Download PQRS 2013

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PQRS
What
• The quality reporting program for Medicare Part
B (traditional fee for service)
Who
• Eligible providers (PT’s) who bill under the
physician fee schedule (part B)
• Includes private practices
• Excludes facility based providers (SNF, OP
hospital, CORF, etc)
Why
• In 2015, practitioners will receive payment
adjustments (-1.5%) in their Medicare part B
reimbursement if they to not participate in the
program (adjustments will be based on CY2013
data)
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PQRS REPORTING: GETTING
STARTED
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Getting Started
Select
measures
Determine
reporting
method
Educate staff
Audit
success
Begin
reporting
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Getting Started: Measure Selection
• Decide which measures best fit for your
Medicare population
– Choose 3 or more applicable individual
measures OR the group measure
• What conditions do you usually treat?
• What types of care or interventions are provided in
the clinic?
– Information on the measures is under the
2013 PQRS Measure Details section of the
webpage: www.apta.org/PQRS
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Measure Type: Individual vs Group
Individual
Group
# Required for
Successful
Reporting
3 measures per therapist
1 measure per therapist
Measure Focus
Variable
Condition or disease specific
Reporting
Threshold (# of
patients)
No threshold
15+ unique patients per 12 month
reporting period (CY); 8+ per 6
month reporting period
Intent to Report
Code
N/A
Must be reported once per
reporting period per practitioner
Success Rate via
Claims (CY2010)
Individual measures 63%
Group measures 51%
Success Rate via
Registry (CY2010)
Individual measures 87%
Group measures 94%
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Getting Started: Reporting Method
and Participation
• Choose a reporting method
– Claims versus registry
• Talk to you billing provider
• Qualified registries
https://www.cms.gov/PQRS/20_AlternativeReporti
ngMechanisms.asp
• Choose reporting participation
– Individual versus group (GPRO)
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Reporting Method Claims vs
Registry
Claims
Registry
Cost
None
Variable
QDC
Selection
Each practitioners is responsible
for choosing and submitting the
QDC’s
Each practitioners is responsible for
entering data into the registry ;
QDC’s generated based on the data
Updating
Annual measure updates must be
monitored by the facility
Registry monitors and incorporates
annual measure updates
Reporting
Requirements
Data must be submitted on +50%
of all eligible Medicare patients
Data must be submitted on +80% of
all eligible Medicare patients
EHR
N/A
EHR and registry can be linked
Auditing
Each facility must establish an
auditing process to ensure
successful reporting
Registry provides participants with
feedback reports throughout the year
Success Rate
(CY2010 data)
Individual measures 63%
Group measures 51%
Individual measures 87%
Group measures 94%
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Reporting Participation: Individual
vs GPRO
Individual
GPRO
Registration
required
No
Yes
Data analysis
Analyzed at the individual (NPI)
level; looks are the reporting rate
of each professional on the
selected measures
Analyzed at the group (TIN) level;
looks are the cumulative reporting
rate of the group on the selected
measures
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Getting Started: Staff Education
• Educate staff about the measure
specifications and billing procedures
– Create processes that support PQRS
implementation
• Flow charts or algorithms for clinicians
– AMA tool for 2013 updates typically posted by February
http://www.ama-assn.org/ama/pub/physicianresources/clinical-practice-improvement/clinicalquality/physician-quality-reporting-system-2012.page
• Checklists for billing staff
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Getting Started: Auditing Your
Success
• Plan an auditing process to evaluate your
success
– Billing audit for claims submission
• Use billing data and N365 remittance advice code on EOB
– Quality Net quarterly dashboard reports
– Registry feedback reports
– Chart review for content
• Documentation must support the clinical quality action as
indicated by the chosen QDC
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PQRS REPORTING: CASE
EXAMPLES
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PQRS Process
Interim Quarterly
Dashboard
Reports
Final 2013
Feedback
Report- Fall
2014
Source: CMS Open Door Forum 3/22/2011
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Case Example: Individual
Measures
Mrs. S is a new
patient she
presents for her
initial evaluation
on with
adhesive
capsulitis of the
shoulder
The therapist
performs the
initial evaluation
and completes
the measures:
The
administrative
staff submits the
bill for
processing
• Ensure patient
is eligible for the
measure
• Select the
corresponding
G-Code or CPT
II modifier
• Document to
support the
quality activities
• Ensure the
claim is
accepted and
check the EOB
for the N365
remittance
advice code
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Case Example: Measure #130
Percentage of patients aged 18 years and older with a list of current medications (includes
prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements)
documented by the provider, including drug name, dosage, frequency and route
Current Medications with Name,
Dosages, Frequency and Route
Documented
G8427: List of current
medications (includes
prescription, over-thecounter, herbals,
vitamin/mineral/dietary
[nutritional] supplements)
documented by the
provider, including drug
name, dosage, frequency
and route
Current Medications with
Dosages not Documented,
Patient not Eligible
G8430: Provider
documentation that
patient is not
eligible for
medication
assessment
Current Medications with Name,
Dosages, Frequency, Route not
Documented, Reason not
Specified
G8428: Current
medications (includes
prescription, over-thecounter, herbals,
vitamin/mineral/dietary
[nutritional] supplements)
with drug name, dosage,
frequency and route not
documented by the
provider, reason not
specified
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Case Example: Measure #131
Percentage of patients aged 18 years and older with documentation of a pain assessment through
discussion with the patient including the use of a standardized tool(s) on each visit AND
documentation of a follow-up plan when pain is present
Pain Assessment Documented as
Positive
G8730: Pain
assessment
documented as
positive utilizing a
standardized tool AND
a follow-up plan is
documented
Pain Assessment
Documented as Negative,
No Follow-Up Plan Required
G8731: Pain
assessment
documented as
negative, no followup plan required
Patient not Eligible for Pain
Assessment for Documented
Reasons
G8442:
Documentation that
patient is not eligible
for a pain assessment
G8509: Documentation
of positive pain
assessment; no
documentation of a
follow-up plan, reason
not specified
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Case Example: Measure #154
Percentage of patients aged 65 years and older with a history of falls who
had a risk assessment for falls completed within 12 months
Risk Assessment for Falls
Completed
3288F: Falls risk
assessment
documented
AND
1100F: Patient
screened for
future fall risk;
documentation of
two or more falls
in the past year or
any fall with injury
in the past year
Risk Assessment
for Falls not
Completed for
Medical Reasons
3288F with 1P:
Documentation of
medical reason(s)
for not completing
a risk assessment
for falls (i.e.,
reduced mobility,
bed ridden,
immobile, confined
to chair, etc)
AND
1100F: Patient
screened for future
fall risk
If patient is not eligible for
this measure because
patient has documentation
of no falls or only one fall
without injury the past year,
report: Patient not at Risk
for Falls
1101F: Patient
screened for future
fall risk;
documentation of
no falls in the past
year or only one fall
without injury in the
past year
If patient is not
eligible for this
measure
because falls
status is not
documented,
report: Falls
Status not
Documented
1101F with 8P:
No
documentation
of falls status
Risk Assessment
for Falls not
Completed,
Reason not
Specified
3288F with
8P: Falls risk
assessment
not
completed,
reason not
otherwise
specified
AND
1100F:
Patient
screened for
future fall risk
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Case Example: Measure #155
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for
falls documented within 12 months
Plan of Care Documented
Plan of Care not
Documented for Medical
Reasons
0518F: Falls plan of care
documented
0518F with 1P:
Documentation of
medical reason(s) for
no plan of care for
falls
Plan of Care not Documented,
Reason not Specified
0518F with 8P: Plan
of care not
documented, reason
not otherwise
specified
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Case Example: Individual Measures
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Additional Resources
• APTA:
– Case studies
– Podcasts on specific measures
– Successful reporting requirements
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