your total Medicare Allowable charges for the year, were at least $20,000 the calculation is: 75% of $20,000 = $15,000 In other words, you needed to bill $20,000 in Medicare allowable charges to received the maximum incentive payment for Medicare if your first year is

5 First Year You Participate: Maximum Medicare Payment 2011 $18, $12,000 $18, $8,000 $12,000 $15, $4,000 $8,000 $12,000 $12, $2,000 $4,000 $8,000 $8,000 $ $2,000 $4,000 $4,000 $0 TOTAL $44,000 $44,000 $39,000 $24,000 $ and Later HITECH Medicare Program - Stages Maximum Payment by Start Year Annual Incentive Payment by Stage of Meaningful Use $44,000 $18,000 $12,000 $8,000 $4,000 $2, $44,000 $18,000 $12,000 $8,000 $4,000 $2, $39,000 $15,000 $12,000 $8,000 $4, $24,000 $12,000 $8,000 $4,000 Reporting Periods Figuring Out the Stages of MU YEAR 1 All Other Years 2014 unless it is your 1 st year How do you figure out: What Stage of Meaningful Use you should be in? When you will do what Stage? Time required to demonstrate Meaningful Use in each Stage? How much money you will get in each Stage? Well CMS has created a Widget to help!. EHR Participation Timeline Let s watch the widget in action! Guidance/Legislation/EHRIncentiveProgra ms/participation-timeline.html 5

6 EHR Incentive Program Registration MEDICARE EHR Incentive Program REGISTRATION You can register online at: Registering does not mean that you have to participate You can cancel your registration at any time You can change your registration Register early in the year you are going to attest Only have to register once for the program (for initial year) Registering helps you become aware of issues that could interfere with or delay your participation Medicare Registration User Guide Before you begin your registration view the Medicare online user guide located at: ds/ehrmedicareep_registrationuserguide.pdf This contains a full step-by-step guide to creating a login as well as dealing with security questions and access requests if working on behalf of an EP Medicare Registration Video Watch the CMS video tutorial on Medicare registration at: It also contains detailed instructions on registering for Medicare Incentive, verifying successful submissions, checking your status and failed registration issues with how to resolve and where to get help 6

7 EHR Incentive Program Registration Items Needed: Must have an NPI and be listed in PECOS NPPES (national plan & provider enumeration system) user ID and password system utilizes this for login EHR certification information (certification number if known not required at this stage but will be for attestation) Individual SSN, Individual NPI, Business Taxpayer Identification Number, group payee NPI, business address, and phone number Registration Process: Login Registration Process: Login National Plan and Provider Enumeration System (NPPES) If you have a NPPES login you are ready If you DO NOT have a NPPES login go to : Registration Process 7

8 Registration Process: Start Registration Process: Choose a Program Software Certification Number Software Certification Number Software Certification Number Software Certification Number 8

9 Software Certification Number Software Certification Number Registration Process: Choose a Program Registration Process: Payment goes to? Registration Process: Submission Registration Process: Submission 9

10 Registration Process: Completed Registration Process: Status Medicare Attestation MEDICARE EHR Incentive Program ATTESTATION Attestation is a legal statement that you have met the requirements of the EHR incentive program You must be a Meaningful User of a certified EHR to Attest! EPs will report numerator, denominator, and exclusion results (if applicable) for the meaningful use objectives and attest that they have successfully met the requirements of the program via an internet based system Once EPs have completed a successful online submission through the Attestation System, they qualify for a Medicare EHR incentive payment The Attestation System for the Medicare EHR Incentive Program opened on April 18, 2011 Medicare Attestation During the attestation process you will be required to enter the information from a report(s) that your certified EHR system has created for: Core Measures Menu Measures Clinical Quality Measures Remember, these reports will change based on Year of Participation and / or Stage of MU 10

11 Attestation Help Review the attestation user guide at: ownloads/ep_attestation_user_guide.pdf This is a detailed guide which covers: Login and working on behalf of an EP Attestation details on each question you will be asked, tips for solving issues, and contact information for all of the Help Desks, if needed Medicare Attestation Video Watch the CMS video tutorial on Medicare attestation at: This is a 22 minute video on the Medicare Incentive Program Attestation process Medicare Attestation Attestation Process To begin the attestation process under the Medicare EHR incentive program you will go to the same site you registered for the EHR incentive program which is: Attestation Web Process Attestation Web Process 11

12 Attestation Web Process Attestation Web Process Attestation Web Process Attestation Web Process Attestation Process 12

13 Attestation Process Attestation Process Attestation Process Attestation Process Practice Before You Attest! Web based app to verify you have met Meaningful Use based on your report(s) from your EHR 13

14 Practice Before You Attest Paper nloads/ep_attestation_worksheet.pdf This is a fill-in-the-blanks document that will help you determine if you have met meaningful use before you then attest EHR Incentive Program Status MEDICARE EHR Incentive Program Questions? MEDICAID EHR Incentive Program Medicaid EHR Incentive Program Can earn up to $63,750 over 6 years Does not have to be consecutive years Must have a Medicaid patient volume of 30% Patient volume is calculated for any continuous 90 day period in the preceding calendar year Includes Medicaid managed care programs: MCOs, prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs) SCHIP (State Children's Health Insurance Program) does not count toward 30% Medicaid encounter (defined by each state) but typically means Medicaid paid for all or part of service or if the patient is enrolled in the State s Medicaid Program 14

15 Medicaid EHR Incentive Program Your State must consider O.D. s as physicians and be able to bill for medical services Currently Optometrists are eligible for the Medicaid EHR Incentive program in a few states (AL, IL, KY, LA, NJ, OH, MI, SC, MD, VA and MS) Year 1 - EPs can qualify just by adopting, implementing, or upgrading to certified EHR technology (AIU) Unlike Medicare which requires meaningful use in year 1 Year 2 EPs start Meaningful Use - 90 day reporting period Years 3-6 EPs continue Meaningful Use 365 day reporting period Incentive is a flat fee intended to cover the net average allowable costs of purchasing, implementing and maintaining an EHR Medicaid EHR Incentive Program By statute, payments will be capped at: Year 1: $21,250 Year 2: $8,500 Year 3: $8,500 Year 4: $8,500 Year 5: $8,500 Year 6: $8,500 You can get total of $63,750 over 6 years Year Medicaid EHR Incentive Program Adopt 2011 Adopt 2012 Adopt 2013 Adopt 2014 Adopt 2015 Adopt $21, $8,500 $21, $8,500 $8,500 $21, $8,500 $8,500 $8,500 $21, $8,500 $8,500 $8,500 $8,500 $21, $8,500 $8,500 $8,500 $8,500 $8,500 $21, $8,500 $8,500 $8,500 $8,500 $8, $8,500 $8,500 $8,500 $8, $8,500 $8,500 $8, $8,500 $8,500 0 $8,500 0 Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750 0 Adopt Registration User Guides Before you begin your registration view the online user guides located at: Medicaid ownloads/ehrmedicaidep_registrationusergui de.pdf Registration Process: Medicaid CMS will notify your state once you have successfully completed your Medicaid registration on the CMS website You will need to follow up with your state to complete any further registration they require at the state level 15

16 Medicaid EHR Incentive Registration Medicaid Attestation To begin the attestation process under the Medicaid EHR incentive program you will go to your states website EHR INCENTIVE PROGRAM HELP MEDICAID EHR Incentive Program Questions? EHR incentive program help: For questions, contact the EHR information center: (TTY ) 7:30am-6:30pm CST M-F (except federal holidays) So is Anyone Registering? Over 405,437 eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) have registered for the Medicare and/or Medicaid EHR Incentive Programs as of June, ,371 Optometrists have registered as of June, 2013 So, are EPs getting any money? More than $ 9.6 Billion in Medicare EHR Incentive Program payments have been made as of June, 2013 More than $ 5.9 Billion in Medicaid EHR Incentive Program payments have been made as of June, 2013 Total amount paid under Medicare and Medicaid as of June 2013 $15,507,963,743 16

17 EHR Incentive Payments to OD s As of June 2013 for Medicare EHR Incentive Payments 10,783 Optometrists have attested and been paid Which totals $151,006,550 6,441 Ophthalmologists have attested Which totals $108,592,877 Incentive Payments by Specialty Incentive Payments by Specialty under Medicare As of June, Family Practice 44, Internal Medicine 39, Cardiology 15, Orthopedic Surgery 10, Optometry 10, OB/GYN 10, Podiatry 9, Gastroenterology 8, General Surgery 8, Neurology 6, Ophthalmology 6,441 CMS EHR Incentive Program Audits All providers attesting to receive an EHR Incentive payment may be subject to an audit Providers should retain ALL relevant supporting documentation for six years Save the supporting electronic or paper documentation that support your attestation of the measures including Clinical Quality Measures CMS will perform Medicare Incentive audits States will perform Medicaid Incentive audits CMS EHR Incentive Appeals If you have been denied an EHR incentive payment, have been determined to be ineligible for the program, or have received an audit decision that you believe to be in error, you can appeal the decision Medicare eligible professionals should file appeals with CMS, while Medicaid eligible professionals should contact their State Medicaid Agency for information about filing an appeal Patient-Assessment- Instruments/QualityMeasures/EHRIncentiveProgramAp peals.html Any questions regarding appeals may be directed to CMS s designated appeals support contractor, Provider Resources, Inc. Providers can submit inquiries on the appeal process via or a toll-free hotline -- Providers can send to [email protected] for general appeal questions and updates on the status of any pending appeals. Toll-free hotline -- Providers may contact call the toll free number, , between 9 a.m. and 5 p.m. EST, Monday through Friday, for general questions on how to file appeals and the status of any pending appeals. Guidance/Legislation/EHRIncentivePrograms/Appeals.h tml 17

18 QUALITY REPORTING EHR Incentive Program Questions? Philip J. Gross, O.D. Jay W. Henry, O.D., M.S. 1. Clinical Quality Reporting under Meaningful Use for the CMS EHR Incentive Programs Covered in our Meaningful Use Survival Lecture 2. Physician Quality Reporting System (PQRS) Formerly PQRI We will cover this next! These are two separate programs that do share some common items but are indeed separate programs at this time Physician Quality Reporting Voluntary reporting program Provides incentive payments to eligible professionals (EPs) who satisfactorily report data on quality measures Applies to covered Physician Fee Schedule services furnished to Medicare Part B beneficiaries Why PQRS Measures? The measures address various aspects of care: Prevention Chronic care management Acute care management Procedure-related care Resource Utilization Care Coordination Why Do PQRS? Measure of Quality of Care! Insurers are tracking usage Patient advocacy groups are tracking usage Not for the money! For your patients! For your self and your practice! For Optometry! We all need this! What really is PQRS? For Medicare patients with certain diagnosis and procedures, specific clinical tasks must be completed and documented To indicate to CMS, that you completed these clinical tasks, you must then attach a Quality-Data Code (QDC) when billing Medicare Part-B Remember The Diagnosis and Procedures trigger QDC In the future, Registry Reporting and EHR Reporting will take over 18

19 What really is PQRS? Example: Medicare patient is in for an office visit Diagnosis of POAG PQRS suggests an ONH Evaluation should be completed If you have documented ONH evaluation in the medical record then When submitting your billing (procedure and diagnosis) to CMS you add a PQRS code which states you completed the PQRS requirement Incentive Percentages Physicians who qualify, may earn a bonus payment on all allowable Medicare Charges 2013 = 0.5% 2014 = 0.5% Penalties for not doing PQRS begin in 2015 = 1.5% penalty and continue thereafter 2015 Penalty based on 2013 participation 2013 PQRS Participation We will discuss today the most common way Eligible Providers will participate in PQRS: Claims Based Using Individual measures We will discuss the most common and easiest codes which apply to OD s Review the CMS PQRS Implementation Guide Detailed guide on implementing PQRS MeasureList-ImplementationGuide zip CMS Quality Measures Format Measure title Reporting option available for each measure (claims-based or registry) Measure description Instructions on reporting including frequency, timeframes, and applicability Denominator statement and coding Numerator statement and coding options Definition(s) of terms where applicable Rationale statement for measure Clinical recommendations or evidence forming the basis for supporting criteria for the measure 2013 PQRS Participation Review the 2013 PQRS Measure Specifications Manual This will discuss Reporting of each Individual Measures Contains all of the details for all of the measures PQRS-IndClaimsRegistry-MeasureSpec- SupportingDocs zip Much more on this to come! We have sorted this out for you from 637 pages! 19

20 No PQRS sign up Individual eligible professionals do not need to sign-up or pre-register in order to participate in PQRS Just start submitting the codes However, to qualify for a Physician Quality Reporting incentive payment an eligible professional must meet the criteria for satisfactory reporting specified by CMS for a particular reporting period For 2013 you must report on at least 3 measures, during the reporting period, at least 50% of the time the measure applies (more on this to come) Each year may change! 2011 How do I participate? The PQRS requirements and measure specifications for the current program year may be different from the PQRS requirements and measure specifications for a prior year Their game and CMS can & will change the rules! Eligible professionals are responsible for ensuring that they are using the PQRS documents for the correct program year CMS 1500 FORM PQRS SAMPLE Billing and PQRS Codes All diagnoses reported on the billing claim will be included in the PQRS Reporting analysis Therefore, if your billing includes a diagnosis which has an associated PQRS code you must make sure you satisfy the PQRS requirements for each code 20

21 Dx 1: POAG # s If your billing Diagnosis are: Dx 3: Dx 4: These Measures should be done as triggered by Dx 1: POAG 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care # s Dx 2: AMD Also, these Measures should be done as triggered by Dx 2: AMD 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement Billing and PQRS Codes If you need more line item space on a claim, you may submit additional claims at the same time, for the same patient, for the same date-of-service by the same TIN Physician Quality Reporting analysis will subsequently join claims based on the same beneficiary for the same date-of-service, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and analyze as one claim. Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses or QDCs are not dropped Billing and PQRS Codes If a denied claim is subsequently corrected through the appeals process to the Carrier/MAC, then QDCs that correspond to the numerator should also be included on the resubmitted claim as instructed in the measure specifications Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs CPT II Modifiers At times you may have a diagnosis code you are billing which requires a PQRS code to be satisfied but for a number of reasons you may not be able to perform the required items to satisfy the PQRS measure CMS has created CPT II modifiers or PQRS modifiers to use in these in cases Let s look at the modifiers CPT II Modifiers 1P Performance measure exclusion modifier due to medical reasons Includes: Not indicated (absence of organ/limb, already received/performed, other) Contraindicated (patient allergy history, potential adverse drug interaction, other) Other medical reasons 2P Performance measure exclusion modifier due to patient reasons Includes: Patient declined Economic, social, or religious reasons Other patient reasons 3P Performance measure exclusion modifier due to system reasons Includes: Resources to perform the services not available (eg, equipment, supplies) Insurance coverage or payer-related limitations Other reasons attributable to health care delivery system The 8P reporting modifier Used when an action described in a measure is not performed and the reason is not specified 2013 PQRS Participation Who gets an incentive: Eligible professionals who satisfactorily report at least three applicable measures will qualify for a PQRS incentive payment Satisfactorily Report: You must have at least 3 measures for which you meet the 50% threshold to be eligible for an incentive payment If the Diagnosis indicates the PQRS measure should be done then you would need to complete and report that specific measure on 50% of those patients where it was indicated 21

22 50% Threshold for at least 3 Measures Measures consist of: denominator (eligible case or patient population) numerator (clinical action required by measure) Numerator over Denominator provides a percentage of a patient population that receive a particular process of care or achieve a particular outcome It is important to review and understand each measure specification which provides definitions and specific instructions for reporting a measure Patient # 50% Threshold for at least 3 Measures Diagnosis Action Suggested by PQRS Completed and Documented in Medical Record Reported by Billing correct PQRS Code Get Completed credit? Running % Met 1 POAG ONH Eval Yes Yes Yes 1/1 = 100% 2 POAG ONH Eval Yes Yes Yes 2/2 = 100% 3 POAG ONH Eval No No No 2/3 = 66% 4 AMD AREDS Yes Yes Yes 1/1 = 100% 5 AMD AREDS Yes Yes Yes 2/2 = 100% 6 DM Dilated Yes Yes Yes 1/1 = 100% 7 DM Dilated No No No 1/2 = 50% 8 DM Dilated No No No 1/3 = 33% Check Your PQRS performance Feedback Reports Let s look at Feedback Reports to see how you qualify CMS produces Feedback Reports detailing your PQRS activities broken down by NPI Feedback Reports are usually available in September / October of the year following the Reporting Year 2012 Feedback Reports available about Sept 2013 Feedback Reports IACS Individuals Authorized Access to the CMS Computer Service This is where you go online to get Feedback Reports Need to sign up to get access to the system Will have a Security Officer (SO) and maybe a Backup SO In order to download your Feedback Reports you or individuals in your account must be assigned a ROLE by your registered Security Officer (SO) 22

23 IACS IACS User Guide r_guide_for_cms_user_communities_2010_03.pdf Quick Reference Guides are available which will provide step-by-step instructions for the registration process under the Quick Reference Guide link near the Sign In button To begin the IACS Registration process, go to To access the Feedback Reports once the IACS registration is complete, go to the Portal at IACS help QualityNet Help Desk :00 a.m. to 7:00 p.m. CST Monday through Friday at TTY You will be asked to provide basic information such as name, practice, address, phone, and What are they KEY PQRS Codes? 2013 Active PQRS Measures for all Eyecare We have trimmed down the list of the 2013 Active Measures! Pick from this condensed list the measures you think you can meet Develop a system to make sure you are: Submitting these when required We will show you the keys to this! Checking EOBs / Remittance and making sure they are processed by your carrier Let s look at this list These are the 9 key ones 2013 Active PQRS Measures for Eyecare # Measure Title 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination 18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) This measure was available in 2012 has been retired for Documentation and Verification of Current Medications in the Medical Record 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention EASY STEPS FOR ALL MEDICAL DX If you see a Medicare patient: For a VISIT (99xxx or 92xxx) AND The have ANY MEDICAL DIAGNOSIS YOU SHOULD THINK ABOUT PQRS! There are 2 PQRS Codes that apply to ANY MEDICARE PATIENT you see for a visit! 23

24 Medicare Patient with ANY Diagnosis How do we code it on 1500 form? Measure CPT II Code Description Dx 1: ANY MEDICAL DX Dx 2: 130 G8427 or G8428 or G F or 1036F List current meds (dosages, frequency, and route) & verification with patient or authorized representative documented Incomplete / no provider documentation of current meds Documentation that patient ineligible for med assessment which includes patient refuses, urgent medical tx, or cognitively impaired Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user Current tobacco non-user Date Service Place Service Procedure (CPT I) and QDC (CPT II) Procedure Description 1/14/ Exam 1 1/14/ G8427 List current meds (dosages) & verification with patient 1/14/ F Current tobacco non-user 1 Dx 1 Why code these on every Patient? How about the eye specific measures? Remember to be a successful quality reporter you must report on 3 Measures 50% of the time the diagnosis warrants Reporting these two measures every time gets 2 of your 3 measures met! Diagnosis triggers that the CPT II code should be used These 2 measures are triggered by any medical diagnosis make sure you use these! EASY STEPS If you see a Medicare patient for any VISIT (99xxx or 92xxx) AND they have Primary Open Angle Glaucoma Age Related Macular Degeneration Diabetes YOU MUST THINK ABOUT the other PQRS codes that apply? Medicare Patient with Diagnosis: POAG, AMD, or DM # Measure Title 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 24

25 EASY STEPS Let s look at the details of these diagnosis POAG AMD DM We suggest, if new to PQRS, to do 1 measures from each of the above diagnosis to start There are more but why make it harder to start Then work on submitting all disease specific codes as you get more comfortable with PQRS Medicare Patient? 18 years or older? Glaucoma Diagnosis? Did you evaluate the optic nerve once in the past 12 months? Yes = 2027F Glaucoma Diagnosis PQRS Measure 12 POAG: Optic Nerve Evaluation If Diagnosis code is or and procedure code is , , , , , or Optic nerve not evaluated use modifiers 2027F - 1P = Medical Reason 2027F - 8P = No Reason Given Glaucoma Diagnosis PQRS Measure 12 Glaucoma Diagnosis PQRS Measure 12 Medicare Patient? 18 years or older? Glaucoma Diagnosis? If Diagnosis code is or And Procedure code is , , , , , or Glaucoma Diagnosis PQRS Measure 12 Glaucoma Diagnosis PQRS Measure 12 Did you evaluate the optic nerve once in the past 12 months? Yes = 2027F 25

26 AMD Diagnosis PQRS Measure 140 AMD: Counseling on Antioxident Supplement AMD Diagnosis PQRS Measure 140 Medicare Patient? 50 years or older? AMD Diagnosis? If Diagnosis code is , , or and procedure code is , , , , , Did you discuss the risks and benefits of AREDS formula with the patient in the past 12 months? Yes = 4177F If you did not discuss AREDS with the patient use modifier 4177F -8P = No Reason Given AMD Diagnosis PQRS Measure 140 If Diagnosis code is , , or and Procedure code is , , , , , AMD Diagnosis PQRS Measure 140 Did you discuss the risks and benefits of AREDS formula with the patient in the past 12 months? Yes = 4177F AMD Diagnosis PQRS Measure 140 Diabetes Diagnosis - PQRS Measure 117 DM: Dilated Eye Exam Medicare Patient? Age 18 75? Diabetes Diagnosis? If Diagnosis code is , , , , , , , , , , 357.2, , , and procedure code is , , , , , , , , G0270, G0271 Did you do a Dilated Fundus Examination within the past 12 months? Yes = 2022F Did you do a Dilated Fundus Examination? NO = 2022F -8P = No Reason Given or 3072F = Low Risk of Retinopathy (No Retinopathy previous year) 26

27 Diabetes Diagnosis PQRS 117 Diabetes Diagnosis PQRS 117 If Diagnosis code is: , , , , , , , , , , 357.2, , , And Procedure code is: , , , , , , , , G0270, G0271 Diabetes Diagnosis PQRS 117 Diabetes Diagnosis PQRS 117 Did you do a Dilated Fundus Examination within the past 12 months? Yes = 2022F The EASY Plan? You know the 2 PQRS codes that apply to all Medicare patients. Use them! You know the other diagnosis (DM, POAG, AMD) that apply to eyecare Use the one key PQRS code we suggest for each diagnosis! Remember, this gives you 5 Measures to worry about and makes this EASY to achieve! Avoiding the PQRS Penalty in 2015 If you begin submitting any codes correctly in 2013 you will not be penalized in 2015 on your Medicare reimbursements! 27

28 2013 PQRS Quality Data Codes # NQF Measure Title Meets Medical Patient System Other Performance Performance Performance Performance Performance Exclusion Exclusion Exclusion Exclusion Performance Not Met 2013 PQRS Quality Data Codes # NQF Measure Title Primary Open Angle Glaucoma : Optic Nerve Head Evaluation * 14 * 0087 Age-Related Macular Degeneration (AMD): Dilated Macular Examination * 18 * 0088 Diabetic Retinopathy: Document the Presence or Absence of Macular and Level of Severity of Retinopathy 2027F 2027F-1P N/A N/A No Report 2027F-8P 2019F 2019F-1P 2019F-2P N/A No Report 2019F-8P 2012F 2021F-1P 2021F-2P N/A No Report 2021F-8P Primary Open Angle Glaucoma : Optic Nerve Head Evaluation * 14 * 0087 Age-Related Macular Degeneration (AMD): Dilated Macular Examination * 18 * 0088 Diabetic Retinopathy: Document the Presence or Absence of Macular and Level of Severity of Retinopathy * 19 * 0089 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetic Care 5010F & G F-1P & G F-2P & G8397 N/A G8398 No Report 5010F-8P & G8397 * 19 * 0089 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetic Care Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 2022F 2024F 2026F 3072F N/A N/A N/A No Report 2022F-8P 2024F-8P 2026F-8P Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Documentation of Current Medications in the Medical Records G8427 N/A N/A N/A G8430 No Report G Documentation of Current Medications in the Medical Records Age-Related Macular Degeneration: Counseling on Antioxidant Supplements 4177F N/A N/A N/A No Report 4177F-8P Age-Related Macular Degeneration: Counseling on Antioxidant Supplements * 141 * 0563 Primary Open-Angle Glaucoma: Reduction of Intraocular Pressure by 15% OR Documentation of a Plan of Care 3284F 0517F & 3285F N/A N/A N/A No Report 0517F-8P & 3285F 3284F-8P * 141 * 0563 Primary Open-Angle Glaucoma: Reduction of Intraocular Pressure by 15% OR Documentation of a Plan of Care Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 4004F 1036F 4004F-1P N/A N/A No Report 4004F-8P Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Black = Easy * Red * = Hard Black = Easy * Red * = Hard Need more help for information? PQRS Questions? Jay W. Henry, O.D., M.S. Philip J. Gross, O.D. E-Prescribing E-Prescribing Definition: A prescriber s ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point of care. E-Prescribing is NOT: Printing a Prescription from an EHR Print to Fax Faxing a hard written prescription 28

29 Why E-Prescribe Reduce errors Drug allergies Drug to Drug interactions Drug to Drug duplication (care by multiple physicians?) Formulary checking Lower cost, therapeutically appropriate alternatives Ultimately saves time One time Rx minimal time savings Refills great time savings Protects privacy Protects against forgery E-Prescribing Incentive program Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Provides financial incentive for physicians to erx Separate program from PQRI starting in 2009 This Program is for your MEDICARE PATIENTS ONLY Incentive done as % bonus of your Medicare allowable billings over a calendar year E-Prescribing Incentive program If E-Prescribing 2009 and 2010 was 2% Bonus 2011 and 2012 was 1% Bonus 2013 get 0.5% Bonus If NOT E-Prescribing, some physicians in: 2012 Started 1% Payment cut if Not erx % Payment cut if not erx 2014 and thereafter a 2% cut if not erx How Do You Get The Bonus? 2013 Medicare erx Incentive Program Only have to erx and report you erx 25 times during calendar year using a Qualified erx System (includes OTC meds if e-prescribed) Report that you erx using CPT II code G8553 At least one Rx created during the encounter was generated and transmitted electronically using a qualified E-Rx System How Do You Avoid the Penalty? 29

30 2014 erx Payment Adjustment Exclusion Criteria The eligible professional is a successful electronic prescriber during the 2012 erx 12-month reporting period (1/1/12-12/31/12) The eligible professional is not an MD, DO, podiatrist, Nurse Practitioner, or Physician Assistant by 6/30/13 based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES) Optometrists are exempt under this category If you do not have at least 100 cases (that is, claims for patient services) containing an encounter code that falls within the denominator of the erx measure for dates of service between 1/1/13 6/30/13 The eligible professional does not have 10% or more of their Medicare Part B PFS allowable charges (per TIN) for encounter codes in the measure s denominator for dates of service from 1/1/13-6/30/13 The eligible professional does not have prescribing privileges and reported G8644 on a payable Medicare Part B service at least once on a claim between 1/1/13-6/30/13 The eligible professional submits at least 10 electronic prescriptions and reports the G-code (G8553) via claims during the 2013 erx 6-month reporting period 1/1/13-6/30/13 Providers who are using erx Prescription Benefit Responses Key to lowering Patient Rx costs E-Prescribing You should start erx as soon as possible! If have EHR: Check with your software vendor about an integrated solution If no EHR yet: Suggest checking out stand alone solution National E-Prescribing Safety Initiative (NEPSI) National E-Prescribing Safety Initiative (NEPSI) Free stand-alone erx to every physician in the country Takes about 15 minutes for initial application Need copy of NPI enumerator Copy of State License with expiration date Copy of Drivers License Most applications completed in same day 30

31 erx Formulary Alert erx Duplicate Therapy Alert erx Drug Interaction erx Drug Interaction erx Compliance Where to Get Help Physician Quality Reporting System (PQRS) E-Prescribing Incentive Program (erx) QualityNet Help Desk (TTY ) 7:00 a.m. 7:00 p.m. CST M-F or Check out 31

32 Simultaneous Incentive Programs PQRS E-Rx EHR Incentive Medicare EHR Incentive Medicaid PQRS YES YES YES E Rx Questions? E-RX YES NO YES Will You Be Ready? International Classification Of Disease Tenth Edition Clinical Modification (CM) ICD-10 Transition The ICD-9 code sets used to report medical diagnoses will be replaced by ICD-10 code sets You will need to prepare for this transition! ICD-10-CM for diagnosis coding (OD s will use) Affects diagnosis coding for everyone covered by HIPAA, not just those who submit Medicare or Medicaid claims ICD-10 does not affect CPT coding for outpatient procedures ICD-10 Transition ICD-10-CM is for use in all U.S. health care settings The transition to ICD-10 is occurring because: ICD-9 produces limited data about patients medical conditions and hospital inpatient procedures ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full 32

33 ICD-10 ICD-10 is currently used in all major countries except the US and Italy Published by the World Health Organization (WHO) Greater number of codes available ICD-9: approximately 13,600 ICD-10-CM: approximately 69,000 forget memorizing Codes report not only the disease but its current clinical manifestation ICD-9 Format vs ICD-10 Format Example of ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus (deposit of urates) One-to-One Mapping One-to-???? Mapping Some ICD-9 codes map easily to ICD-10 in a simple one-to-one conversion Unfortunately, just because a code converts does not mean it matches in all details ICD-10-CM H00: Hordeolum: H00.021: Hordeolum internum right upper eyelid H00.022: Hordeolum internum right lower eyelid H00.023: Hordeolum internum right eye, unspecified eyelid H00.024: Hordeolum internum left upper eyelid H00.025: Hordeolum internum left lower eyelid H00.026: Hordeolum internum left eye, unspecified eyelid H00.029: Hordeolum internum unspecified eye, unspecified eyelid ICD-10 Transition Plan It is important to prepare now for the ICD-10 transition and have a plan! No surprises! Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget Check with your billing service, clearinghouse, and practice management software vendor about their compliance plans 33

34 Interesting ICD-10 Codes W04 Fall while being carried or supported by other persons Accidentally dropped while being carried Different code if dropped ON PURPOSE? The appropriate 7th character is to be added to code W04 for: A - initial encounter D - subsequent encounter S - sequela Interesting ICD-10 Codes W27.4XXA - Contact with kitchen utensil, initial encounter R Very low level of personal hygiene Interesting ICD-10-CM Codes Sucked into jet engine ICD-10 code = V9733xD Problems in relationship with in-laws ICD-10 code = z631 Parental overprotection ICD-10 code = z621 ICD-10 Realities Electronic Health Records will be key Clinical documentation done in EHR EHR can suggest ICD-10 codes based on data Correct codes based on: Condition Eye Level of disease / condition Ask your software vendor if they are woring on ICD-10 implementation updates Privacy & Security The HIPAA Privacy Rule establishes a set of national standards for the use and disclosure of individually identifiable health information Protected Health Information (PHI) HIPAA also adds standards for providing individuals with health information privacy rights This is to help individuals understand and control how their health information is used HIPAA New 2013 Privacy Rules New rules effective 3/26/2013 but most covered entities have until 9/23/2013 to comply with most of the rules provisions New rules put in to place several provisions aimed at updating patient privacy safeguards while also recognizing how information needs to be made securely accessible 34

35 HIPAA New 2013 Privacy Rules Key changes: Patients will now be able to request an electronic copy of the Electronic Medical Record Patients will also have the right to instruct their doctors not to share information about treatment with insurance companies when patients pay with cash for the services rendered Notices of Privacy Practices need to be updated to reflect patients rights regarding breaches of PHI and rights when paying cash HIPAA New 2013 Privacy Rules Under the new revisions, the Privacy and Security Rules will apply not only to those health care practitioners and their business associates but for the first time, the subcontractors of the business associates Privacy and Security Guide Designed to help health care practitioners and practice staff understand the importance of privacy and security of health information at various stages of implementation t/files/pdf/privacy/privacy-andsecurity-guide.pdf CyberSecure: Your Medical Practice Video Game Training for Providers and Staff Intended to raise awareness and increase understanding of common privacy and security issues related to health information technology secure/cybersecure.html Secure Messaging Secure Messaging In late 2011 the federal DIRECT Project through the Office of National Coordinator for Health IT (ONCHIT) and Nationwide Health Information Network (NwHIN) established the standards and regulations for the nation s firstever HIPAA-compliant health information communications system This new Federal Healthcare system is live and more than 25 companies, like Allied HIE Company, are serving as on-ramps to this secure communications system 35

36 Secure Messaging Sending a Summary of Care Record for Transitions of Care A core requirement toward meeting Stage 2 meaningful use Capability to exchange key clinical information Perform at least one test of the EHRs ability to electronically exchange key clinical information and there is no exclusion for this measure Must involve the transfer of information to another provider of care in a different office which utilizes a different certified EHR other than your own Transmit 10% of your Summary of Care Records electronically using CEHRT to a recipient CCD or Continuity of Care document in XML format specifies the encoding and structure of information Incentive Programs Update, Quality Reporting and Information Exchange QUESTIONS? Jay W. Henry, O.D., M.S. Philip J. Gross, O.D. 36