2015 PQRS Requirements: What Eligible Professionals Need to Know to Avoid the PQRS Penalty in 2017

Transcription

1 2015 PQRS Requirements: What Eligible Professionals Need to Know to Avoid the PQRS Penalty in 2017 Presented by: Camille Bonta, MHS Summit Health Care Consulting

2 Physician Quality Reporting System What is PQRS? Quality reporting program that effects Medicare payments made to eligible professionals based on whether they satisfactorily report data on quality measures for covered professional services furnished during a specified reporting period. Program is required by law. Initially authorized by Congress in Affordable Care Act extended incentives through 2014 and required a penalty beginning in 2015.

3 Physician Quality Reporting System Why Participate in PQRS? -2% payment penalty in 2017 and beyond. PQRS reporting forms the basis for Physician Compare. Value-based modifier tied to PQRS participation. Commercial payers are paying attention.

4 2015 PQRS Participation Options Individual Eligible Professional Group (2+ eligible professionals) EP means: 1) physician; 2) other practitioner (PA, NP, clinical nurse specialist, CRNA/anesthesiologist assistant, nurse midwife, clinical social worker, clinical psychologist, registered dietitian, nutrition professional); 3) physical or occupational therapist, qualified speech-language pathologist; 4) qualified audiologist.

5 How to Get Started First, decide whether to report as an individual or as a group Second, choose reporting mechanism Claims (individuals only) PQRS Qualified Registry EHR (qualified direct EHR product & qualified EHR data submission vendor) Web Interface (groups of 25+ eligible professionals only) Qualified Clinical Data Registry (individuals only)

6 How to Get Started Third, choose measures If PQRS qualified registry option is chosen, decide to report individual measures or measures group. Fourth, report No need to register for PQRS for individual reporting, groups must register.

7 How to Avoid 2015 Penalty: Individual EP Qualified Clinical Data Registry Report at least 9 measures covering at least 3 NQS domains for 50% of applicable patients. Of the 9 measures, at least 2 must be outcome measures. If 2 outcomes measures are not available, the eligible professional can report on at least 1 outcome measure and at least 1 of the following types of measures: resource, patient experience of care, efficiency/appropriate use, or patient safety.

8 GIQuIC: An ASGE-ACG Benchmarking Program Improve outcomes through better documentation. Set the stage for improved reimbursements. Metrics from participating physicians, ASCs, offices and hospitals will be shared to:...identify gaps in care...develop quality indicators...provide benchmarking reports Click Practice Management at ASGE online. 8

9 How to Avoid 2015 Penalty: Medicare Claims: Individual EP Report at least 9 measures covering at least 3 National Quality Strategy (NQS) domains and report each measure for at least 50% of Medicare Part B FFS patients seen during the reporting period to which the measure applies (Jan. 1-Dec. 31, 2015). One measure must be a cross-cutting measure. Qualified Registry: Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains. One measure must be a cross-cutting measure. or Report at least 1 measures group and report each measures group for at least 20 patients, a majority (11) of whom must be Medicare Part B FFS patients.

10 How to Avoid 2015 Penalty: Individual EP Electronic Health Record: Report 9 measures covering at least 3 NQS domains. If the Certified Electronic Health Record Technology does not contain patient data for at least 9 measures across 3 domains, then the eligible professional/group is required to report all of the measures for which there is Medicare data. At least one measure must have Medicare patient data.

11 Group Practice Reporting What is the benefit of the Group Practice Reporting Option (GPRO)? Billing and reporting staff may report one set of quality measures data on behalf of all EPs within a group practice, reducing the need to keep track of EPs reporting efforts separately. Those EPs who have difficulty meeting the reporting requirements for individual EPs may benefit from group reporting.

12 How to Report as a Group Practice First, meet group criteria Defined as: a single Tax Identification Number (TIN), with 2 or more individual EPs (as identified by individual NPIs) who have reassigned their billing rights to the TIN. The size of the group practice must be established by the time the group is selected to participate in the GPRO. If the practice changes its TIN after being selected, it cannot continue to participate in PQRS through the GPRO.

13 How to Report as a Group Practice Second, self-nominate for GPRO A group practice must self-nominate via the Web to participate in the PQRS Group Practice Reporting Option (GPRO). The group must register to participate in the GPRO by June 30 of the reporting period (June 30, 2015).

14 How to Avoid 2015 Penalty: Group Qualified Registry: Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains. One measure must be a cross-cutting measure. Electronic Health Record: Report 9 measures covering at least 3 NQS domains. If the Certified Electronic Health Record Technology does not contain patient data for at least 9 measures across 3 domains, then the eligible professional/group is required to report all of the measures for which there is Medicare data. At least one measure must have Medicare patient data.

15 How to Avoid 2015 Penalty: Group CMS-Certified Survey Vendor: CMS gives the option for group practices of 25 or more eligible professionals to report the CG-CAHPS measures via a Certified Survey Vendor. (CG-CAHPS = Clinicians & Groups Consumer Assessment of Healthcare Providers and Systems Survey) CMS requires group practices with 100 or more eligible professionals that participate in the PQRS GPRO to report the CG- CAHPS measures. Group practices that report the CG-CAHPS measures must also report on additional PQRS measures using a registry, EHR or GPRO Web Interface.

16 Claims vs. Registry Reporting In 2012, ~25% of EPs who submitted measures via claims did not earn an incentive payment. The most common claims-based submission error was reporting a measure-specific Quality Data Code (QDC) on a claim that did not also have the required procedure code. Highest success rates with GPRO Web Interface (100%), EHR (94%), Registry (85%).

17 PQRS Measures 2015 PQRS Measures List with Specifications When choosing measures, pay attention to: Can your measure be reported via your selected mechanism? (Range of reporting mechanisms not available for all measures.) Do your measures cover 3 quality domains? Do you have patients for which the measures will be applicable? (Measures with zero performance will not be counted.) For claims and registry, have you chosen a cross-cutting measure (See Table 52 of Final Rule.)

18 PQRS Measures PQRS Measures for 2015 Endoscopy and Polyp Surveillance: #320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (claims, registry) #185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use (claims, registry) Screening Colonoscopy: Adenoma Detection Rate Measure - #343 (registry) Colorectal Cancer Screening - #113 (claims, registry, EHR, GPRO Web-Interface, Measures Group)

19 PQRS Measures What happens if an EP doesn t have 9 applicable measures? CMS will use the measure application validation (MAV) process to determine whether an eligible professional should have reported quality data codes for additional measures. MAV process will also be used for the cross-cutting measure requirement. When choosing measures, consider the Value-based Payment Modifier (VBM). Your performance on PQRS measures will be benchmarked against other EPs that report that measure (regardless of specialty).

20 Value-Based Payment Modifier What is the Value-Based Payment Modifier? Affordable Care Act requires Medicare to phase in a value-based payment modifier (VBM) that applies to Medicare physician FFS payments starting in 2015, with the VBM applying to all physicians by The VBM assesses both quality of care and the cost of the care delivered.

21 Value-Based Payment Modifier Application of the VBM for the 2017 payment year VBM will be applied to physician payment for all groups of 2+ eligible professionals and solo practitioners. Performance year for the 2017 VBM is Application of the VBM is tied to successful PQRS participation.

22 Value-Based Payment Modifier Two VBM Categories: Category 1: PQRS reporters Category 2: Non-PQRS reporters (automatic penalty) Two ways to get placed in Category 1: #1 Self-nominate for GPRO and successfully report (avoid 2017 PQRS penalty). #2 At least 50% of EPs in the group practice successfully report (avoid 2017 PQRS penalty) in PQRS as individuals.

23 Value-Based Payment Modifier What Happens to Groups in Category 1? Mandatory quality tiering to calculate performance on clinical quality and cost measures. Groups 2-9 EPs and solo practitioners are held harmless from any downward adjustments in Groups 10+ EPs can receive upward, neutral or downward adjustment (capped at -4%).

24 Value-Based Payment Modifier Application of the Value-Based Payment Modifier in 2017

25 Value-Based Payment Modifier Application of the Value-Based Payment Modifier in 2017 (x) = the upward payment adjustment factor which will be established after the performance period has ended. Because the VBP modifier is budget neutral, (x) is based on the aggregate amount of downward payment adjustments.

26 PQRS Resources QualityNet Help Desk: Program and measure-specific questions (866) CMS: How to get started, measure specifications, reporting mechanisms/criteria

27 Additional Questions Regulatory Compliance Lakitia Mayo ASGE Director of Health Policy and Quality (630) ASGE Quality Improvement / GIQuIC Eden Essex ASGE Assistant Director of Quality and Health Policy eessex@asge.org (630)

28 QUESTIONS

29 2015 PQRS Requirements: What Eligible Professionals Need to Know to Avoid the PQRS Penalty in 2017 Presented by: Camille Bonta, MHS Summit Health Care Consulting

30 Physician Quality Reporting System What is PQRS? Quality reporting program that effects Medicare payments made to eligible professionals based on whether they satisfactorily report data on quality measures for covered professional services furnished during a specified reporting period. Program is required by law. Initially authorized by Congress in Affordable Care Act extended incentives through 2014 and required a penalty beginning in 2015.

31 Physician Quality Reporting System Why Participate in PQRS? -2% payment penalty in 2017 and beyond. PQRS reporting forms the basis for Physician Compare. Value-based modifier tied to PQRS participation. Commercial payers are paying attention.

32 2015 PQRS Participation Options Individual Eligible Professional Group (2+ eligible professionals) EP means: 1) physician; 2) other practitioner (PA, NP, clinical nurse specialist, CRNA/anesthesiologist assistant, nurse midwife, clinical social worker, clinical psychologist, registered dietitian, nutrition professional); 3) physical or occupational therapist, qualified speech-language pathologist; 4) qualified audiologist.

33 How to Get Started First, decide whether to report as an individual or as a group Second, choose reporting mechanism Claims (individuals only) PQRS Qualified Registry EHR (qualified direct EHR product & qualified EHR data submission vendor) Web Interface (groups of 25+ eligible professionals only) Qualified Clinical Data Registry (individuals only)

34 How to Get Started Third, choose measures If PQRS qualified registry option is chosen, decide to report individual measures or measures group. Fourth, report No need to register for PQRS for individual reporting, groups must register.

35 How to Avoid 2015 Penalty: Individual EP Qualified Clinical Data Registry Report at least 9 measures covering at least 3 NQS domains for 50% of applicable patients. Of the 9 measures, at least 2 must be outcome measures. If 2 outcomes measures are not available, the eligible professional can report on at least 1 outcome measure and at least 1 of the following types of measures: resource, patient experience of care, efficiency/appropriate use, or patient safety.

36 GIQuIC: An ASGE-ACG Benchmarking Program Improve outcomes through better documentation. Set the stage for improved reimbursements. Metrics from participating physicians, ASCs, offices and hospitals will be shared to:...identify gaps in care...develop quality indicators...provide benchmarking reports Click Practice Management at ASGE online. 8

37 How to Avoid 2015 Penalty: Medicare Claims: Individual EP Report at least 9 measures covering at least 3 National Quality Strategy (NQS) domains and report each measure for at least 50% of Medicare Part B FFS patients seen during the reporting period to which the measure applies (Jan. 1-Dec. 31, 2015). One measure must be a cross-cutting measure. Qualified Registry: Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains. One measure must be a cross-cutting measure. or Report at least 1 measures group and report each measures group for at least 20 patients, a majority (11) of whom must be Medicare Part B FFS patients.

38 How to Avoid 2015 Penalty: Individual EP Electronic Health Record: Report 9 measures covering at least 3 NQS domains. If the Certified Electronic Health Record Technology does not contain patient data for at least 9 measures across 3 domains, then the eligible professional/group is required to report all of the measures for which there is Medicare data. At least one measure must have Medicare patient data.

39 Group Practice Reporting What is the benefit of the Group Practice Reporting Option (GPRO)? Billing and reporting staff may report one set of quality measures data on behalf of all EPs within a group practice, reducing the need to keep track of EPs reporting efforts separately. Those EPs who have difficulty meeting the reporting requirements for individual EPs may benefit from group reporting.

40 How to Report as a Group Practice First, meet group criteria Defined as: a single Tax Identification Number (TIN), with 2 or more individual EPs (as identified by individual NPIs) who have reassigned their billing rights to the TIN. The size of the group practice must be established by the time the group is selected to participate in the GPRO. If the practice changes its TIN after being selected, it cannot continue to participate in PQRS through the GPRO.

41 How to Report as a Group Practice Second, self-nominate for GPRO A group practice must self-nominate via the Web to participate in the PQRS Group Practice Reporting Option (GPRO). The group must register to participate in the GPRO by June 30 of the reporting period (June 30, 2015).

42 How to Avoid 2015 Penalty: Group Qualified Registry: Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains. One measure must be a cross-cutting measure. Electronic Health Record: Report 9 measures covering at least 3 NQS domains. If the Certified Electronic Health Record Technology does not contain patient data for at least 9 measures across 3 domains, then the eligible professional/group is required to report all of the measures for which there is Medicare data. At least one measure must have Medicare patient data.

43 How to Avoid 2015 Penalty: Group CMS-Certified Survey Vendor: CMS gives the option for group practices of 25 or more eligible professionals to report the CG-CAHPS measures via a Certified Survey Vendor. (CG-CAHPS = Clinicians & Groups Consumer Assessment of Healthcare Providers and Systems Survey) CMS requires group practices with 100 or more eligible professionals that participate in the PQRS GPRO to report the CG- CAHPS measures. Group practices that report the CG-CAHPS measures must also report on additional PQRS measures using a registry, EHR or GPRO Web Interface.

44 Claims vs. Registry Reporting In 2012, ~25% of EPs who submitted measures via claims did not earn an incentive payment. The most common claims-based submission error was reporting a measure-specific Quality Data Code (QDC) on a claim that did not also have the required procedure code. Highest success rates with GPRO Web Interface (100%), EHR (94%), Registry (85%).

45 PQRS Measures 2015 PQRS Measures List with Specifications When choosing measures, pay attention to: Can your measure be reported via your selected mechanism? (Range of reporting mechanisms not available for all measures.) Do your measures cover 3 quality domains? Do you have patients for which the measures will be applicable? (Measures with zero performance will not be counted.) For claims and registry, have you chosen a cross-cutting measure (See Table 52 of Final Rule.)

46 PQRS Measures PQRS Measures for 2015 Endoscopy and Polyp Surveillance: #320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (claims, registry) #185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use (claims, registry) Screening Colonoscopy: Adenoma Detection Rate Measure - #343 (registry) Colorectal Cancer Screening - #113 (claims, registry, EHR, GPRO Web-Interface, Measures Group)

47 PQRS Measures What happens if an EP doesn t have 9 applicable measures? CMS will use the measure application validation (MAV) process to determine whether an eligible professional should have reported quality data codes for additional measures. MAV process will also be used for the cross-cutting measure requirement. When choosing measures, consider the Value-based Payment Modifier (VBM). Your performance on PQRS measures will be benchmarked against other EPs that report that measure (regardless of specialty).

48 Value-Based Payment Modifier What is the Value-Based Payment Modifier? Affordable Care Act requires Medicare to phase in a value-based payment modifier (VBM) that applies to Medicare physician FFS payments starting in 2015, with the VBM applying to all physicians by The VBM assesses both quality of care and the cost of the care delivered.

49 Value-Based Payment Modifier Application of the VBM for the 2017 payment year VBM will be applied to physician payment for all groups of 2+ eligible professionals and solo practitioners. Performance year for the 2017 VBM is Application of the VBM is tied to successful PQRS participation.

50 Value-Based Payment Modifier Two VBM Categories: Category 1: PQRS reporters Category 2: Non-PQRS reporters (automatic penalty) Two ways to get placed in Category 1: #1 Self-nominate for GPRO and successfully report (avoid 2017 PQRS penalty). #2 At least 50% of EPs in the group practice successfully report (avoid 2017 PQRS penalty) in PQRS as individuals.

51 Value-Based Payment Modifier What Happens to Groups in Category 1? Mandatory quality tiering to calculate performance on clinical quality and cost measures. Groups 2-9 EPs and solo practitioners are held harmless from any downward adjustments in Groups 10+ EPs can receive upward, neutral or downward adjustment (capped at -4%).

52 Value-Based Payment Modifier Application of the Value-Based Payment Modifier in 2017

53 Value-Based Payment Modifier Application of the Value-Based Payment Modifier in 2017 (x) = the upward payment adjustment factor which will be established after the performance period has ended. Because the VBP modifier is budget neutral, (x) is based on the aggregate amount of downward payment adjustments.

54 PQRS Resources QualityNet Help Desk: Program and measure-specific questions (866) CMS: How to get started, measure specifications, reporting mechanisms/criteria

55 Additional Questions Regulatory Compliance Lakitia Mayo ASGE Director of Health Policy and Quality (630) ASGE Quality Improvement / GIQuIC Eden Essex ASGE Assistant Director of Quality and Health Policy eessex@asge.org (630)

56 QUESTIONS