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Quality
Reporting Now
and in the Future
Heather Smith, PT, MPH
Mandy Frohlich
Future of High Quality Patient Care
Future of Medicare Part B Quality
Reporting
DOPTA
PQRS
FLR
Future reporting
systems
PTPCS
SGR
PAC
Congressional Medicare Payment Reform
What is the Sustainable Growth Rate (SGR)?
• Created in the Balanced Budget Act of 1997
• Payment formula for all outpatient Medicare services
• Intended to ensure that yearly increases match the
growth in GDP
• Flawed formula results in the need for a yearly “doc fix”
Congressional Medicare Payment Reform
What will the SGR be replaced with?
• 5% annual updates through 2018
• Incentive payments starting in 2018 through Merit-
Based Incentive Payment System (MIPS)
• Alternative to MIPS is participation in Alternative
Payment Models
It’s Not Just SGR
Functional Limitation Reporting as Part of
Therapy Cap Reform
• FLR will be reformed and expanded to include additional
variable as identified by the Secretary and stakeholders in
2017 (demographic info, diagnosis, severity, affected body
structures/functions, limitations with ADLs and
participation, functional status, etc)
• Data to be submitted via web-portal or other mechanism
• Data utilized to report to Congress on new payment
system
It’s Not Just SGR
Post-Acute Care Reform
• IMPACT Act Discussion Draft
• Requires standardized patient assessment data
• Reports to Congress based on comparing patient outcome
data to reform payment
• Interest in going to bundles, site neutral payment in the
future
• Protecting Access to Medicare Act of 2014 (H.R. 4302)
• Establishment of a new Value Based Purchasing (VBP) program for
Skilled Nursing Facilities (SNF) based on performance on hospital
readmission measures beginning in 2019. This new program would
provide $2 billion in savings.
Quality Reporting
Today
Future
Separate and distinct reporting programs
(FLR, PQRS, MU, etc.)
One quality program under Medicare Part B
Varied methods of data reporting
Electronic reporting via patient registries
High percentage of process measures
Focus on outcome measures and
patient/family centered measures
Multiple measures of patient function
One measure of global patient function that
crosses the continuum of care
Identification of measure gaps by
government/ national measurement groups
Increasing role of associations in the creation
of meaningful quality measures for
professionals
10
Physical Therapy Outcome Registry
EHR’s
EMR’s
Billing
vendors
Components
PT
Outcome
Registry
Facility
based
practices
Health
systems
Private
practice
clinics
11
Registry: Meeting Compliance Needs
PQRS
Future
Programs
FLR
12
Registry 2014 and Beyond
Minimum
data set
• Core data
elements
• PQRS
• FLR
Modules
• Based on
CPGs
• Tied to
quality
measures
Future
evolutions
• Changing
policy/
payment
• Potential
partnerships
Current Quality Reporting Programs Under Medicare
Healthcare Setting
Quality
Program(s)
Inpatient
(Acute Care Hospitals)
IQR, Readmissions &
VBP
Yes
Yes
P4R & P4P in 2013
Long Term Care Hospitals
(LTCH)
Beginning in 2014
Yes
Yes
P4R Penalty 2%
Inpatient Rehabilitation Facilities
(IRF)
Beginning in 2014
Yes
Yes
P4R Penalty 2%
Skilled Nursing Facilities (SNF)
MDS 3.0
Yes
No
Beginning in 2014
Yes
Yes
P4R Penalty2%
OASIS, HH CAHPS
Yes
Yes
P4R Penalty 2%
PQRS
No, payment
adjustments for nonparticipation beginning in
2015 (based on 2013
data)
Yes P4R Incentive
0.5% through 2014, 1.5% 2015, -2.0% 2016
and beyond
Accountable Care Organizations ACO program
(ACO)
Yes
P4P data performance
tied to shared savings
Functional Limitation Reporting
(FLR)
Yes
Non-compliance =
claims returned unpaid
Hospice
Home Health
Outpatient
Therapy services
provided under Part
B
Mandatory
Reporting
Payment Incentive/
Penalty
PQRS vs Functional Limitation Reporting
Program Detail
PQRS
Functional Limitation Reporting
Program start date
•2007 (incentive program)
•2015 (penalty program)
•January 1, 2013
•July 1, 2013 (non-payment)
Participants
(Medicare Part B)
•Eligible professionals (including PT, OT,
SLP) billing for outpatient physical
therapy services in private practice
settings
•Facility based outpatient practices are
not able to participate
•All practice settings that provide
outpatient therapy services (PT, OT,
and SLP) furnished in all outpatient
settings including facilities
Reporting method
•Claims
•Registry
•Claims
Reporting frequency
•Determined by CPT codes submitted
(Example: 97001, 97002 , 97110,
97140, 97532, several wound care
codes)
•Determined by visit (evaluation,
minimum of every 10th visit, reevaluation, discharge)
Tracking of data
•NPI (provider)
•Beneficiary, NPI/ Tax ID facility,
Service provided (PT, OT, SLP)
Information reported
•Quality Data Code (QDC) G-code
•QDC modifier (1P, 8P)
•Functional limitation G-code
•Therapy modifier
•Severity modifier
PQRS Reporting and Payment
PQRS Program
Reporting Year
Data Year Utilized to
Inform Payment
Incentive/ Penalty
Payment
2013
2013
+0.5%
2014
2014
+0.5%
2015
2013
-1.5%
2016
2014
-2.0%
2017
2015
-2.0%
PQRS Eligible Providers
• In 2014, eligible providers who bill under the
physician fee schedule (includes PTs in private
practice) can receive a bonus payment of 0.5% if
they report on quality measures
• Rehab agencies, outpatient hospitals, SNFs Part B unable to
participate in PQRS; use UB-92 (UB-04) or 837I for billing to
intermediary
• No place on claim form for individual NPI
PQRS
• Major changes to the reporting system for 2014
• 2 successful reporting thresholds established:
• Eligible for 0.5% 2014 bonus AND avoid -2.0% 2016 penalty
• Avoid the -2.0% 2016 penalty ONLY
• Can choose not to participate and take the -2.0% 2016 penalty
• Major changes to available measures, reporting mechanisms for
measures, and measure details
Should I participate in PQRS
in 2014 ?
Yes- I want qualify for
the bonus and avoid the
penalty
Report via claims
Report all available
individual measures (6
or 7*)
Select 9 individual
measures (or if less
available 1-8)
Report via registry
Report one measures
group
Report via claims
Yes – I want to avoid
the penalty
Select 3 individual
measures
Select 3 individual
measures
Report via registry
No – I will take the 2.0% penalty in 2016
Report one measures
group
Should I participate in PQRS
in 2014 ?
Report via claims
I want qualify for the
bonus 0.5% bonus in
2014 AND avoid the 2.0% penalty in 2016
Report via registry
Report all available
individual measures
(128, 130, 131, 154,
155, 182, and 245*)
Select 9 individual
measures (or if less
available 1-8)
Need to confirm with
your registry which
measures are available
Report one measures
group
(Back pain: 148-151)
* Providers will report all applicable measures; however, the chronic wound
care measure may not apply to all clinics
Should I participate in PQRS
in 2014 ?
Report via claims
I ONLY want to avoid
the -2.0% penalty in
2016
Report via registry
Select 3 individual
measures
(may choose from: 128,
130, 131, 154*, 155*,
182, or 245)
Select 3 individual
measures
(select 3 of the
individual measures
offered by your registry)
Report one measures
group
(Back pain)
* Providers who choose to report 154 must also select 155 as these measures
are paired; they count as two individual measures but 154 triggers 155
2014 Individual Measures for PTs
#
Measure Description
Claims
Registry
126
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral
Neuropathy: Neurological Evaluation
X
127
Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention
Evaluation of Footwear
X
128
Preventive Care and Screening: Body Mass Index (BMI) Screening and
Follow-up
X
X
130
Documentation and Verification of Current Medications in the Medical X
Record
X
131
Pain Assessment Prior to Initiation of Patient Treatment
X
X
154
Falls: Risk Assessment
X
X
155
Falls: Plan of Care
X
X
182
Functional Outcome Assessment
X
X
245
Use of Wound Surface Culture Technique in Patients with Chronic Skin
Ulcers (Overuse Measure)
X
X
2014 Individual Measures for PT’s
#
Measure Description
Claims
Registry
217
Change in Risk-Adjusted Functional Status for Patients with Knee
Impairments
X
218
Change in Risk-Adjusted Functional Status for Patients with Hip
Impairments
X
219
Change in Risk-Adjusted Functional Status for Patients with Lower Leg,
Foot or Ankle Impairments
X
220
Change in Risk-Adjusted Functional Status for Patients with Lumbar
Spine Impairments
X
221
Change in Risk-Adjusted Functional Status for Patients with Shoulder
Impairments
X
222
Change in Risk-Adjusted Functional Status for Patients with Elbow,
Wrist, or Hand Impairments
X
223
Change in Risk-Adjusted Functional Status for Patients with a
Functional Deficit of the Neck, Cranium, Mandible, Thoracic Spine,
Ribs, or other General Orthopedic Impairment
X
2014: Measures Group for PTs
•
Group Back Pain Measure
• Must report all 4 measures in the group; may not
be reported individually
#
Measure Description
Claims Registry
148
Back Pain: Initial Visit
X
149
Back Pain: Physical Exam
X
150
Back Pain: Advice for Normal Activities
X
151
Back Pain: Advice Against Bed Rest
X
PQRS Measure Changes for 2014
Measure
Number
Measure Title
Changes
Details
126 &
127
Diabetes Measures
Registry reporting
only in 2014
The diabetes measures (126 & 127)
will not be reportable via claimsbased reporting in 2014
130
Current
Medications
Reporting every visit
for 97001, 97002
AND 97110, 97140,
97532
Therapists must now report this
measure when billing 97110,
97140, AND 97532 in addition to
97001 and 97002
131
Pain Assessment
Reporting every visit
for 97001, 97002
AND 97532;
measure updated
Therapists must now report this
measure when billing 97001,
97002, AND 97532
148-151
Back Pain
Measures Group
Registry reporting
only in 2014
The back pain measures group
(148-151) will not be reportable via
claims-based reporting in 2014
Please review all 2014 measure specifications in detail for your clinic’s selected measures to
ensure that you are up to date with the current measures requirements
PQRS Measure Changes for 2014
Measure
Number
Measure Title
Changes
Details
155
Falls Plan of Care
Change in
instructions and
numerator definitions
Consideration of Vitamin D
supplementation and balance,
strength, and gait training
182
Functional
Outcome
Assessment
Change in numerator
definitions AND
addition of new
numerator code
G9227: Functional outcome
assessment documented, care plan
not documented, documentation the
patient is not eligible for a care plan
246
Chronic Wound
Care (Wet to Dry
Dressing)
Removal of 97001
and 97002 from
numerator
Therapists cannot report this
measure in 2014; 97001 and 97002
removed from measure numerator
definition
321
Participation in
Systematic Clinical
Database Registry
Measure removed
from program
This measure will be removed from
the PQRS program in 2014
Please review all 2014 measure specifications in detail for your clinic’s selected measures to
ensure that you are up to date with the current measures requirements
PT Measures and National Quality
Strategy Domains
Communication an care
coordination
• Falls plan of care (#155)
• Functional assessment (#182)
• FOTO measures (#217-223)
Community / population
health
• BMI screening (#128)
• Pain assessment (#131)
Efficiency and cost
reduction
Safety
Effective clinical care
Person- and caregivercentered experience and
outcomes
• Back pain measures group (#148)
• Medication verification (#130)
• Falls risk (#154)
• Diabetes measures (#126 &127)
• Back pain measures group (#149-151)
• Chronic wound measure (#245)
• N/A
PQRS 2014 Challenges
Challenges
Confusion about the number of measures
to submit in 2014
Resources
•
www.apta.org/pqrs
• Reporting Requirements for 2014
• Podcast: PQRS 2014 Summary of
Changes
Unsure about where to find data collection
forms for claims- based submission in 2014
•
2014 Data Collections Sheets
Looking for measure updates for 2014
•
•
•
2014 PQRS Group Measures
2014 PQRS Individual Measures
Claims Measures Quick Reference
Guide
2014 Podcasts
•
Unsure of how to handle measure #130
•
Podcast: Measure Specifications
for Measure 130: Documentation of
Current Medications
Future Trends PQRS
• Move to 9 measures for successful reporting
• Elimination of claims-based data submission
• Increased use of registry and EHR reporting
• Elimination of claims-based reporting 2017?
PQRS Resources
• APTA: Quality Resources
http://www.apta.org/PQRS
• CMS- PQRS page
https://www.cms.gov/PQRS/
• Quality Net (general questions or feedback reports)
https://www.qualitynet.org/
866 288 8912 (option #1, then #7)
Functional Limitation Reporting (FLR)
Middle Class Tax
Relief Act of 2012
February 2012
Congress mandates
CMS to collect
functional info on
Medicare
beneficiaries
receiving therapy
services under Part
B
FLR Ongoing
February 2014
Medicare
continues to
work through
system
modifications;
anticipating
future
evolutions of
FLR
FLR
Implementation
January 1, 2013
Testing phase
begins for the
collection of
functional data
Final Physician
Fee Schedule
Rule
November 2012
Outlines the
regulations around
the new claimsbased reporting
program for
therapy services
FLR Payment
Adjustment Phase
October 1, 2013
Originally slatted for
July 1, 2013 this
was delayed until
October 1; providers
began reporting
processing issues in
mid November
From Law to Implementation
Legislative
Congress
MCTRA
Regulations/
Guidelines
CMS
2012 Final Physician
Fee Schedule, FAQs,
MLN Matters
Implementation
Medicare
Administrative
Contractors
NGS
CGS
Novitas
Palmetto
Cahaba
First
Coast
APTA
resources
WPS
Noridan
FLR: Continuing to Evolve
Tracking of FLR Episode
• FLR tracking:
• per beneficiary,
• per therapy discipline, and
• per billing provider NPI
• (ie, per facility or practice, as
identified by National Provider
Identification or tax
identification).
Beneficiary
(HIC#)
Discipline
(PT, OT,
SLP)
Facility
(Tax ID or
NPI)
Discharge of FLR Episode
Formal DC
appointment
Unanticipated DC
Submit
Gcodes- DC
and goal
No codes submitted
Medicare DCs episode
60 calendar days from
the last recorded date
of service
Patient returns to therapy within 60 calendar days of
last recorded date of service
If same issue/
limitation, continue
reporting on that
limitation
If new issue/ limitation DC
original primary and report
on subsequent (DC
original on visit 1 and
begin reporting of new
primary on visit 2
Return to Therapy within 60 Days
• Therapist must decide if
• The patient is returning for the
same issue/ primary limitation
(carry, moving and handling
objects) OR
• There is a new primary
limitation associated with a
new diagnosis (changing and
maintaining body position)*
Determine primary
functional limitation
Carrying, moving
and handling
objects (original
diagnosis)
Changing and
maintaining body
position (new
diagnosis)
* If the therapist determines that there is a new primary functional limitation, the he/she would end
reporting on primary functional limitation for the previous episode (carry, moving and handling objects)
and begin reporting on the new primary limitation on visit 2.
Return to Therapy After 45 Day Absence
Initial Evaluation
Visit
1/6/2014
G8984 CK GP*
G8985 CI GP
6th visit
(Unanticipated
DC)
1/23/2014
No codes
submitted;
unanticipated
1st Visit
(Returns
(Returns
with
with
new
same
DX)DX)
2/12/2104
2nd Visit
(Begin reporting
subsequent)
G8984 CJ GP
G8985 CI GP
G8986 CI GP
G8981 CJ GP*
G8982 CI GP
*Carrying, moving, and handling objects
**Changing and maintaining body position
Multiple Diagnoses and POCs
• FLR must occur for every beneficiary being seen by each
discipline in a given facility/ practice
• Two plans of care can exist concurrently for a beneficiary
being seen with two different diagnoses by two different
referring physicians
• Two plans can be combined into a single plan of care if one of the
two referring physician is willing to certify the POC
Multiple Plans of Care
Same Facility or Practice
Different Facility or
Practice
Different discipline
Multiple POC
Same discipline
Multiple POC
Same discipline
Multiple POC
Each therapist identifies
primary limitation for their
POC
Therapists coordinate and
identify one primary limitation
to be reported under one
POC
Each therapist identifies a
primary limitation for the POC
Treatment days for both
conditions are counted towards
the reporting frequency –each
treatment day counts towards
the total number of days the
beneficiary received services,
under both POCs. Note: It
counts as one treatment day
when services are received on
the same date of service under
both POCs
FLR with Addition of Second Diagnosis to
POC
New DX for
active POC
FLR Coding
Ongoing
reporting
Therapist performs
evaluative
procedure
Limitation
associated with
new DX is different:
submit 3 Gcodes
(like one time visit)
Can submit updated
current and goal
status on day of
evaluative
procedure; restart
count
Can choose to
end reporting on
primary and begin
reporting on new
limitation for
second DX on the
next visit
Limitation is same
as primary; revise
POC and report
current and goal
codes
Ongoing reporting
continues; count
restarts
Addition of Second DX to an Active POC
Initial
Evaluation Visit
Re-evaluation
(6th Visit)*
G8984 CK GP
G8984 CJ GP
G8985 CI GP
G8985 CI GP
14th Visit
(End reporting
primary)
15th Visit
(Begin
reporting
subsequent)
D/C Visit
G8985 CI GP
G8986 CI GP
G8981 CJ GP
G8981 CJ GP
G8982 CI GP
G8982 CI GP
G8983 CJ GP
G8982 CI GP
G8983 CI GP
* Count does not restart when billing only the 3 Gcodes; must submit updated data on primary limitation to
restart count
PTA and FLR
• Special exceptions in which a PTA may report Gcodes as
determined by the PT:
• Reporting of a new, subsequent functional limitation (PT ended
reporting of primary limitation and determined Gcodes for
subsequent limitation on previous visit)
• Discharge anticipated within 3 treatment days of the progress
report (PT determined Gcodes on date of progress report)
Unique Clinical Situations
Clinical Situation
FLR: No
FLR: Yes
Comment
Observation status
X
Emergency department
X
Short procedure stay
X
Typically billed under Medicare part
B
Re-billing under part B
X
Re-billing a denied part A acute
care stay under part B subject to
FLR
DME billing
X
Once pt admitted, typically
converted to part A; FLR not
required if billing under part A
FLR required for all therapy
services associated with the
always and sometimes therapy
code list*. Also includes CPT
codes for “Application of Casts and
Strapping”, as clinically applicable
*http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html
Resources for Ongoing Guidance
Challenges
Strategies
Tracking of FLR episode, including
discharge of episodes
• Podcast on discharge reporting
• Report D/C G-codes in charts even
if you do not submit the data
Multiple diagnoses and plans of care
(POC)**
• Case scenarios
• Podcast on mult. dx and POC
Role of PTA in FLR
• Podcast on PTA and FLR
Unique clinical situations: observation
status patients, re-billing
• FAQ documents
• Podcast observation status
Current status of claims and FLR
•
•
•
•
FAQ documents
Claim form examples
Case scenarios
PTNow
Current Status of Claims and FLR
• National implementation delayed until October 1, 2013
• Systems issues
• Claims splitting
• Delayed/ out of sequence processing
• Incorrect visit counts
• Required reporting at 10th/20th/etc despite early reporting
• Problems with 60 day discharge
• Issues with 3Gcode submission with an active POC
• New FLR complaint form
• Data being shared with Medicare staff weekly
45
Complaints by Month/ Year
Month
Year
Number of
Complaints
October
2013
3
November
2013
7
December
2013
3
January
2014
15
February
2014
42*
March
2014
89**
* Standardized data collection implemented
** Data complete thru 3/25/2014
46
FLR: % of Complaints by MAC
1%
8%
8%
6%
14%
Cahaba
9%
CGS
NGS
Noridian
Novitas
Palmetto
19%
35%
WPS
First Coast
47
FLR: Number of Complaints by Type and
32
MAC
30
24
22
20
15
12
6
3
2
3 2423
1
1
Cahaba
6
NGS
8
Novitas
7
11
8
5
1314
45 5
Palmetto
6
2
4
9
6
2
WPS
4
2
44
1
Noridian
4
1
CGS
2
2
First Coast
Count of Count discrepancy
Count of October 1 restart
Count of Delayed payment
Count of Claims Splitting
Count of Processing out of order
Count of Other
Simple FLR Coding Errors
• Common issues that may cause claims to be returned
unpaid:
• Use of $0.00 instead of $0.01
• Leaving off the GP or severity modifiers
• Incorrect submission of Gcodes
• Changing categories mid episode
• Submission of wrong Gcode (discharge vs current)
• Claims splitting
• Recommend placing FLR codes as line items directly after procedural
codes
APTA Functional Limitation Resources
• http://www.apta.org/FLR
• Resources include:
• FAQ documents
• Case scenarios
• Webinar
• Discussion forum
• Toolkit
• CMS links
• PTNow (other tests and measure information)
http://www.ptnow.org/FLR/Tests
Questions
[email protected]
OR
800-999-2782 ext 8511