Download the slides. - Vermont Information Technology Leaders

The Centers for Medicare & Medicaid Services
Vermont Information
Technology Leaders
PQRS, eRx and Enrollment Revalidation Webinar
September 13, 2011
Andy Finnegan
Division of Medicare Financial Management
Fee For Service Operations
CMS RO1
PQRS, eRx and Enrollment Revalidation Webinar
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This presentation was current at the time it was published or uploaded onto the web.
Medicare policy changes frequently so links to the source documents have been provided
within the document for your reference.
This presentation was prepared as a tool to assist providers and is not intended to grant
rights or impose obligations. Although every reasonable effort has been made to assure
the accuracy of the information within these pages, the ultimate responsibility for the
correct submission of claims and response to any remittance advice lies with the provider
of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents,
and staff make no representation, warranty, or guarantee that this compilation of Medicare
information is error-free and will bear no responsibility or liability for the results or
consequences of the use of this guide. This publication is a general summary that explains
certain aspects of the Medicare Program, but is not a legal document. The official
Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a
registered trademark of the American Medical Association. Applicable FARS\DFARS
Restrictions Apply to Government Use. Fee schedules, relative value units, conversion
factors and/or related components are not assigned by the AMA, are not part of CPT, and
the AMA is not recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data contained
or not contained herein
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PQRS, eRx and Enrollment Revalidation Webinar
2010 Incentive Payments: Distribution
Available this late summer/fall
eRx: August–September
PQRI: September–October
Paid as lump-sum to the Taxpayer Identification Number (TIN)
under which the eligible professional’s claims were submitted
or to the GPRO TINTIN decides distribution within practice
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Electronic Remittance Advice (RA)For
eligible professionals receiving 2010
eRx/PQRI incentive payments in 2011:
LE indicator appears instead of LS
4-digit code indicates incentive type/reporting
year
2010 eRx = RX10
2010 PQRI = PQ10
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eRx…It’s not too late to start participating in the 2011 Electronic
Prescribing (eRx) Incentive Program and potentially qualify to receive
a full-year incentive payment
Eligible professionals may begin reporting eRx at any time
throughout the 2011 program year (January 1-December 31, 2011) to
be incentive eligible
eRx is a separate incentive program from Physician Quality
Reporting, with different reporting requirements To successfully
meet reporting criteria and be considered incentive eligible,
individual eligible professionals must report the eRx measure at
least 25 times(for eligible patient encounters) and
Medicare Part B PFS allowed charges for services in the eRx
measure’s denominator must be comprised of 10%or more of the
eligible professional’s total 2011 estimated allowed charges
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PQRS, eRx and Enrollment Revalidation Webinar
• Determine whether or not you are
eligible to participate in the program. A
list of professionals who are eligible
and able to receive an incentive for
participating the eRx Incentive
Program is available on the CMS eRx
website at: http://www.cms.gov/ERXincentive
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• Review the 2011 eRx Measure
Specification, which is available as a
downloadable document in the eRx
Measure section of the CMS eRx
website, to determine if this measure
applies to your practice
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Determine if your practice has the resources needed to participate: Do
you have a “qualified” eRx system/program that is being used routinely?
Generates a complete active medication list incorporating electronic data
received from applicable pharmacies and pharmacy benefit managers
(PBMs), if available
Selects medications, prints prescriptions, electronically transmits
prescriptions, and conducts all alerts (defined below)
Provides information related to lower-cost, therapeutically appropriate
alternatives, if any (the availability of an eRx system to receive tiered
formulary information would meet this requirement for 2010)
Provides information on formulary or tiered formulary medications, patient
eligibility, and authorization requirements received electronically from the
patient’s drug plan, if available
Note: All functionalities must be enabled
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 Do you expect your Medicare Part B PFS charges for the
codes in the denominator of the measure (listed below) to
make up at least 10% of your total Medicare Part B PFS
allowed charges for 2011?Current Procedural Terminology
(CPT) or Healthcare Common Procedure Coding System
(HCPCS) G-codes:90801, 90802, 90804, 90805, 90806,
90807, 90808, 90809, 90862, 92002, 92004, 92012,
92014, 96150, 96151, 96152, 99201, 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214, 99215,
99304, 99305, 99306, 99307, 99308, 99309, 99310,
99315, 99316, 99324, 99325, 99326, 99327, 99328,
99334, 99335, 99336, 99337, 99341, 99342, 99343,
99345, 99347, 99348, 99349, 99350, G0101, G0108,
G0109
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PQRS, eRx and Enrollment Revalidation Webinar
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Once you have decided to participate in the 2011 eRx
Incentive Program, follow these steps when reporting the
measure:
Bill one of the CPT or HCPCS G-codes noted on slide 10 for
the patient you are seeing
 Report the following G-code (or numerator code) on the
claim form that is submitted for the Medicare patient visit:
G8553 -At least one prescription created during the
encounter was generated and transmitted electronically
using a qualified eRx system
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Electronically generated refills not associated with
an eligible patient visit do not count and faxes do not
qualify as eRx
New prescriptions not associated with a code in
the denominator of the measure specification are
not accepted as an eligible patient visit and do not
count toward the minimum 25 unique eRx events
If multiple prescriptions are electronically
prescribed at one eligible patient visit, this only
counts as one eRx event
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An eligible professional will not be subject to the 2012
payment adjustment if one of the following applies:
• The eligible professional is not a physician (MD, DO, or
podiatrist), nurse practitioner, or physician assistant as of June
30, 2011 (This determination is based on the primary
taxonomy code in the National Plan and Provider Enumeration
System (NPPES)) and does not generally have prescribing
privileges, and reports g-code G8644 (defined as not having
prescribing privileges) at least one time on an eligible claim
prior to June 30, 2011;
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The eligible professional does not have at least 100
cases containing an encounter code in the
electronic prescribing measure’s denominator;
The eligible professional’s allowed charges for
covered professional services submitted for the
electronic prescribing measure’s denominator codes
is less than 10 percent of the eligible professional’s
total 2011 Medicare Part B PFS allowed charges;
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The eligible professional reports a significant hardship code
and CMS determines that the hardship code applies and is
granted an exemption; OR
• The eligible professional becomes a successful electronic
prescriber for purposes of the 2012 payment adjustment by
reporting the electronic prescribing measure via claims for at
least 10 unique electronic prescribing events for patients in the
denominator of the measure between January 1, 2011 and
June 30, 2011
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A group practice that is participating in the 2011
eRx group practice reporting option will not be
subject to the 2012 payment adjustment if one of
the following applies:
• The group practice reports a significant hardship in
its 2011 self-nomination letter for participation in the
eRx Incentive Program group practice reporting
option and is granted an exemption;
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The group practice becomes a successful electronic
prescriber. The group practice becomes a
successful electronic prescriber for purposes of the
2012 payment adjustment by reporting the
electronic prescribing measure via claims for
between 75-2,500 unique electronic prescribing
events (depending on the group practice size) for
patients in the denominator of the measure between
January 1, 2011 and June 30, 2011.
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Significant Hardship Exemptions. Section
1848(a)(5)(B) of the Act provides that the Secretary
may, on a case-by-case basis, exempt an eligible
professional from the payment adjustment, if the
Secretary determines, subject to annual renewal,
that compliance with the requirement for being a
successful electronic prescriber would result in a
significant hardship.
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In the CY 2011 MPFS Final Rule, CMS established
the following two significant hardship exemptions in
the form of g-codes for purposes of the 2012
payment adjustment:
• The eligible professional practices in a rural area
without sufficient high speed internet access (report
code G8642)
• The eligible professional practices in an area
without sufficient available pharmacies for electronic
prescribing (report code G8643)
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Changes to the Medicare eRx Incentive Program
for Calendar Year 2011
Since publication of the 2011 MPFS Final Rule,
CMS has received public comments raising
concerns that the Medicare eRx Incentive program
did not better align with the Medicare or
Medicaid EHR Incentive Program as well as the
need for additional significant hardship exemption
categories. To address these concerns the following
changes have been finalized:
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Modify the existing 2011 electronic prescribing
measure to address uncertainties related to the
technological requirements of the Medicare eRx
Incentive Program: The existing 2011 electronic
prescribing measure is revised to indicate that a
qualified electronic prescribing system includes
certified EHR technology as defined at 42 CFR
495.4 and 45 CFR 170.102
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Provide additional significant hardship exemption
categories for purposes of the 2012 payment adjustment:
The eligible professional or group practice must
demonstrate that one of these situations applies to the
respective practice:
Eligible professionals who register to participate in the
Medicare or Medicaid EHR Incentive Programs and adopt
certified EHR technology;
Inability to electronically prescribe due to local, state, or federal
law or regulation;
Limited prescribing activity; or
Insufficient opportunities to report the electronic prescribing
measure.
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• Extend the deadline for requesting
significant hardship exemptions to
November 1, 2011. This extended reporting
deadline would apply to the two significant
hardship exemptions established in the CY
2011 MPFS Final Rule as well as the
additional significant hardship exemption
categories above.
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Require submission of significant hardship
exemption requests for the 2012 eRx payment
adjustment via a web-based tool for individual
eligible professionals and via a mailed letter for
group practices that are participating in the 2011
eRx group practice reporting option. Instructions on
how to request a hardship via the web-based tool will be
available on the eRx Incentive Program website at
http://www.cms.gov/ERXincentive
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• IT’S NOT TOO LATE FOR 2011
PHYSICIAN QUALITY REPORTING
SYSTEM
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2011 1% incentive payment
Reporting mechanisms for individual eligible professionals
Claims
Qualified registry
Qualified EHR
Reporting periods for individual eligible professionals12 months:
January 1–December 31, 2011
6 months: July 1-December 31, 2011 (claims and registry-based
reporting only)
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Individual eligible professionals may report individual Physician
Quality Reporting System measures or measures groups
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Affordable Care Act (ACA) (Section 10331, March 2010) Provides Physician
Quality Reporting incentives through 2014 and added PFS reductions starting in
2015Authorized incentive payment amounts for each program year2007 –1.5%
subject to a cap
2008 –1.5%
2009, 2010 –2.0%
2011 –1%
2012, 2013, 2014 –0.5%
Authorized payment adjustment to fee schedule amount beginning in 2015 for
those who do not satisfactorily report2015 –98.5%
2016 and subsequent years –98.0%
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Supports public reporting of quality data
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It’s not too late to start participating in 2011 Physician Quality Reporting and potentially
qualify to receive an incentive payment
A new 6-month reporting period began on July 1
You can begin reporting data for July 1-December 31, 2011 using any of these 4 options
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Claims-based reporting of individual measures (6 months) –report 50% or more of
applicable Medicare Part B FFS patients on at least 3 individual measures OR on
each measure if less than 3 measures apply to the eligible professional
Claims-based reporting of one measures group for 50% or more of applicable
Medicare Part B FFS patients of each eligible professional (with a minimum of 8
patients) (6 months)
Registry-based reporting of at least 3 individual Physician Quality Reporting
measures for 80% or more of applicable Medicare Part B FFS patients of each
eligible professional (6 months)
Registry-based reporting of one measures group for 80% or more of applicable
Medicare Part B FFS patients of each eligible professional (with a minimum of 8
patients) (6 months)
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Other :
Several patient-level measures in the program only need to be
reported once per patient per reporting period
Find an applicable measures group that could be reported via
registry for a potential 12-month incentive (registry-based
reporting of 1 measures group for 30 patients)
See 2011 Physician Quality Reporting System Measures List and
2011Implementation Guide –Decision Tree (Appendix C) for specifics
List of qualified registries is posted on CMS
websitehttp://www.cms.gov/PQRS/20_AlternativeReportingMechanisms
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Eligible professionals can choose whether to report individual
quality measures or a group of related measures (aka
“measures groups”)
194 individual measures, including 44 registry-only measures,
20measures for EHR-based reporting, and 20 new measures
14 measures groups: Diabetes Mellitus, CKD, Preventive
Care, CABG, Rheumatoid Arthritis, Perioperative Care, Back
Pain, CAD, HF, IVD, Hepatitis C, HIV/AIDS, CAP, and Asthma
(new) Registry-only includes: CABG, CAD, HF, & HIV/AIDS
Back Pain measures group are reportable as a measures
group only
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When reviewing the measure specifications and reporting instructions
for individual measures and measures groups, notice that each
measure has a QDC (which consists of a Current Procedural
Terminology [CPT] II code or a G-code) associated with it Note that
several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and
the 8P reporting modifier
Only allowable CPT II modifiers may be used with a CPT II code
Eligible professionals should use the 8P modifier judiciously for
applicable measures and measures groups they have selected to
report8P modifier may not be used indiscriminately in an attempt to
meet satisfactorily reporting criteria without regard to meeting quality
improvement goals
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Reporting QDCs for Physician Quality Reporting measures
CPT Category II code(s) and/or G-code(s), which supply the
numerator, must be reported:
on the same claim as the denominator billing code(s)
for the same beneficiary
by the same Eligible Professionals (individual National Provider
Identifier or NPI) who performed the covered service as the
payment codes, usually ICD-9-CM, CPT Category I or HCPCS
codes, which supply the denominator
for the same date of service (DOS)
Claims can not be re-submitted just to add QDCs
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Determine if you are eligible to participate See http://www.cms.gov/PQRS> Overview >
Downloads
Review the 2011 Physician Quality Reporting System Measures List, and determine
which measures apply to practice To help select measures, search for billed codes:
Single Source Master Code Table(claims/registry for individual measures)
Understand the measures and how to report them!
Claims processed by the Carrier/MAC must reach the national Medicare claims
system data warehouse (National Claims History file) by February 24, 2012
to be included in the analysis Claims for services furnished toward the end
of the reporting period should be filed promptly.
Review RA notices from Carrier/MAC to ensure receipt of N365 remark code for
each QDC submitted N365 indicates, "This procedure code is not payable. It is for
reporting/information purposes only.
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If reporting using claims, ensure billing software and clearinghouse can capture all the codes and associated modifiers used
in Physician Quality Reporting for the measures selected
Discuss with vendors if applicable
Submitted charge field cannot be left blank (use $0.00 if able or a
nominal amount such as a penny)
Review reporting principles (if using claims) and specifications for
each measure or measures group selected
Begin reporting on appropriate Medicare Part B FFS patients via
CMS-1500 form or electronically
Or, submit through a qualified registry (work with registry on specifics)
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CMS Physician Quality Reporting
websitehttp://www.cms.gov/PQRS
CMS eRx Incentive Program website
http://www.cms.gov/ERxIncentive
2012 PFS Proposed
Rulehttp://www.ofr.gov/OFRUpload/OFRData/2011-16972_PI.pdf
eRx Proposed Rule
http://www.cms.gov/ERxIncentive/04_Statute_Regulations.asp>
Downloads or directly at http://www.gpo.gov/fdsys/pkg/FR-201106-01/pdf/2011-13463.pdf
Frequently Asked Questions
Medicare and Medicaid EHR Incentive Programs
http://www.cms.gov/EHRIncentivePrograms
Physician Compare
http://www.medicare.gov/find-a-doctor/provider-search.aspx
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QualityNet Help Desk: Portal password issues
PQRI/eRx feedback report availability and access
IACS registration questions
IACS login issues
Program and measure-specific questions
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866-288-8912 (TTY 877-715-6222)
7:00 a.m.–7:00 p.m. CST M-F or [email protected]
You will be asked to provide basic information such as name, practice, address, phone, and
e-mail
Provider Contact Center: Questions on status of 2010 eRx/PQRI incentive payment
(during distribution timeframe)
See Contact Center Directory at
http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip
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EHR-ARRA Information Center:
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888-734-6433 (TTY 888-734-6563)
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Common pitfalls with Physician Quality Reporting
Missing your eligible population
Reporting incorrect information Using incorrect specifications
Quality-data codes
Individual National Provider Identification numbers
Missing the reporting frequency
Confusing with other CMS programs (Meaningful Use)
Knowing who to call for help
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Enrollment Revalidation
Section 6401 (a) of the Affordable Care Act
established a requirement for all enrolled providers
and suppliers to revalidate their enrollment
information under new enrollment screening criteria.
This revalidation effort applies to those providers
and suppliers that were enrolled prior to March 25,
2011.
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Newly enrolled providers and suppliers that
submitted their enrollment applications to
CMS on or after March 25, 2011, are not
impacted. Between now and March 23,
2013, MACs will send out notices on a
regular basis to begin the revalidation
process
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Providers and suppliers must wait to
submit the revalidation only after being
asked by their MAC to do so.
The most efficient way to submit your
revalidation information is by using the
Internet-based PECOS.
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All institutional providers and suppliers who respond
to a revalidation request must submit an enrollment
fee via Pay.Gov (reference 42 CFR 424.514). You
may submit your fee by electronic check, debit, or
credit card. Revalidations are processed only when
fees have cleared. To pay your application fee, go to
http://www.pay.gov and type “CMS” in the
search box under Find Public Forms, and click
the GO button. Click on the CMS Medicare
Application Fee link.
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Upon receipt of the revalidation request,
providers and suppliers have 60 days from
the date of the letter to submit complete
enrollment forms.
Failure to submit the enrollment forms as
requested may result in the deactivation
of your Medicare billing privileges.
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When you receive notification from your MAC to
revalidate:
1. Update your enrollment through Internet-based
Provider Enrollment, Chain and Ownership System
(PECOS) or complete the 855;
2. Sign the certification statement on the application;
3. If applicable, pay your fee thru pay.gov; and
4. Mail your supporting documents and certification
statement to your MAC.
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Questions?
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