PQRS Clinical Quality Reporting

PQRS clinical quality measure reporting is required to avoid Medicare payment rate reductions. This document summarizes the PQRS program and how it is aligned with Meaningful Use CQMs. PQRS Quality Reporting Overview by Xpio Health June 1, 2015

Table of Contents Physician Quality Reporting System Overview... 2 What is Physician Quality Reporting System (PQRS)?... 2 Eligibility... 2 What are the PQRS Rules?... 3 What is a Measure?... 3 How are PQRS Measures Reported?... 4 Individual EPs and PQRS Group Practices Reporting Mechanisms... 4 Group vs. Individual Reporting... 4 Group Practice... 4 Individual Reporting... 6 Participation via Qualified Data Registry (QCDR)... 7 2015 PQRS Measures that Align with Meaningful Use... 8 2015 Cross-Cutting Measures Requirement... 29 Measure-Applicability Validation... 29 Payment Adjustments... 30 Value-Based Modifier... 32 Sample PQRS Implementation Strategy... 33 Where to Call for Help... 34 Appendices... 35 Appendix 1: Decision Trees-2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment(QCDR Reporting)... 35 Appendix2: QCDR... 36 Appendix 3: Group Practices-2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment(QCDR Reporting)... 37 Acronyms... 38 1

Physician Quality Reporting System Overview What is Physician Quality Reporting System (PQRS)? PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of quality information by individual EPs and group practices. Those who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare Part B beneficiaries (including Railroad Retirement Board, Medicare Secondary Payer, and Critical Access Hospitals [CAH] method II) will be subject to a negative payment adjustment under PQRS. Medicare Part C Medicare Advantage beneficiaries are not included. Reporters may choose from the following reporting options to submit their quality data: Reporting electronically using an electronic health record (EHR) Qualified Registry Qualified Data Registry (QCDR) PQRS Group Practice Reporting Option (GPRO) via Web Interface CMS-Certified Survey Vendor Claims All EPs who do not meet the criteria for satisfactory reporting or participating for 2015 PQRS will be subject to the 2017 negative payment adjustment with no exceptions. Participation in PQRS benefits healthcare quality and the negative payment adjustments that will be applied. Driving quality improvement is a core function of CMS and their vision to optimize health outcomes by leading clinical quality improvement and health system transformation. Eligibility PQRS includes more EPs than the Meaningful Use program. The CMS table below documents the EPs for 3 incentive programs; PQRS, the Value Modifier incentives/penalties and the EHR Incentive Program, or Meaningful Use. Notice that in PQRS, incentives and penalties apply to all EPs, not just the Physicians. The impact of the PQRS incentives/penalties may have a greater impact on your organization than Meaningful Use. 2

Table 1 What are the PQRS Rules? CMS has defined a reporting structure that utilizes the National Quality Strategy (NQS) domains for reporting. An EP or Group (GPRO) must report on 9 clinical quality measures from 3 of the NQS domains. The domains are the same for MU Quality Measures which help with clinical reporting for both MU and PQRS. The NQS domains are as follows: Patient Safety Person and giver-centered Experience and Outcomes Communication and Coordination Community/Population Health Efficiency and Cost Reduction What is a Measure? Measures consist of two major components: denominators and numerators. Numerator The upper portion of a fraction used to calculate a rate, proportion or ratio. The numerator must detail the quality clinical action expected that satisfies the condition(s) and is the focus of the measurement for each patient, procedure or other unit of measurement established by the denominator (that is, patients who received a particular service or providers that completed a specific outcome/process). 3

Denominator The lower portion of a fraction used to calculate a rate, proportion or ratio. The denominator must describe the population eligible (or episodes of care) to be evaluated by the measure. This should indicate age, condition, setting, and timeframe (when applicable). For example, Patients aged 18 through 75 years with a diagnosis of diabetes. Each component is defined by specific codes described in the respective measure's specification along with the reporting instructions and use of modifiers. How are PQRS Measures Reported? PQRS offers several reporting mechanisms for reporting measures. EPs or Groups (TIN) will determine the best reporting options when configuring their PQRS reporting. Following are reporting mechanisms available to individual EPs and PQRS group practices. Individual EPs and PQRS Group Practices Reporting Mechanisms Individual EPs PQRS Group Practices EHR direct product that is Certified Electronic GPRO Web Interface (25+ providers) Health Record Technology (CEHRT) Qualified PQRS registry (2+ providers) EHR data submission vendor (DSV) that is CEHRT EHR direct product that is CEHRT (2+ providers) Qualified PQRS registry EHR data submission vendor that is CERT (2+ Qualified Data Registry (QCDR) providers) Medicare Part B claims submitted to CMS CAHPS for PQRS using CMS-certified survey vendor (2+ providers) (CAHPS is supplemental to other reporting mechanisms) PQRS group practices must register for their selected reporting mechanism by June 30, 2015. For more information about reporting PQRS measures as a group, visit the Group Practice Reporting Option webpage. Group vs. Individual Reporting Group Practice A group practice under PQRS consists of a physician group practice as defined by a single TIN, with 2 or more individual EPs that have reassigned their billing rights to the TIN. Registering the group allows the data to be analyzed at the group or TIN level. An individual EP who is a member of a group practice participating as a GPRO is not eligible to separately earn a PQRS incentive payment as an individual EP under the same TIN. Group size is determined at the time of registration. Groups are able to collect the Value-based Payment Modifier (VM) sooner than individual EPs; groups of 100 or more collect in 2015, groups with greater than 25 EPs collect in 2016 and then all individual providers collect in 2017. 4

Measure groups cannot be reported from a GPRO, but measure groups do not apply to Behavioral Health at this time. A group reporting via a Qualified Registry has two sets of criteria; one is to earn the PQRS incentive and one to only avoid the 2016 payment adjustment. Reporting criterial for PQRS Group Practices for 2015 are: There are some benefits to reporting out as a 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 Incentive-eligible group practices will receive a larger incentive payment as it is calculated at the TIN-level (0.5% of all Medicare Part B PFS claims paid under that TIN) Those EPs who have difficulty meeting the reporting requirements for individual EPs may benefit from group reporting. o All EPs in the group who meet the reporting requirements can represent the group and if data is approved, there will be a neutral or upward Value Based Modifier for all providers in the Group. Individual reporting requires 50% of the EPs need to meet the reporting requirements or the TIN will receive a downward or negative Value Based Modifier on all services for all EPs. GPRO participation will count for: PQRS VM ecqm component of Meaningful Use o Only if the group registers to report via Web Interface or EHR reporting methods o Cannot meet this requirement through registry reporting 5

Individual Reporting Individual EPs will use the individual reporting regulations for their submissions. There are different clinical quality measures used for individual and group reporting. Requirements for 2015 PQRS are below: 6

Participation via Qualified Data Registry (QCDR) A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. A QCDR will complete the collection and submission of PQRS quality measures data on behalf of EPs so that they may meet criteria for satisfactorily participating in 2015 PQRS. The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare. Reporting via QCDR is one of three reporting mechanisms (Qualified Registry, EHR, and QCDR) that provides calculated reporting and performance rates to CMS. The QCDR also collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. A qualified clinical data registry (QCDR) is a new and important reporting mechanism available for the Physician Quality Reporting System (PQRS) beginning in 2014. A QCDR will complete the collection and submission of PQRS quality measures data on behalf of Eligible Professionals (EPs), and is able to specialize in specific practice areas, such as Behavioral Health, to foster quality improvement relevant to a given specialty. EPs who satisfactorily participate in PQRS through a QCDR in 2015 will avoid the 2017 payment adjustment (-2.0%). Another advantage of a QCDR is that they are able to work with agencies on data submittal files, measures, and workflows, enabling an end to end reporting process that can be submitted directly to CMS from the QCDR, helping mitigate some of the challenges associated with measure applicability, as well as formatting QRDA 3 files for testing and submittal. To be considered a QCDR for purposes of PQRS, an entity successfully complete a rigorous qualification process, submit measure testing protocols and quality assurance for approval, and ideally be a Subject Matter Expert (SME) in the domains and measures that will be reported. The 2014 Medicare Physician Fee Schedule (MPFS) final rule includes the finalized, detailed information regarding this new reporting mechanism. Please note: A QCDR is different from a qualified registry in that it is not limited to measures within PQRS, please refer to the documents referenced below for more information. Xpio Health as been approved as a CMS QCDR for 2015, and is working with CiBHS and other entities around the nation to help integrate CQM collection strategies into EHR systems and as well as evolving the Behavioral Health specific measures and analytics framework on the registry side. 7

EPs can avoid the 2017 PQRS negative payment adjustment by satisfactorily participating via a QCDR, according to the following criteria: 2015 PQRS Measures that Align with Meaningful Use Providers were required to submit 2014 CQM data from a certified EHR technology regardless if they are in Stage 1 or Stage 2 reporting. This reporting will prevent the Medicare and Medicaid Electronic Health Record Incentive penalties as noted above. In 2015, the PQRS and CQMs are in alignment to provide a more efficient reporting mechanism. Providers who can align: EPs (both individual and group) who are beyond their first year of meaningful use EPs who are using an EHR certified to the June 2013 version of the ecqms Similar to your decisions about PQRS, the following items should be taken into consideration for aligning: Individual or group reporting Method of reporting PQRS What measures to report Is your EHR certified to the 2014 certification standards? To report for a full year for MU CQMs; MU core and menu objectives only required a threemonth reporting period in 2014. 8

The table below documents the PQRS measures that are in alignment with Meaningful Use ecqms. CMS does routinely retire PQRS measures; this list was effective in December 2014. There is additional information that will also need to be considered as each measure is not approved for submission by all submission types; contact your specialty QCDR to determine what measures are supported. Measure Number Measure Title CMS NQF PQRS Measure Description NQS Domain Measure Type Diabetes: Hemoglobin A1c Poor Control Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dl) Heart Failure (HF): Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 122v3 0059 001 Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period 163v3 0064 002 Percentage of patients 18 75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dl) during the measurement period 135v3 0081 005 Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge Intermediate Outcome Intermediate Outcome 9

Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) Heart Failure (HF): Beta- Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Anti-Depressant Medication Management 145v3 0070 007 Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy 144v3 0083 008 Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed betablocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge 128v3 0105 009 Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant 10

Primary Open- Angle Glaucoma (POAG): Optic Nerve Evaluation: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Diabetic Retinopathy: Communication with the Physician Managing Ongoing medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months). 143v3 0086 012 Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months 167v3 0088 018 Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months 142v3 0089 019 Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus 11

Diabetes Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Testing for Children with Pharyngitis Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Proges terone Receptor (ER/PR) Positive Breast Cancer exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months 154v3 0069 065 Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode 146v3 0002 066 Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode 140v3 0387 071 Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period Efficiency and Cost Reduction Efficiency and Cost Reduction 12

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 141v3 0385 072 Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period 129v3 0389 102 Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer 161v3 0104 107 Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified Efficiency and Cost Reduction 13

Preventive and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults Breast Cancer Screening Colorectal Cancer Screening Diabetes: Eye Exam 147v4 0041 110 Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. 127v3 0043 111 Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. 125v3 N/A 112 Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months 130v3 0034 113 Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer 131v3 0055 117 Percentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the Community /Population Health Community /Population Health 14

measurement period Diabetes: Medical Attention for Nephropathy Preventive and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 134v3 0062 119 The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period 69v3 0421 128 Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Community /Population Health Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 ; Age 18 64 years BMI 18.5 and < 25 kg/m 2 15

Documentation of Current Medications in the Medical Record Preventive and Screening: Screening for Depression and Follow-Up Plan Oncology: Medical and Radiation Pain Intensity Quantified 68v4 0419 130 Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, overthe-counters, herbals, and vitamin/mineral/dieta ry (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. 2v4 0418 134 Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. 157v3 0384 143 Percentage of patients, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in Patient Safety Community /Population Health Person and giver- Centered Experience and Outcomes 16

which pain intensity is quantified HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis Diabetes: Foot Exam Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures 52v3 0405 160 Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis 123v3 0056 163 Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period 133v3 0565 191 Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery 132v3 0564 192 Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days Patient Safety Outcome Outcome 17

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence 164v3 0068 204 Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period 18

Preventive and Screening: Tobacco Use: Screening and Cessation Intervention 138v3 0028 226 Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Community /Population Health Controlling High Blood Pressure Use of High-Risk Medications in the Elderly 165v3 0018 236 Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement period. 156v3 0022 238 Percentage of patients 66 years of age and older who were ordered highrisk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications. Patient Safety Intermediate Outcome 19

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Childhood Immunization Status 155v3 0024 239 Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Physician (PCP) or Obstetrician/Gynecol ogist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity 117v3 0038 240 Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and Community /Population Health Community /Population Health 20

two influenza (flu) vaccines by their second birthday. Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL- C Control (< 100 mg/dl) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 182v4 0075 241 Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dl) 137v3 0004 305 Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of Intermediate Outcome 21

Cervical Cancer Screening Chlamydia Screening for Women Use of Appropriate Medications for Asthma Use of Imaging Studies for Low Back Pain patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. 124v3 0032 309 Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer 153v3 0033 310 Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period 126v3 0036 311 Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period 166v4 0052 312 Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within Community /Population Health Efficiency and Cost Reduction 22

28 days of the diagnosis. Preventive and Screening: Cholesterol Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C 61v4 & 64v4 N/A 316 Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed AND percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL- C goal. *There are three criteria for this measure based on the patient s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent OR 10-Year Framingham Risk >20% 2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10- Year Framingham Risk 10-20% 3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10% Intermediate Outcome 23

Preventive and Screening: Screening for High Blood Pressure and Follow-Up Documented Falls: Screening for Fall Risk Hemoglobin A1c Test for Pediatric Patients ADHD: Follow- Up for Children Prescribed Attention- Deficit/Hyperacti vity Disorder (ADHD) Medication 22v3 N/A 317 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. 139v3 0101 318 Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period. 148v3 0060 365 Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period 136v4 0108 366 Percentage of children 6-12 years of age and newly dispensed a medication for attentiondeficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of Community /Population Health Patient Safety 24

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use HIV/AIDS: Medical Visit Pregnant Women that had HBsAg Testing children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended 169v3 N/A 367 Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use. 62v3 N/A 368 Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit 158v3 N/A 369 This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy. 25

Depression Remission at Twelve Months Depression Utilization of the PHQ-9 Tool Maternal Depression Screening 159v3 0710 370 Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ- 9 score indicates a need for treatment 160v3 0712 371 Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit. 82v2 N/A 372 The percentage of children who turned 6 months of age during the measurement year, who had a face-toface visit between the clinician and the child during child s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. Community /Population Health Intermediate Outcome 26

Hypertension: Improvement in Blood Pressure Closing the Referral Loop: Receipt of Specialist Report Functional Status Assessment for Knee Replacement Functional Status Assessment for Hip Replacement Functional Status Assessment for Complex Chronic Conditions 65v4 N/A 373 Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period. 50v3 N/A 374 Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. 66v3 N/A 375 Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and followup (patient-reported) functional status assessments. 56v3 N/A 376 Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and followup (patient-reported) functional status assessments 90v4 N/A 377 Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patientreported functional status assessments Communic ation and Coordinatio n Person and giver- Centered Experience and Outcomes Person and giver- Centered Experience and Outcomes Person and giver- Centered Experience and Outcomes Intermediate Outcome 27

Children Who Have Dental Decay or Cavities Primary Caries Prevention Intervention as Offered by Primary Providers, including Dentists ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range HIV/AIDS: RNA Control for Patients with HIV Child and Adolescent Major Depressive Disorder (MDD): 75v3 N/A 378 Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period 74v4 N/A 379 Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period. 179v3 N/A 380 Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period 77v3 N/A 381 Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/ml. 177v3 1365 382 Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of Patient Safety Patient Safety Outcome Intermediate Outcome Outcome 28

Suicide Risk Assessment Table 4 major depressive disorder with an assessment for suicide risk 2015 Cross-Cutting Measures Requirement In order for eligible professionals (EPs) to satisfactorily report Physician Quality Reporting System (PQRS) measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. Eligible professionals or group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter. Measure-Applicability Validation The 2015 Physician Quality Reporting System (PQRS) requires eligible professionals to report at least nine measures across three domains within the period January 1, 2015 December 31, 2015. The Centers for Medicare & Medicaid Services (CMS) recognizes that a limited number of eligible professionals may not be able to identify nine measures across three domains that are applicable to their practice. The objective of registry-based MAV is for CMS to validate if there were additional measure(s) or domain(s) that may have been applicable to submit by the eligible professional or group practice. For registry-based submissions, MAV applies a one-step validation process of the clinical/domain relation test. Eligible professionals or group practices that submit less than nine measures or less than three NQS domains would be subject to MAV. If the eligible professional or group practice passes MAV, they would avoid the 2017 PQRS payment adjustment. For those eligible professionals or group practices that fail MAV, the 2017 PQRS Payment Adjustment would apply. There are several ways to report data to PQRS and Xpio Health is now an approved Quality Data Registry vendor to assist you with your PQRS project. The process flow below documents how the MAV process flows for Registry submissions. 29

Table 2 Payment Adjustments As noted above, PQRS is a reporting program that uses payment adjustments (penalties) to promote reporting of quality information by EPs and group practices. The Social Security Act requires CMS to subject EPs and group practices who do not report data on PQRS quality measures to a payment adjustment in 2015. EPs who do not satisfactorily report data on quality measures for covered professional services will be subject to a payment adjustment under PQRS in 2015. Accordingly, EPs 30

receiving a payment adjustment in 2015 will be paid 1.5% less than the Medicare PFS amount for each service. For 2016 and subsequent years, the adjustment is 2.0%. Below is a CMS table that explains the different incentive programs and the possible incentives/penalties that will be imposed for PQRS, Value Based Modifier (explanation below) and the MU EHR Incentive program. For all Physicians, there is a possible 4% reduction if there is no PQRS or MU EHR clinical quality measures reported in 2014 and additional Value Modifier reduction in 2016 based on the number of EPs in your organization. In 2017, all EPs will be subject to the Value Modifier incentive or reduction. The possible penalty may reach 6% if none of the quality measures are reporting by 2017. Table 3 31

Table 4 Below is an example of possible incentives/penalties related to MU, erx and PQRS reporting. Your organization s estimates will be completed during the Phase 1-Assessment portion of the PQRS project. Value-Based Modifier CMS will begin applying a value modifier under the Medicare PFS that is calculated by both cost and quality data. 2015-Value modifier applied to physicians in group practices of 100 or more EPs who submit claims to Medicare under a single tax ID (TIN) based on their performance in 2013 2016-Value modifier applied to physicians in group practices of 10 or more EPs who submit claims to Medicare under a single TIN based on their performance in 2014 2017-Value modifier applied to all physicians who participate in FFS Medicare Quality tiering is the analysis used to determine the type of adjustment (upward, downward or neutral) and the range of adjustment based on performance quality and cost measures. The deadline for groups to register to participate in the PQRS Group Practice Reporting Option (GPRO) as a group in CY2014 has 32

passed. Therefore, in order to avoid the automatic -2.0% Value Modifier payment adjustment in 2016, groups with 10 or more EPs must ensure that at least 50% of the EPs in the group participate in PQRS as individuals in 2014 and meet the satisfactory reporting criteria as individuals via a qualified registry or EHR. Sample PQRS Implementation Strategy Below is a sample implementation process that should be considered when working on the PQRS program. Your agency will need to make several decisions before you build or purchase a reporting solution. There are vendors available to assist with your PQRS reporting. Individual or Group? Most agencies will benefit from participating in Group Reporting option if they have more than 2 Eligible Professionals. The PQRS group option allows all the data to be aggregated for all EP s, helping average out lower performing and higher performing EP s, which can enable the entire group to avoid the penalty and receive an incentive. Also, the incentive for a group is larger than for the EP, allowing for up to a 6% increase in Medicare revenue under the Value Modifier component. Which Measures? Ideally, an organization can locate a CMS authorized Quality Data Registry (QCDR) for their specialty, identify cross cutting measures to align PQRS and Meaningful Use for example, and select CQM s that have clinical relevance and applicability, and integrate well with the practice EHR. A significant advantage of a QCDR is also their ability to create custom measures that can be designed assess quality in specific populations. EHR Integration In order to extract numerator and denominator logic from an EHR, the measure specifications need to be integrated into both the clinical workflows, as well as the technical framework. ONC certified EHR s are often certified for a subset of CQM s typically related to Meaningful Use reporting; organizations need to work with their EHR vendor and their QCDR to determine PQRS measure applicability, overlap with other requirements, practice fit, value to practice, and reportability. 33

Where to Call for Help Xpio Health QCDR Help Desk o Secure Portal Login and Password Issues o Measure Selection o EHR integration o MU and PQRS Overlap o CQM Workflow and Training o QRDA 3 file formatting o Regulatory and Penalty questions qcdrsupport@xpiohealth.com Quality Net Help Desk o Portal Password Issues o PQRS Feedback report availability and access o IACS registration questions o IACS login issues o PQRS Program Questions 866-288-8912 7:00am-7:00pm CST M-F or qnetsupport@hcqis.org You will be asked to provide basic information such as name, practice, address, phone and email EHR Incentive Program Information Center o 888-734-6433 34

Appendices Appendix 1: Decision Trees-2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment (QCDR Reporting) *17. Qualified clinical data registry-based reporting of at least 9 measures covering at least 3 NQS domains for 50% or more of the EP s applicable Medicare Part B FFS patients; of these measures report at least 2 outcome measures, OR if 2 outcome measures are not available, report on at least 1 outcome measure and at least one of the following types of measures - resource use, patient experience of care, efficient/appropriate use, or patient safety measure. (all payers) (12 months) 35

Appendix2: QCDR 36

Appendix 3: Group Practices-2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment (QCDR Reporting) 37

Acronyms CEHRT-Certified Electronic Health Record Technology ecqm-electronic Quality Measure EP- Eligible Professional GPRO-PQRS Group Practice Reporting Option MAV-Measure-Applicability Validation MU-Meaningful Use NQS-National Quality Strategy QCDR-Qualified Data Registry TIN-Tax Identification Number VM-Value-based Payment Modifier 38