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1 Medicare PQRS Coding With Mario Fucinari DC, MCS-P, MCS-I Certified Insurance Consultant Certified Medical Compliance Specialist (MCS-P) Sponsored by Foot Levelers The information contained in these notes is for educational purposes and is not intended to be and is not legal advice. NO RECDING OF ANY TYPE ALLOWED Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal. LEGAL NOTICE: The information contained in this workbook is for educational purposes and is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly PROHIBITED during the presentations. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal services are required, the services of a healthcare attorney should be attained. The information in this class workbook is for educational purposes only and should not be construed as written policy for any federal agency. All clinical examples are based on true stories. The patient names in the clinical examples have been changed to protect the innocent. No part of this workbook covered by the copyright herein may be reproduced, transmitted, transcribed, stored in a retrieval system or translated into any language in any form by any means (graphics, electronic, mechanical, including photocopying, recording, taping or otherwise) without the expressed written permission of Mario Fucinari DC. Making copies of this seminar workbook and distributing for profit or non-profit is ILLEGAL. Mario Fucinari DC assumes no liability for data contained or not contained in this workbook and assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this seminar workbook. CPT is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this seminar workbook. This seminar workbook provides information in regard to the subject matter covered. Every attempt has been made to make certain that the information in this seminar workbook is 100% accurate, however it is not guaranteed. Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 1

2 Medicare s Definition of Medical Necessity 1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services must have a direct therapeutic relationship to the patient s condition. (Medicare does not pay for pain). 2. You must have a reasonable expectation of recovery or improvement of function. 3. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. A diagnosis of pain is not sufficient for medical necessity Medicare Medical Necessity Acute subluxation - treatment for a new injury, identified by x-ray or physical exam. The treatment is expected to improve, arrest, or retard the patient s condition. Chronic subluxation - A patient's condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered. Maintenance Therapy Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care. A treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program. Physician Quality Reporting Initiative (PQRS 2014) The 2006 Tax Relief and Health Care Act (TRHCA) (P.L ) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries. Providers do not need to sign-up or pre-register in order to participate in the PQRS program. Submission of the quality data codes for the measures will indicate your intent to participate in the PQRS. However, to qualify for a Physician Quality Reporting incentive payment an eligible professional must meet the criteria for satisfactory reporting specified by CMS. The 2014 results will drive the "payment adjustments" (penalties) in The Centers for Medicare & Medicaid Services (CMS) will impose a 1.5% penalty in 2015 (for 2013) and a 2% penalty for 2016 and after, if you have not met the threshold for the use of the PQRS codes. The PQRS measures will only count if you report the measures on active care patients. Do NOT report PQRS measures on maintenance care claims. Reporting is counted according to the number of claims that have a spinal CMT code (98940/98941/98942). Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 2

3 The database will consider the percentage of claims with a spinal CMT code that also have successfully reported PQRS measure codes. If the number is greater than the threshold (50% for 2014), they will generate a check based on the total allowed services for that year. CMS has indicated that PQRS will serve as the basis for its Value-Based Modifier initiative. In the coming years, CMS intends to move Medicare from the position of passive payer to a purchaser of high-quality, efficient care through a value-based purchasing initiative. The Affordable Care Act of 2010 mandates that by 2014, CMS must begin to apply a value-based modifier under the Medicare Physician Fee Schedule. In other words, cost and quality data will be factored into the calculation of payments for physicians. Starting in 2015, some payments will be affected by the value-based modifier; by 2017, most physician payments will incorporate a quality calculation. Given this fact, participation in PQRS offers doctors a valuable opportunity to prepare for the transition from fee-for-service reimbursements to payments based on quality performance. Starting in 2016, chiropractic payments will be affected by the value-based modifier. In 2016, those doctors that do not report PQRS measures will also be assigned the lowest level of Value-Based Payment Modifier of -1%. Total # of Individual PQRS Measures: There are 288 measures for Most of the Quality Measures do not pertain to chiropractic. Others may pertain indirectly, but are not eligible for a measure, since they are included in other services and are not mutually exclusive. Some measures require only a one time submission. Three of the measures must be reported by chiropractors: 1. Pain Assessment # Functional Outcomes Assessment # Preventive Care and Screening: Screening for High Blood Pressure #317 PQRS # 131 Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Definition: Pain Assessment - A clinical assessment of pain using a standardized tool for the presence and characteristics of pain; characteristics may include location, intensity, quality, and onset/duration. Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 3

4 Brief Pain Inventory (BPI), Faces Pain Scale (FPS) (for mentally disabled) 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) a.k.a. Borg scale Visual Analog Scale (VAS). Follow-Up Plan Proposed outline of treatment to be conducted as a result of pain assessment. Follow-up must include a planned reassessment of pain and may include documentation of future appointments, education, referrals, pharmacological intervention, or notification of other care providers as applicable. The documented follow-up plan must be related to the presence of pain. Return next visit for re-assessment of pain Associated Follow-up Options: Follow-up appointment, Referral, Notification to another provider, indicate the initial treatment plan is still in effect. Not Eligible A patient is not eligible if one or more of the following reasons exist: - Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools. - 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. Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 4

5 Pain Assessment Codes to use: Pain assessment documented as positive utilizing a standardized tool AND a follow-up plan is documented Pain assessment documented as negative, no follow-up plan required Documentation that patient is not eligible for a pain assessment Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate NO documentation of pain assessment, reason not given Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given G8730 G8731 G8442 G8939 G8732 G8509 PQRS # 182 Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies Measure #182, the Functional Outcome Assessment measure, has an additional definition for quality data code G8942, which now is reported to reflect functional outcome assessment documented, no functional deficiencies identified, care plan not required, or functional outcome assessment and care plan documented in the previous 30 days. DESCRIPTION: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies INSTRUCTIONS: This measure is to be reported each visit indicating the appropriate numerator code; however, the assessment is required to be current as defined for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 5

6 coding. Documentation of a current functional outcomes assessment must include identification of the standardized tool used. Clarification: 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 at 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 G8942 should be used for reporting purposes. Definitions: Standardized Tool 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), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS). 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. Functional Outcome Assessment Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms. Current A patient having a documented functional assessment within the previous 30 days. Functional Outcome Deficiencies Impairment or loss of physical function related to neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches. Care Plan A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient s health care problems. Care plans may also be known as a treatment plan. Not Eligible A patient is not eligible if the following reasons(s) exist: - Patient refuses to participate - Patient unable to complete questionnaire Oswestry Disability Index (ODI) Revised Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability/Activity Questionnaire (RM) Neck Pain Disability Index Questionnaire (NDI) Physical Mobility Scale (PMS) Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 6

7 Function Begins from the Ground Up!! Functional Assessment Documentation of a functional outcome assessment using a standardized tool AND documentation of a care plan based on identified deficiencies on the date of the functional assessment. Documentation of a functional outcome assessment using a standardized tool; no functional deficiencies identified, care plan not required Documented functional outcome assessment and care plan within the previous 30 days Documentation that the patient is not eligible for a functional outcome assessment Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan Functional outcome assessment using a standardized tool not documented, reason not given Documentation of a functional outcome assessment using a standardized tool; care plan not documented, reason not given Code G8539 G8542 G8942 G8540 G9227 G8541 G PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. Eligible professionals who report the measure must perform the blood pressure screening at the time of a qualifying visit and may not obtain measurements from external sources. Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 7

8 The documented follow up plan must be related to the current BP reading as indicated, example: Patient referred to primary care provider for BP management. Blood Pressure Classifications: Normal Pre-Hypertensive First Hypertensive Second Hypertensive BP Classification Systolic BP mm HG Diastolic BP mm HG Recommended Follow-up Normal BP < 120 AND <80 No Follow-Up required Pre-Hypertensive BP 120 AND 139 AND 89 Rescreen BP within a minimum of 1 year AND recommend lifestyle modifications Refer to Primary Care Provider First Hypertensive Reading Second Hypertensive BP Reading Rescreen BP within a minimum of 1 year AND recommend lifestyle modifications Refer to Primary Care Provider Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions (see definitions) Referral to Primary Care Provider Follow-up plan of care Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) BP screening intervals, lifestyle modifications and interventions based on the current BP reading Lifestyle Modifications: Weight reduction, Dietary approaches to stop hypertension, Dietary sodium restriction, Increased physical activity, or Moderation in Alcohol consumption Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 8

9 Blood Pressure Screening Normal blood pressure reading documented, follow-up not required Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented Blood pressure reading not documented, documentation the patient is not eligible Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible Blood pressure reading not documented, reason not given Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given Code G8783 G8950 G8784 G8951 G8785 G8952 Example: (Circle one of the following) Pain Assessment G8730 Pain Assessed, present G8731 Pain assessed, but no pain G8732 Pain NOT assessed Outcomes Assessment (OATS) G8539 OATS done today G8942 OATS not done today; but within the last 30 days G8542 OATS done today; no deficiency G8541 OATS NOT done in the last 30 days Blood Pressure Screening G8783 Normal BP G8950 HyperBP with follow-up G8785 BP not documented New information posted regularly at Like us Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 9