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 your organization can meet the reporting requirements. PQRS Clinical Quality Reporting 2015 Program Year

Table of Contents PQRS Overview... 2 What is PQRS... 2 Eligibility... 2 What are the PQRS Rules?... What is a Measure?... 4 How are PQRS Measures Reported?... 4 Individual EPs PQRS Group Practices... 4 Group vs. Individual Reporting... 5 Group Practice... 5 Individual Reporting... 7 Participation via Qualified Clinical Data Registry (QCDR)... 8 Xpio Health - PQRS Measures... 9 2015 Cross- Cutting Measures Requirement... 1 Measure- Applicability Validation... 16 Payment Adjustments... 18 Value- Based Modifier... 20 Aligning PQRS with Meaningful Use CQMs... 21 Xpio Services for PQRS Reporting... 1 Appendix 1: Decision Tree 2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment- Qualified Clinical Data Registry Based Reporting... 2 Appendix 2: Group Practices- 2015 Participation to Avoid 2017 PQRS Payment Adjustment Decision Tree... Appendix : QCDR... 4 1

PQRS Overview What is 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 Clinical 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 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

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 of the NQS domains. The domains are the same for MU Clinical Quality Measures which help with clinical reporting for both MU and PQRS. The NQS domains are as follows: Patient Safety Person and Caregiver- Centered Experience and Outcomes Communication and Care Coordination Effective Clinical Care 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). 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 PQRS Group Practices Individual EPs EHR direct product that is Certified Electronic Health Record Technology (CEHRT) EHR data submission vendor (DSV) that is CEHRT Qualified PQRS registry Qualified Clinical Data Registry (QCDR) Medicare Part B claims submitted to CMS PQRS Group Practices GPRO Web Interface (25+ providers) Qualified PQRS registry (2+ providers) EHR direct product that is CEHRT (2+ providers) EHR data submission vendor that is CERT (2+ providers) 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 0, 2015. For more information about reporting PQRS measures as a group, visit the Group Practice Reporting Option webpage. 4

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. 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 ned 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. 5

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 6

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: 7

Participation via Qualified Clinical 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. 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. For 2014, 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. EPs who satisfactorily participate in PQRS through a QCDR may earn the 2014 incentive payment (0.5%) and avoid the 2016 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 files for testing and submittal. To be considered a QCDR for purposes of PQRS, an entity successfully completes 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 has 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. 8

Xpio Health - PQRS Measures Xpio Health has been approved to report on the following 62 Clinical Quality measures to PQRS. The Xpio Health team will work with you to determine the best 9 measures to report across domains. Measure Title CMS NQF PQRS Diabetes: Hemoglobin A1c Poor Control 122v 0059 001 Diabetes: Low Density Lipoprotein (LDL- C) Control (<100 mg/dl) 16v 0064 002 Anti- Depressant Medication Management 128v 0105 009 Medication Reconciliation N/A 0097 046 Care Plan N/A 026 047 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Preventive Care and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults 161v 0104 107 147v4 0041 110 127v 004 111 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow- Up Plan 69v 0421 128 Documentation of Current Medications in the Medical Record 68v4 0419 10 Pain Assessment and Follow- Up N/A 0420 11 Preventive Care and Screening: Screening for Clinical Depression and Follow- Up Plan 2v4 0418 14 Falls: Risk Assessment N/A 0101 154 Falls: Plan of Care N/A 0101 155 Preventive Care and Screening: Unhealthy Alcohol Use Screening N/A N/A 17 9

Elder Maltreatment Screen and Follow- Up Plan Functional Outcome Assessment N/A N/A 181 N/A N/A 182 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 18v 0028 226 Controlling High Blood Pressure 165v 0018 26 Use of High- Risk Medications in the Elderly 156v 0022 28 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Childhood Immunization Status Dementia: Staging of Dementia 155v 0024 29 117v 008 240 N/A N/A 280 Dementia: Cognitive Assessment 149v N/A 281 Dementia: Functional Status Assessment N/A N/A 282 Dementia: Neuropsychiatric Symptom Assessment N/A N/A 28 Dementia: Management of Neuropsychiatric Symptoms Dementia: Screening for Depressive Symptoms N/A N/A 284 N/A N/A 285 Dementia: Counseling Regarding Safety Concerns N/A N/A 286 Dementia: Counseling Regarding Risks of Driving N/A N/A 287 10

Dementia: Caregiver Education and Support N/A N/A 288 Parkinson s Disease: Annual Parkinson s Disease Diagnosis Review N/A N/A 289 Parkinson s Disease: Psychiatric Disorders or Disturbances Assessment N/A N/A 290 Parkinson s Disease: Cognitive Impairment or Dysfunction Assessment N/A N/A 291 Parkinson s Disease: Querying about Sleep Disturbances Parkinson s Disease: Rehabilitative Therapy Options N/A N/A 292 N/A N/A 29 Parkinson s Disease: Parkinson s Disease Medical and Surgical Treatment Options Reviewed N/A N/A 294 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Use of Appropriate Medications for Asthma Use of Imaging Studies for Low Back Pain 17v 0004 05 126v 006 11 166v4 0052 12 Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented 22v N/A 17 Falls: Screening for Fall Risk 19v 0101 18 CAHPS for PQRS Clinician/Group Survey N/A 0005 & 0006 21 Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions N/A N/A 25 11

Maternity Care: Post- Partum Follow- Up and Care Coordination N/A N/A 6 Pain Brought Under Control Within 48 Hours N/A 0209 42 ADHD: Follow- Up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication 16v4 0108 66 Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use 169v N/A 67 HIV/AIDS: Medical Visit 62v N/A 68 Depression Remission at Twelve Months 159v 0710 70 Depression Utilization of the PHQ- 9 Tool 160v 0712 71 Maternal Depression Screening 82v2 N/A 72 Hypertension: Improvement in Blood Pressure 65v4 N/A 7 Closing the Referral Loop: Receipt of Specialist Report 50v N/A 74 Functional Status Assessment for Complex Chronic Conditions 90v4 N/A 77 Children Who Have Dental Decay or Cavities Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists 75v N/A 78 74v4 N/A 79 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment 177v 165 82 Discussion and Shared Decision Making Surrounding Treatment Options N/A N/A 90 Follow- up After Hospitalization for Mental Illness (FUH) N/A N/A 91 12

Immunizations for Adolescents N/A 1407 94 Tobacco Use and Help with Quitting Among Adolescents N/A N/A 402 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. The 2015 Cross Cutting Measures are below: PQRS# CMS# GPRO# 001 CMS122v NQF# 0059 Reporting Method Claims, Registry, EHR, GPRO Web Interface, Measures Group (Diabetes) 046 0097 Claims, Registry 047 026 Claims, Registry, Measures Group (CKD, HF, HIV/AIDS, COPD, Dementia, Parkinson s) National Quality Strategy Domain Effective Clinical Care Communication and Care Coordination Communication and Care Coordination Measure Title: Description Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Medication Reconciliation: Percentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 0 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented. Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. 1

110 CMS147v4 111 CMS127v 128 CMS69v 10 CMS68v4 0041 004 0421 0419 Claims, Registry, EHR, GPRO Web Interface, Measures Group (Diabetes, CKD, Prev Care, HF, Asthma, COPD, IBD, Oncology) Claims, Registry, EHR, GPRO Web Interface, Measures Group (Prev Care, COPD, IBD) Claims, Registry, EHR, GPRO Web Interface, Measures Group (Prev Care, Sleep Apnea, Asthma, RA, CAD) Claims, Registry, EHR, GPRO Web Interface, Measures Group (CKD, Oncology, COPD, Cataracts, General Surgery, HF, Hepatitis C, Sinusitis, Sleep Apnea, Total Knee Replacement, Asthma, AOE, CAD) Community/ Population Health Community/ Population Health Community/ Population Health Patient Safety Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 1 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: 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 Normal Parameters: Age 65 years and older BMI 2 and < 0 kg/m2; Age 18 64 years BMI 18.5 and < 25 kg/m2 Documentation of Current Medications in the Medical Record: 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, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. 11 0420 14 CMS2v4 0418 Claims, Registry, Measures Group (AOE, Sinusitis, RA) Claims, Registry, EHR, GPRO Web Interface, Measures Group (Prev Care, HIV/AIDS) Community/ Population Health Community/ Population Health Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan: 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. 14

182 N/A Claims, Registry 226 CMS18v 0028 Claims, Registry, EHR, GPRO Web Interface, Measures Group (Prev Care, HF, CAD, COPD, IBD, Asthma, Oncology, CKD, Cataracts, Diabetes, General Surgery, Hepatitis C, HIV/AIDS, Sinusitis, Sleep Apnea, Total Knee Replacement, AOE) Communication and Care Coordination Community/ Population Health 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 encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 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. 26 CMS165v 240 CMS117v 17 CMS22v 18 CMS19v 0018 Claims, Registry, EHR, GPRO Web Interface 008 EHR N/A 0101 Claims, Registry, EHR, GPRO Web Interface, Measures Group (AOE) EHR, GPRO Web Interface Effective Clinical Care Community/ Population Health Community/ Population Health Patient Safety Controlling High Blood Pressure: 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. Childhood Immunization Status: 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 two influenza (flu) vaccines by their second birthday. 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. Falls: Screening for Fall Risk: Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period. 15

21 74 CMS50v 0005 0006 N/A CSV EHR 400 N/A Registry 402 N/A Registry, Measures Groups (Asthma) Person and Caregiver-Centered Experience and Outcomes Communication and Care Coordination Effective Clinical Care Community/ Population Health CAHPS for PQRS Clinician/Group Survey: Getting timely care, appointments, and information; How well providers Communicate; Patient s Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; Courteous and Helpful Office Staff; Care Coordination; Between Visit Communication; Helping Your to Take Medication as Directed; and Stewardship of Patient Resources Closing the Referral Loop: Receipt of Specialist Report: 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. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection. Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user. Measure- Applicability Validation Measures with a 0% performance rate will not be counted. CMS acknowledges that some EPs may not meet the requirement for 9 measures across domains, and have set up a process for evaluate data that does not meet the requirements. The Measure- Applicability Validation (MAV) process may be activated to further evaluate the data to see if the EP could have reported additional measures. MAV is triggered in situations where the EP or group practice reports any combination of measures and domains with less than 9 measures across domains. There are several ways to report data to PQRS and Xpio Health is now an approved Registry vendor to assist you with your PQRS project. The process flow below documents how the MAV process flows for Registry submissions. 16

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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 2016. 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 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%. 18

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. 19

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 201 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 20

to register to participate in the PQRS Group Practice Reporting Option (GPRO) as a group in CY2014 has 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. Aligning PQRS with Meaningful Use CQMs 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 201 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 three- month reporting period in 2014. At the time of this publication, there are 64 measures that align PQRS with Meaningful Use Stage 2. These measures should be referenced when the measures your agency wants to report are finalized. The table below is the 2015 PQRS measures that align with MU that Xpio Health are qualified to report as a registry. Additional focus on the Behavioral Health measures identified by the National Council may also be considered when measures are selected. Measure Title CMS NQF PQRS Measure Description NQS Domain Measure Type Diabetes: Hemoglobin A1c Poor Control Diabetes: Low Density Lipoprotein (LDL- C) Control (<100 122v 16v 005 9 006 4 001 Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period 002 Percentage of patients 18 75 years of age with diabetes whose LDL- C was Effective Clinical Care Effective Clinical Care Intermediate Outcome Intermediate Outcome 21

mg/dl) Anti- Depressant Medication Management Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 128v 161v 010 5 010 4 adequately controlled (< 100 mg/dl) during the measurement period 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 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). 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 Effective Clinical Care Effective Clinical Care 22

Preventive Care and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow- Up Plan 147v 4 127v 004 1 004 69v 042 1 110 Percentage of patients aged 6 months and older seen for a visit between October 1 and March 1 who received an influenza immunization OR who reported previous receipt of an influenza immunization. 111 Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. 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/Populati on Health Community/Populati on Health Community/Populati on Health Normal Parameters: Age 65 years and older BMI 2 and < 0 kg/m 2 ; Age 18 64 years BMI 18.5 and < 25 kg/m 2 2

Documentation of Current Medications in the Medical Record Preventive Care and Screening: Screening for Clinical Depression and Follow- Up Plan 68v4 041 9 2v4 041 8 10 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, over- the- counters, herbals, and vitamin/mineral/dieta ry (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. 14 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. Patient Safety Community/Populati on Health 24

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 18v 002 8 226 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/Populati on Health Controlling High Blood Pressure Use of High- Risk Medications in the Elderly 165v 156v 001 8 002 2 26 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. 28 Percentage of patients 66 years of age and older who were ordered high- risk 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. Effective Clinical Care Patient Safety Intermediate Outcome 25

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Childhood Immunization Status 155v 117v 002 4 00 8 29 Percentage of patients - 17 years of age who had an outpatient visit with a Primary Care 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 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 two influenza (flu) vaccines by their second birthday. Community/Populati on Health Community/Populati on Health 26

Use of Appropriate Medications for Asthma Use of Imaging Studies for Low Back Pain Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented Falls: Screening for Fall Risk 126v 166v 4 00 6 005 2 11 Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period 12 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 28 days of the diagnosis. 22v N/A 17 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. 19v 010 1 18 Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period. Effective Clinical Care Efficiency and Cost Reduction Community/Populati on Health Patient Safety 27

ADHD: Follow- Up Care for Children Prescribed Attention- Deficit/Hyperactiv ity Disorder (ADHD) Medication Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use HIV/AIDS: Medical Visit 16v 4 169v 010 8 011 0 66 Percentage of children 6-12 years of age and newly dispensed a medication for attention- deficit/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 0- Day Initiation Phase. b. Percentage of 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 67 Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use. 62v N/A 68 Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the Effective Clinical Care Effective Clinical Care Effective Clinical Care 28

Depression Remission at Twelve Months Depression Utilization of the PHQ- 9 Tool Maternal Depression Screening 159v 160v 071 0 071 2 measurement year with a minimum of 90 days between each visit 70 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 71 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 72 The percentage of children who turned 6 months of age during the measurement year, who had a face- to- face 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. Effective Clinical Care Effective Clinical Care Community/Populati on Health Intermediate Outcome 29

Hypertension: Improvement in Blood Pressure Closing the Referral Loop: Receipt of Specialist Report Functional Status Assessment for Complex Chronic Conditions Children Who Have Dental Decay or Cavities Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment 65v4 N/A 7 Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period. 50v N/A 74 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. 90v4 N/A 77 Percentage of patients aged 65 years and older with heart failure who completed initial and follow- up patient- reported functional status assessments 75v N/A 78 Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period 74v4 N/A 79 Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period. 177v 16 5 82 Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk Effective Clinical Care Communication and Care Coordination Person and Caregiver- Centered Experience and Outcomes Effective Clinical Care Effective Clinical Care Patient Safety Intermediate Outcome Outcome 0

Xpio Services for PQRS Reporting Xpio Health helps behavioral healthcare organizations and hospitals under Medicare manage facilities and over 00 EP s throughout all phases of Meaningful Use. This expertise is now applied to the 2015 PQRS reporting; Xpio Health specializes in data collection for behavioral health care organizations utilizing a combination of secure Data Warehouse and EHR systems along with a HIPAA compliant and encrypted web- based tool. The Xpio Health data warehouse has been programmed to meet the 2015 PQRS reporting requirements, giving the customer one standard process for MU and PQRS data monitoring and reporting. Xpio Health is a CMS approved 2015 PQRS Registry that can submit quality measures on behalf of customers; individual or group practices. Data by EP is analyzed and reported to CMS in a valid QRDA III format. Additionally, continuous data monitoring is possible by using the PQRS dashboard. PQRS services provided by Xpio Health include: Phase 1- Assessment and Planning o Includes evaluation of the organization s EP status, client payer mix, assessment of the current operating and technical environment, including EHR, to determine the best clinical quality measures to report, analysis of the possible incentive/penalty that the organization may incur, a proposed budget for administering the additional phases and an initial implementation plan/project schedule. Phase 2- PQRS Build/Reporting Effort o Includes utilizing a combination of secure Data Warehouse and the organization s EHR system with a HIPAA compliant and encrypted web- based tool. Data is analyzed by EP or group and then reported to CMS in a valid QRDA III format. Continuous data monitoring is possible by using the PQRS dashboard and other reports. Phase - PQRS Maintenance Effort o Includes customizing the PQRS dashboard, adding additional clinical quality measures and end user support/training as required A typical decision tree/process workflow for the PQRS project is below. Our Xpio Health team will work with your organization to customize the process flow as needed. 1

Appendix 1: Decision Tree 2015 PQRS Reporting/Participation for Avoiding the 2017 Negative Payment Adjustment- Qualified Clinical Data Registry Based Reporting 2

Appendix 2: Group Practices- 2015 Participation to Avoid 2017 PQRS Payment Adjustment Decision Tree

Appendix : QCDR 4