Download PQRS and You 2014 http://www.cms.gov/Medicare/Quality

PQRS and You 2014
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/pqrs/index.html
ABOUT PQRS
PQRS is a reporting program, mandated by federal legislation that uses a combination of
incentive payments and payment adjustments to promote reporting of quality information
by eligible professionals (EP’s).
The program provides an incentive payment to practices with EPs (identified on claims by
their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]).
EPs satisfactorily report data on quality measures for covered Physician Fee Schedule
(PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries
(including Railroad Retirement Board and Medicare Secondary Payer).
Beginning in 2015, the program also applies a payment adjustment to EPs who do not
satisfactorily report data on quality measures for covered professional services.
How long do I have to Report?
You have two options for how long you report.

1 year period (January 1st - December 31st)

6 month period (July 1st – December 31st)
Which one you choose may depend on how long you have been on Falcon Physician and
whether you plan on reporting via group or individual measures (more information
below).
Do I have to Sign Up

No upfront registration is required.

Falcon will communicate with EP’s in the late summer/early Fall to determine if
they would like to consent to have their PQRS data submitted on their behalf by
Falcon.

Falcon is considered a certified registry and we submit data via the registry method.
What is the Incentive?
Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures
data for services furnished during the 2014 reporting period will qualify to earn an
incentive payment. If they qualify, they will receive an incentive payment equal to 0.5% of
their total estimated Medicare Part B PFS allowed charges for covered professional
services furnished during that same reporting period.
What is the Penalty/ Payment Adjustment?
EPs who do not satisfactorily report data on quality measures for covered professional
services during the 2014 PQRS program year will be subject to a 2% payment adjustment
to their Medicare PFS amount for services provided in 2016.
What do I have to report?
You have two options for what you report:
Individual Measures:
For the 12 month reporting period, choose at least none (9) measures from all of the
individual measures that Falcon EHR offers.
Group Measures:
For the 6 or 12 month reporting period, choose the CKD measure group. Report all
measures in the group.
Falcon has chosen measures from each of these categories that are applicable to
Nephrologists and made it easy for you to report directly on the Superbill. You do not need
to decide in advance whether you will be reporting the group or individual measures.
Reporting Individual Measures
You must have at least one patient “meet performance” or be in the numerator of the
measure.
Reporting CKD Group Measures
Instead of picking and choosing measures, you can instead choose to select the CKD
measure group. You have a couple of options in regards to reporting.
If you are reporting for the 1-year or the 6-month period:
• Report on minimum of 20 unique sample patients (11 of which need to be Medicare Part
B patients) (Same 20 patients in the denominator for each measure)
The CKD measure group consists of:
How do I report the measures?
Falcon is a certified registry for reporting PQRS so Falcon Physician will assist you at the
beginning of 2015 to collect the appropriate measure data for 2014 PQRS from the Falcon
Physician system and format properly and submit to the registry by the stated deadline.
In order to indicate which measures you are meeting for each patient visit during the
reporting period, simply check the appropriate checkboxes on the Falcon Physician
Superbill for that visit.
If you choose not to use the Superbill then the applicable CPT codes will need to be entered
into the encounter note in the Procedures section to record the measure criteria was met.
Medicare Part B Checkbox:
You will also need to indicate in the patient demographics which patients are Medicare Part
B.
These E & M encounter codes used on the superbill or in the encounter procedures section
will indicate which patient visits qualify for the PQRS measures:
CPT VARY BASED ON MEASURE
97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211,99212, 99213, 99214,
99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238,
99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308,
99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99455,
99456, G0270, G0271, G0402, G0438, G0439
Measure Specifications Link:
http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaim
sRegistry_MeasureSpecs_SupportingDocs_12132013.zip
#1 (NQF 0059): Diabetes Mellitus: Hemoglobin A1c Poor Control
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most
recent hemoglobin A1c greater than 9.0% (reverse measures – so less performance (less in
numerator) is better)
Denominator = Seen in the reporting period AND age 18 to 75 yrs AND
One of the Diabetes Mellitus ICD code entered in Problem List:
250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21,
250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50,
250.51,
250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80,
250.81,
250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04,
362.05,
362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04
Numerator = Most recent Hgb A1c >9.0% Quality Measures button in the SuperbillCheck box for #1 - OR
Lab Result for Hemoglobin A1c entered in Falcon (Interfaced or Manually entered)
OR
Use 3046F: to indicate the most recent hemoglobin A1c level > 9.0%
#2 (NQF 0064): Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most
recent LDL-C level in control (less than 100 mg/dL)
Denominator = Seen in the reporting period AND age 18 to 75 yrs AND
One of the Diabetes Mellitus ICD code entered in Problem List:
250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21,
250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50,
250.51,
250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80,
250.81,
250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04,
362.05,
362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04
Numerator = LDL-C < 100 mg/dl - Quality Measures button in the Superbill- Check
box for #2 OR
Lab Result for LDL-C entered in Falcon (Interface or Manually entered)
OR Use 3048F: to indicate Most recent LDL-C < 100 mg/dL
#110 (NQF 0041): Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and
March 31 who received an influenza immunization OR who reported previous receipt of an
influenza immunization
Measure #110 only needs to be reported a minimum of once during the reporting period
when the patient’s visit included in the patient sample population is between January and
March for the 2014-2015 influenza season OR between October and December for the
2014-2015 influenza season. When the patient’s office visit is between April and
September, Measure #110 is not applicable and will not affect the eligible provider’s
reporting or performance rate.
Denominator = Patients > 6 mos. old AND Office Visit with valid E & M Code AND Visit
is between Jan – Mar 2014 OR Oct – Dec 2014.
Numerator = Quality Measures button in the Superbill- Check box for #110
OR
Use CPT code G8482: Influenza immunization administered or previously received
#111 (NQF 0043): Pneumonia Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a
pneumococcal vaccine
Denominator = Seen in the reporting period AND are age > 65 yrs.
Numerator = Patients who have ever received a pneumococcal vaccination
Quality Measures button on the superbill - Check the box in the superbill - Check box
for #111
OR
Use CPT II 4040F: Pneumococcal vaccine administered or previously received in
the procedures section of your encounter.
OR
Pneumococcal Vaccination not Administered or Previously Received, Reason not
Otherwise Specified Use CPTII 4040F with Modifier 8P in the procedures section of
your encounter.
#121: Adult Kidney Disease: Laboratory Testing (Lipid Profile
Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not
receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at
least once within a 12-month period
Denominator = Patient with CKD 3, 4 or 5 diagnosis code AND Patients > 18 yrs. old
AND Office Visit w/ valid E & M Code
Numerator = Quality Measures button in the Superbill- Check box for #121
OR
Lab Test Results for Lipid Profile (Interface or Manually entered)
OR
Use CPT code G8725: Fasting lipid profile performed (Triglycerides, LDL-C, HDL-C, and
Total Cholesterol)
#122: Adult Kidney Disease: Blood Pressure Management
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of
CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy [RRT]) and documented
proteinuria with a blood pressure
< 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care
 Plan of Care - A documented plan of care should include one or more of the
following: recheck blood pressure within 90 days; initiate or alter
pharmacologic therapy for blood pressure control; initiate or alter nonpharmacologic therapy (lifestyle changes) for blood pressure control;
documented review of patient’s home blood pressure log which indicates
that patient’s blood pressure is or is not well controlled
Denominator = Patient with CKD 3, 4 or 5 diagnosis code AND Patients > 18 yrs. old
AND Office Visit with valid E & M Code AND Proteinuria (791.0) in the patient
Problem List.
Numerator = Enter Vitals into Vitals section OR Quality Measures button in the
Superbill- Check box for #122 (checking the box indicates you documented a Plan of
Care if required)
OR
Use G8476: to indicate the most recent blood pressure has a systolic measurement of
< 130 mmHg and a diastolic measurement of < 80 mmHg
AND
Use CPT 0513F: to indicate elevated BP plan of care documented
#123: Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent (ESA) Hemoglobin Level > 12.0 g/dL
Percentage of calendar months within a 12-month period during which a hemoglobin level
is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4
or 5, not receiving RRT [Renal Replacement Therapy]) or End Stage Renal Disease (ESRD)
(who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy AND
have a hemoglobin level > 12.0 g/dL
Denominator = Patient with CKD 4 or 5 diagnosis code AND Patients > 18 yrs. old
AND Office Visit with valid E & M Code AND are receiving ESA from you or any
provider
Numerator = Quality Measures button in the Superbill- Check box for #123
OR
Lab Result for Hemoglobin entered in Falcon (Interface or Manually entered) > 12
OR G0908: Most Recent Hemoglobin (Hgb) level > 12.0 g/dL
AND
Use CPT 4171F: Patient receiving erythropoiesis-stimulating agents (ESA) therapy
#128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening
and Follow-Up
Percentage of patients aged 18 years and older with a calculated BMI in the past six months
or during the current visit documented in the medical record AND if the most recent BMI is
outside of normal parameters, a follow-up plan is documented within the past six
months or during the current visit
BMI Parameters:
Age 65 years and older BMI ≥ 23 and < 30
Age 18 – 64 years BMI ≥ 18.5 and < 25
Denominator = patients > 18 Yrs old AND Office Visit with valid E & M Code
Numerator = BMI calculated in range OR if BMI is out of range (document Plan of
Care as required) – Quality Measures button in the Superbill- Check box for #128
OR if patient has V65.3 (Dietary Surveillance and counseling) in their problem list
OR
G8417: Calculated BMI above normal parameters and a follow-up plan was
documented OR
G8418: Calculated BMI below normal parameters and a follow-up plan was
documented
Measure #130 (NQF 0419): Documentation of Current Medications in the Medical
Record
DESCRIPTION:
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-thecounters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must
contain the medications’ name, dosage, frequency and route of administration d route
of administration
DENOMINATOR:
All visits for patients aged 18 years and older who had a visit during the reporting period
AND
NUMERATOR:
Eligible professional attests to documenting, updating or reviewing a patient’s current
medications using all immediate resources available on the date of encounter. This list
must include ALL prescriptions, over-the counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain the
medications’ name, dosages, frequency and route of administration d route of
administration
Select the quality measures button in the superbill – Measures #130
OR
Select the 3rd check box in the Medications/Allergies section in your encounter.
OR
G8427: Current medications documented
#226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and
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
Cessation Counseling Intervention – Includes brief counseling (3 minutes or less),
and/or pharmacotherapy
Denominator = Patients > 18 Yrs old AND Office Visit with valid E & M Code
Numerator = Enter ANY Smoking Status history in the encounter AND
Checkbox in Assessment & Plan section of the encounter to indicate smoking
cessation was discussed
OR screened for tobacco use AND received tobacco cessation intervention
(counseling, pharmacotherapy, or both), if identified as a tobacco user 4004F: Patient
screened for tobacco use AND received tobacco cessation intervention, if identified
as a tobacco user
OR Patient Screened for Tobacco Use and Identified as a Non-User of Tobacco
1036F: Current tobacco non-user
OR Select the checkbox under Quality Measures in the Superbill select – Checkbox # 226
Measure #236 (NQF 0018): Controlling High Blood Pressure
DESCRIPTION:
Percentage of patients 18 through 85 years of age who had a diagnosis of
hypertension and whose blood pressure was adequately controlled (< 140/90
mmHg) during the measurement period
DENOMINATOR:
Patients 18 through 85 years of age who had a diagnosis of essential hypertension 401.0,
401.1, 401.9 within the first six months of the measurement period or any time prior to
the measurement period
NUMERATOR:
Patients whose most recent blood pressure is adequately controlled (systolic blood
pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement
period
**If you enter the BP in the encounter and put the diagnosis code on the problem list,
Falcon will detect this measure automatically.**
OR
G8752: Most recent systolic blood pressure < 140 mmHg OR G8753: Most recent
systolic blood pressure ≥ 140 mmHg
AND
G8754: Most recent diastolic blood pressure < 90 mmHg OR
G8755: Most
recent diastolic blood pressure ≥ 90 mmHg
OR
Patient not Eligible for Recommended Blood Pressure Parameters for
Documented Reasons
G9231: Documentation of end stage renal disease (ESRD), dialysis, renal
transplant or pregnancy.
OR
Blood Pressure Measurement not Documented, Reason not Given
G8756: No documentation of blood pressure measurement, reason not given
OR Check the box on the Superbill- Checkbox # 236
Measure #317: Preventive Care and Screening: Screening for High Blood Pressure
and Follow-Up Documented
DESCRIPTION:
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
DENOMINATOR:
Percentage of patients aged 18 years and older who have an encounter in the reporting
period.
AND
NUMERATOR:
Patients who had BP recorded in Falcon AND have a recommended follow-up plan
documented, as indicated if the blood pressure is pre-hypertensive or hypertensive
• Check the box under quality measures in the superbill – Checkbox #317
OR G8783: Normal blood pressure reading documented, follow-up not required
OR G8783: Normal blood pressure reading documented, follow-up not
required
OR G8950: Pre-Hypertensive or Hypertensive blood pressure reading
documented, AND the indicated follow-up is documented
OR G8784: Blood pressure reading not documented, documentation the
patient is not eligible
OR G8951: Pre-Hypertensive or Hypertensive blood pressure reading
documented, indicated follow-up not documented, documentation the patient is not
eligible OR G8785: Blood pressure reading not documented, reason not given
OR G8952: Pre-Hypertensive or Hypertensive blood pressure reading
documented, indicated follow-up not documented, reason not given
HOW DO I TRACK MY PROGRESS ON THE MEASURES IN FALCON
Reporting Period Setup
Main Menu->Quality Scorecard->Reporting Period Setup->Add Reporting Period
Falcon displays your PQRS measure denominators and numerators on the Quality
Scorecard under Main Menu > Quality Reporting. Note that the Goal and Status columns are
not relevant for PQRS measures. The Denominator and numerator columns are where to
focus to track your progress. Falcon at this time has no method to track the 50% required
for the individual measures.
Maintenance of Certification Program
In 2014, EPs have the opportunity to earn the PQRS incentive and an additional incentive
of 0.5% by working with a Maintenance of Certification entity. Here is what is required:
Satisfactorily submitting data, without regard to method, on quality measures under PQRS,
for a 12-month reporting period either as an individual physician or as a member of a
selected group practice
AND
More frequently than is required to qualify for or maintain board certification:
Participate in a Maintenance of Certification Program and
Successfully complete a qualified Maintenance of Certification Program practice
assessment.
Feedback Reports
EPs who report PQRS quality measures data can request to receive National Provider
Identifier (NPI)-level Physician Quality Reporting Feedback Reports.
The reports include information on reporting rates, clinical performance, and incentives
earned by participating individual professionals, with summary information on reporting
success and incentives earned at the practice level. The feedback reports can be accessed
through the Web portal in the fall of the year following the reporting (e.g. 2013 feedback
reports will be available in the fall of 2014).