stratishealth pqrs qa session 11182013 v2 [read …...background (cont.) • pqrs incentive payments...

Physician Quality Reporting System

Q & A Session

November 18, 2013

Presented by:

Deepika Sharma - Research Analyst, Stratis Health

Jerri Hiniker - Program Manager, Stratis Health

Agenda

• PQRS Overview - 15 mins� PQRS Reporting Options to earn incentive

payments

� PQRS Reporting Options to avoid payment

adjustments

• Q&A Session – 45 mins

Background

• A quality reporting program established by Center for

Medicare and Medicaid Services (CMS) in 2007

• Combination of incentive payments and payment

adjustments to promote reporting of quality information by adjustments to promote reporting of quality information by

eligible professionals (EPs)* for services furnished to

Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer)

Resources:

Getting Started with PQRS- http://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html

Background (cont.)

• PQRS Incentive Payments:

� 2011 – 1.0%

� 2012 – 0.5%

� 2013 – 0.5%

� 2014 – 0.5%

• PQRS Payment Adjustments: • PQRS Payment Adjustments:

� Will be applied in 2015 to eligible professionals who do not

satisfactorily report data on quality measures* for all Part B covered

professional services

� Based on 2013 reporting

� Payment Adjustment amount is 1.5% for 2015 and 2.0% for 2016

(based on 2014 reporting) and subsequent years

Resources:

Getting Started with PQRS- http://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html

PQRS Quality Measures

• INDIVIDUAL QUALITY MEASURES (Report on at least 3)

• MEASURE GROUPS (Report on at least one)Measures groups include reporting on a group of clinically-related measures identified by CMS, either through claims-based and/or registry-based submission. Twenty-two measures groups have been established for 2013 PQRS: Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), for 2013 PQRS: Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Preventive Care, Coronary Artery Bypass Graft (CABG), Rheumatoid Arthritis (RA), Perioperative Care, Back Pain, Hepatitis C, Heart Failure (HF), Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), HIV/AIDS, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Inflammatory Bowel Disease (IBD), Sleep Apnea, Dementia, Parkinson’s Disease, Hypertension (HTN), Cardiovascular Prevention, Cataracts, and Oncology.

Choosing Measures for Reporting

Consider Following Factors

�Clinical conditions commonly treated

�Types of care delivered frequently – e.g., preventive, chronic, acute

�Settings where care is often delivered – e.g., office, emergency department (ED), surgical suitedepartment (ED), surgical suite

�Quality improvement goals for 2013

Resources:

� 2013 PQRS Quality Measures List for all Reporting Options

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_IndClaimsRegistry_MeasureSpec_SupportingDocs_12192012.zip

� 2013 PQRS Individual Claims and Registry Measures List and Specifications

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_IndClaimsRegistry_MeasureSpec_SupportingDocs_12192012.zip

� PQRS Measure Groups Specifications and Other Supporting Documents

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_MeasuresGroupsSpecs_ReleaseNotes_SupportingDocs_03042013.zip

2013 PQRS Reporting Options to

Earn Incentive Payments

CLAIMS – BASED REPORTING

REGISTRY – BASED REPORTING

EHR – BASED REPORTINGEHR – BASED REPORTING

GROUP PRACTICE REPORTING OPTION (GPRO)

PQRS EHR MEDICARE INCENTIVE PILOT

Claims Based Reporting

• For Individual Eligible Professionals

• Requires satisfactorily reporting on at least 50 percent of eligible instances for at least 3 individual measures* OR at least 20 patients when for at least one measures group* via claims to qualify for the incentive.

• If less than three measures are applicable to EP, CMS will apply the Measure-Applicability

Validation (MAV) process* - determine if an EP should have reported on 3 measure

Note:

� Individual measures with a 0% performance rate will not be counted as satisfactorily reporting

� When a lower rate indicates better performance, a 0% performance rate will be counted as

satisfactorily reporting (100% performance rate would not be considered satisfactorily reporting)satisfactorily reporting (100% performance rate would not be considered satisfactorily reporting)

� If a measure within a measures group is not applicable to a patient, the patient would not be

counted in the performance denominator for that measure

• Reporting time period for both individual and group measures – 12 months (1/1/2013 –

12/31/2013)

Resources:

� 2013 PQRS Claims Reporting Made Simple - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2013_PQRS_SatisfRprtng-Claims_12192012.pdf

� Claims Based Coding and Reporting Principles - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/2013-PQRS-Claims-Based-Coding-and-Reporting-Principles-.pdf

Claims Based Reporting (Cont.)

• How to Report:

� Read and Understand specifications for your selected measures*

� If your practice management software has the capability, turn-on alerts/flags to help identify eligible PQRS patients as they are seen. If not, identify manual method of flagging the cases

� Record correct PQRS codes on the claims – CPT and Quality Data Codes (QDC) and follow your usual process of submitting the claim (using 1500 claim form

� Refer to this CMA -1500 PQRS claim example to understand the recording of correct PQRS codes: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_sampleCMS1500claim_12-19-2012.pdf

� Access feedback reports via IACS account to track the progress for individuals or � Access feedback reports via IACS account to track the progress for individuals or organizations. The feedback reports are available mid-year and end-of-year.

- Individual EPs Feedback Reports - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/2013-PQRS-IACS-Feedback-Reports.pdf

- Group Practice Feedback Reports - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_IACS-Organizations_12192012.pdf

� Deadline – All claims should be finalized and submitted by February 28, 2014 for consideration in 2013 PQRS reporting.

Registry Reporting• Submit data on quality measures via qualified registry vendor - A Registry Vendor is an entity that

collects data from a source other than an electronic health record and transmits it in an aggregate form to CMS on behalf of an eligible professional or group practice.

• List of Qualified Registry Vendors:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013ParticipatingRegistryVendors_05172013.pdf

The listing identifies the vendors, measures and/or measures groups they support, costs and contact information. Contact the Registry for specific information regarding requirements, deadlines, and procedures for participation

• Requires satisfactory submission on at least 80 percent of eligible instances for at least three individual quality measures or report on a 20-patient sample (if reporting measures groups)individual quality measures or report on a 20-patient sample (if reporting measures groups)

Note:


� When a lower rate indicates better performance, a 0% performance rate will be counted as satisfactorily reporting (100% performance rate would not be considered satisfactorily reporting)

� If a measure within a measures group is not applicable to a patient, the patient would not be counted in the performance denominator for that measure

• Reporting Time Periods:

� Individual Measures: 12 months (1/1/2013 – 12/31/2013)

� Group Measures: 12 months (1/1/2013 – 12/31/2013) OR

6 months (7/1/2013 – 12/31/2013)

Registry Reporting (Cont.)

• How to Report:

� Read and Understand specifications for your selected measures*

� Verify that your selected registry support the measures/measure groups you have

chosen for reporting

� Your registry will provide you with specific instructions on how to submit data for the

selected measures or measures group on which you choose to report. The registry will

submit PQRS data to CMS on your behalf during the first quarter of 2014 . You will

work directly with your registry to ensure data is submitted appropriately for incentive

purposes.purposes.

� Access feedback reports via IACS account to track the progress for individuals or

organizations. The feedback reports are available mid-year and end-of-year.

- Individual EPs Feedback Reports - http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/2013-PQRS-

IACS-Feedback-Reports.pdf

- Group Practice Feedback Reports - http://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_IACS-

Organizations_12192012.pdf

� Deadline: 31st March, 2014

Resources:

� 2013 PQRS Registry Reporting Made Simple - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2013_PQRS_SatisfactoryReporting-Registry_041813.pdf

Registry Reporting for Providers

Individual Providers Group Practice(2+ Eligible Professionals)

Self Nominate Via Web by 10/18/2013

Submit at least 3 individual measures for 12 months (1/1/2013 – 12/31/2013)

Self Nomination not required

Submit at least 3 individual measures Submit at least one

Submit data on at least 80% of the groups applicable Medicare Part B

Service Patients

individual measures or at least one group

measure for 12 months

(1/1/2013 – 12/31/2013)

Submit at least one group measure for 6

months (7/1/2013 – 12/31/2013)

OR

Submit data on at least 80% of applicable Medicare Part B Service Patients for Individual Measures

ORSubmit data for at least 20 applicable patients for a

measure group (only a majority [11] patients needs to be Medicare Part B FFS patients)

EHR Based Reporting• Submit data on quality measures directly from your EHR system. You must first determine if it is a PQRS-

qualified EHR product OR via EHR data submission vendor.

� An EHR data submission vendor is an entity that receives and transmits data on PQRS measures from an EHR to CMS. The EHR data submission vendor then submits the PQRS measures data to CMS in the CMS-specified format(s) on the eligible professional’s behalf.

• List of Qualified EHR Vendors and their product version:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013QualifiedEHRDirectVendors.pdf

• List of Qualified EHR Data Submission Vendors

http://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/ 2013QualifiedDSVs_022813.pdf

• Requires satisfactory submission on 80 percent of eligible instances for at least three individual quality measures or report on 3 HITECH core measures + 3 additional HITECH measures if participating in PQRS - EHR Medicare Incentive Pilot

• Successful submission of HITECH data will quality EPs for PQRS incentive and demonstrate meaningful use for the CQM component of Medicare EHR Incentive Pilot – Serve Dual Purpose

Note:


� If the denominator for one or more core measures is 0, substitute one alternate core measure

Reporting Time Period:

� 12 months (1/1/2013 – 12/31/2013)

Resources:

� 2013 PQRS Registry Reporting Made Simple –

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_SatisfactoryReporting-Registry_041813.pdf

EHR Based Reporting (Cont.)

• How to Report:

� Determine your eligibility for EHR based reporting. The following requirements must be met:

� The EHR must have been in use for the entire reporting period (January 1 – December 31, 2013). You may be

able to upgrade to a newer qualified version during the reporting period. Contact your vendor to determine when

the upgrade must occur.

� All eligible encounters for the year must be documented in the EHR, along with all diagnoses, services and

procedure codes. Some measures include SNF, hospital, or other types of visits.

� Data elements must be recorded as structured data in the manner specified by your vendor

� Read and understand the specifications for the selected measures*

� Identify and capture all eligible cases per each measure denominator you choose to report. Review all of the denominator codes that can affect EHR - based reporting to ensure the correct quality action is of the denominator codes that can affect EHR - based reporting to ensure the correct quality action is performed and reported for the eligible case as instructed in the measure specifications.

� If submitting quality measure data directly from your EHR system, register for an Individuals Authorized Access to CMS Computer Services (IACS)* account to submit data to CMS.

*Note: IACS registration is not required if reporting via EHR data submission vendor.

� Work with your PQRS-qualified EHR vendor to create the required reporting files in correct format (QRDA) from your EHR system, so they can be uploaded through the Portal using IACS. If you are using a “qualified” system, it should already be programmed to generate these files.

Data Submission Vendors will create and submit the QRDA files on your behalf

� Deadline - Submit final EHR reporting files with quality measure data, or ensure your EHR data submission vendor submits your files by the data

submission deadline of February 28, 2014.

Group Practice Reporting Option (GPRO)

• A “group practice” under 2013 consists of a single Tax Identification Number (TIN) with 2 or

more EPs who have reassigned their Medicare billing rights to the TIN.

� Benefit:

� Less effort for each EP within the group - one set of quality measures data is

reported on behalf of all EPs within the group

� Larger Incentive Payments – based on all Medicare Part B FFS claims submitted under TIN

� Drawback”

� Unsatisfactorily reporting by GPRO – all EPs would loose incentives

• Group of 2-99 EPs - can elect to report individually or as a group

• Group of 100+ EPs – must report as a group• Group of 100+ EPs – must report as a group

• Reporting Method based on GPRO size :

(All methods requires GPRO to self nominated via web by 10/18/2013)

� 2+ EPs – Registry Reporting

� 25-99 EPs – GPRO Web Interface*

� Report on all measures included in web interface for pre-populated beneficiary sample (218) provided

by CMS

� 100+ EPs – GPRO Web Interface*

� Report on all measures included in web interface for pre-populated beneficiary sample (411) provided

by CMS

Resources:

� GPRO Reporting Made Simple –

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRSGPROMadeSimple_F508_06032013.pdf

Group Practice Reporting Option (GPRO)

• Reporting Time Period: 12 months (1/1/2013 – 12/31/2013)

NOTE

• GPRO does not allow reporting of group measures

• How to Report:� Read and understand the specifications for the chosen measure

� Create an IACS* account and self nominate via PV-PRQS Registration System* . Select Create an IACS* account and self nominate via PV-PRQS Registration System* . Select

method of PQRS reporting in PV-PQRS registration system

� 100+ group should also indicate if they intend to elect “Quality Tiering” for the 2013

Value-Based Modifier

� Determine a Workflow that Assigns each Staff and Provider Specific Responsibilities for

Performing Services and Capturing Data for each of the Measures

� If using an EHR, Use Clinical Decision Support to Identify Eligible

� If reporting via the Web-Based Interface, Complete all Data Fields upon Receipt of the

Assigned Beneficiary Files from CMS and Submit to CMS

� Deadline – Files should se sent during Q1 2014

2013 PQRS Reporting Options to Avoid

Payment Adjustments - Less Stringent Requirements

Meet the requirements for satisfactorily reporting for the

2013 PQRS incentive payment (Individuals or GPRO, as

explained before

Option 1

explained before



Individual EPs: Report at least one valid measure or

measures group via claims, qualified registry, or qualified

EHR

Option 2: Report one valid measure

EHR

GPRO: Report at least one valid measure via qualified

registry or Web-Interface



Individual EPs and GPRO: Elect to participate in CMS-

calculated Administrative Claims and must Register in

Option 3

calculated Administrative Claims and must Register in

the CMS Portal* prior to October 18, 2013

Resources*• List of Eligible Professionals

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-

of-EligibleProfessionals_022813.pdf

• 2013 PQRS Quality Measures List for all Reporting Options

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_IndClaimsRegistry_MeasureSpec_

SupportingDocs_12192012.zip

• 2013 PQRS Individual Claims and Registry Measures List and Specifications

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_IndClaimsRegistry_MeasureSpec_

SupportingDocs_12192012.zip

• PQRS Measure Groups Specifications and Other Supporting Documents

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_MeasuresGroupsSpecs_ReleaseN

otes_SupportingDocs_03042013.zip

• EHR Measure Specifications • EHR Measure Specifications

http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_EHR_Documents_for_Eligible_Professional

s_12192012.zip

• Measure Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2013_PQRS_MeasureApplicabilityValidation_Docs_030413.zip

• IACS Account Registration

https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

• PV – PQRS Registration System

https://portal.cms.gov/wps/portal/unauthportal/home/!ut/p/b1/04_SjzQ0NjAzsDCzMDfWj9CPykssy0xPLMnMz0vM

AfGjzOLdDSDAyN_QzMjA08vF3MMryNHYwN8MqCASqMAAB3A0IKTfzyM_N1U_NyrHAgAE6qj9/dl4/d5/L2dBISE

vZ0FBIS9nQSEh/2

More Useful Resources

• CMS Sponsored PQRS Call


Instruments/PQRS/CMSSponsoredCalls.html

• PQRS Implementation Guide:

Provides guidance on:

� Claims based Reporting

� Measure Selection Consideration

� Understanding measure specifications� Understanding measure specifications

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_Mea

suresList_ImplementationGuide_12192012.zip

• IACS Account and PQRS Portal Webinar by CMS:


Instruments/PQRS/Downloads/2013_PQRS_GPRO_and_ACO_Web_Interface_Sub

mission_IACS.pdf

Give us your Feedback!

http://www.cvent.com/d/t4q9cc

Questions?

Deepika Sharma, BHMS, MHI

952-853-8562

[email protected]

Jerri Hiniker, BSN, RN, CPEHR

952-853-8540

[email protected]

www.stratishealth.org

Stratis Health is a nonprofit organization that leads

collaboration and innovation in health care quality and safety,

and serves as a trusted expert in facilitating improvement for

people and communities.

This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with

the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The

materials do not necessarily reflect CMS policy. 10SOW-MN-C9-13-33 111813