PQRS Claims-based Reporting in 2014

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Physician Quality Reporting System (PQRS) is a CMS reporting program that uses a combination of incentive payments and penalties to promote reporting of quality data. This presentation discusses.

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  • Welcome to the Practice Fusion PQRS Webinar.
  • The Physician Quality Reporting System, or PQRS, is a CMS reporting program that uses a combination of incentive payments and penalties to promote reporting of quality data. Providers are eligible for participation in PQRS if they are reimbursed under the Medicare Physician Fee Schedule (PFS) and see Medicare Part B patients.This includes physicians, chiropractors, dentists, PAs, NPs, and other eligible practitioners and therapists.Under PQRS, payment incentives and penalties are determined based on eligibleprofessional services that are paid under or based on the Medicare Physician Fee Schedule.
  • Your PQRS participation in 2013 determines both your potential payment incentive and possible adjustment penalties that will effect future Medicare reimbursements.As you can see, reporting in 2013 can result in either a 0.5% payment incentive or a 1.5% payment penalty. Note that in 2014, the payment penalty increases to 2.0% of your Medicare Part B reimbursements
  • To qualify for the 2013 PQRS incentive, you must use one of the following reporting options:Claims-Based Reporting involves reporting quality data codes, or g-codes, on Medicare claims. To achieve the payment incentive, providers must report 3 individuals measures for at least 50% of Medicare patients or report 1 measures group for at least 20-patient sampleRegistry-based reporting is used when a provider registers or connects with a data registry. This means that the registry submits the data to CMS on behalf of the provider. For registry based reporting, providers must report at least 80% of eligible instances for at least three measures or report on a 20-patient sample (if reporting measures groups)The Group Practice Reporting Option, or GPRO, is available for group practices of two or more providers with a single Tax ID number. Group practices who wish to report via the GPRO web interface or GPRO registry reporting option must register with CMS prior to October 15, 2013. When submitting data to CMS for the PQRS payment incentive, keep in mind that:You will not receive credit for any measures that result in ‘0’ (zero) values in the numerator or denominatorThe 2013 PQRS program requires that all patients included for reporting must be Medicare Part B patients.Not all providers may want to put in the effort required to achieve the 2013 PQRS payment incentive. However, all providers must act in 2013 if they want to avoid the 2015 PQRS payment penalty. Since the PQRS registration for the administrative claims reporting option has passed, and the end of 2013 is nearing quickly, we are going to go through the remaining options that providers have to participate in PQRS in 2013 to avoid the 2015 penalty.
  • If you want to avoid the 2015 PQRS payment penalty as an individual eligible provider, you must participate in PQRS in 2013 via one of three options:Elect to be analyzed under the administrative claims-based reporting mechanism by registering with CMS prior to October 15, 2013 Report at least one applicable measure or measures group using one of the reporting options (claims reporting using quality data codes or registry reporting)Reporting via Medicare Claims can seem like a daunting task, but once you understand the steps needed, you may find that reporting via claims to avoid the penalty is very accessible.
  • If you want to report for PQRS using the claim-based reporting option, there are a few things you will want to do to prepare.
  • We will now go through the steps to follow in order to report for PQRS using the Claims-Based reporting method. The information in purple throughout the remaining slides are referencing support documentation that you should download and/or print when going through the steps to familiarize yourself with PQRS reporting. Review the specific criteria for the chosen reporting option in order to satisfactorily report.  If you choose individual measures, you will need to report at least one measure for at least one eligible Medicare beneficiary before the end of 2013 to avoid the penalty. If you choose measures group, you will need to report at least one entire measures group for at least one eligible Medicare beneficiary before the end of 2013.Select which measure or measures group you want to report on. Make sure that the measure or measures
  • Being able to read and understand a CMS measure specification is critical to successful PQRS reporting. Measure specifications are formatted in a specific way – once you understand how to read one measure specification, it becomes much easier to read and understand other measure specifications that you may come across, for example, in Meaningful Use or other CMS quality reporting programs. Now let’s take an example measure and go through each of these parts of the measure specification to understand what it will look like when you are reviewing the CMS PQRS documentation.
  • Read the description to understand if this measure is right for your practice. You’ll see that there is information about which patients this measure applies to and what clinical action must be taken to meet the measure requirements.
  • This section tells you how to report this measure. Note that for PQRS measures, the instructions will say that you should report this measure for every single visit during the 12 month reporting period, which is the calendar year. If you are trying to avoid the PQRS penalty, it’s okay that you did not previously report on this measure. If you are going for the incentive, you will need to report all individual measures for at least 50% of your patients. This section also tells you that the measure can be reported via claims.
  • The denominator section tells you which patients are eligible for this measure. As you can see, a list of CPT codes that represent eligible encounters for this measure are listed. If you have a way of flagging these CPT codes in your billing system, that will help you with remembering to report for PQRS.
  • The numerator tells you what clinical action must be taken to get credit for the PQRS measure. Note that it is important to familiarize yourself with all the information in this section to ensure that you are reporting on the measure accurately. There may be additional information, such as the numerator note found in Measure #130, that give you more information on how to report this measure satisfactorily.
  • The Numerator Quality Data Coding Options section will tell you which PQRS quality data codes you should report on your Medicare Part B claims for eligible beneficiaries in order to get credit for reporting this measure satisfactorily. You’ll notice that there are three QDC options for this measure. Depending on what clinical actions you take, you will need to report the applicable code. We will now go through a scenario for this measure to help you understand when you would report each of these codes for a specific encounter.
  • Now lets walk through the reporting scenarios for the three quality data codes we just talked about for PQRS Measure #130. As you can see in the diagram, there are three scenarios that exist after a Medicare beneficiary, Mr. Jones, arrives at the office of Dr. Thomas. In scenario 1, Dr. Thomas attests to documenting Mr. Jones’ current medications to the best of his knowledge and ability. In scenario 2, Dr. Thomas attests that Mr. Jones is not eligible for medication documentation. In scenario 3, Dr. Thomas does not document Mr. Jones medications and he does not give a reason for not doing so. Which if these scenarios would represent satisfactorily reporting for this measure? Scenario 1 = yes, scenario 2 = yes, but scenario 3 = no. Make sure that you are doing the clinical action necessary to satisfactorily report for the measure that you choose and that you are reporting the appropriate and applicable quality data code on the claim to match up with that. Now let’s look an example claim to see how you would report QDCs on a CMS 1500 claim.
  • There is an example CMS 1500 claim form in the PQRS implementation guide, but we will go through the key parts of reporting PQRS via CMS 1500 claims forms in this slide. Keep in mind that if you can still report QDCs to Medicare for PQRS even if you report Medicare claims electronically using the Version 5010 form.Let’s go into the key areas of the CMS 1500 paper claims form. The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease (CAD), and urinary incontinence: • Measure #2 (LDL-C) with QDC 3048F + diabetes line-item diagnosis (24E points to DX 250.00 in Item 21); • Measure #3 (BP in Diabetes) with QDCs 3074F + 3078F + diabetes line-item diagnosis (24E points to Dx 250.00 in Item 21); • Measure #6 (CAD) with QDC 4011F + CAD line-item diagnosis (24E points to Dx 414.00 in Item 21); and • Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRS, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter. • Note: All diagnoses listed in Item 21 will be used for PQRS analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21. • NPI placement: Item 24J must contain the NPI of the individual provider who rendered the service when a group is billing. • If billing software limits the line items on a claim, you may add a nominal amount such as a penny to one of the QDC line items on that second claim. PQRS analysis will subsequently join both claims based on the same beneficiary, for the same date-of-service, for the same TIN/NPI and analyze as one claim.
  • There are even more things to remember when reporting quality data codes.
  • QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed. The submitted charge field cannot be blank If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted Entire claims with a zero ($0.00) charge will be rejected Whether a $0.00 charge or a nominal amount is submitted to the Carrier or A/B Medicare Administrative Contractor (MAC), the PQRS code line will be denied but will be tracked in the National Claims History (NCH) for analysis Let’s talk about what it means that the PQRS code line will be denied.
  • The RA/EOB denial code N365is your indication that the PQRS codes were received by CMS. It seems a bit counter intuitive, but this denial code actually means that your Medicare claim with the quality data code was received. If you haven’t seen one of these codes before, then you must be very good at submitting Medicare claims! This code reads:“This procedure code is not payable. It is for reporting/information purposes only.” Keep in mind that the N365 code just indicates that the claim with the code was received, it does not guarantee the QDC was correct or that incentive quotas were met. However, when a QDC is reported satisfactorily (by the individual eligible professional), the N365 can indicate that the claim will be used for calculating incentive eligibility. Keep track of all cases reported so that you can verify QDCs reported. Each QDC line-item will be listed with the N365 denial remark code.
  • Beginning in 2014, Practice Fusion providers will have more reporting options available for meeting the requirements for the 2014 PQRS payment incentive:In addition to the three options that are available in 2013, providers will also be able to reporting measures directly to CMS via their EHRPractice Fusion will support a set number of CMS certified quality measures that will be available for PQRS reportingThe list of quality measures that will be available in 2014 will be released before the end of 2013. Reporting changes are just part of what’s new in 2014 for PQRS. There are also additional program changes that effect providers who are also participating in Meaningful Use.
  • In 2014, providers participating in the CMS EHR Incentive Program will also have the option of meeting the Meaningful Use program Clinical Quality Measure (CQM) reporting requirements by successfully participating in PQRS.This option is available to providers who will be in Stage 1 or Stage 2 in 2014.CQMs will be submitted by Practice Fusion prior to February 28, 2015 for the full 2014 calendar year.Providers will still use a 3-month reporting period for the MU program Core and Menu measures.Note that providers who will be in their first year of the Meaningful Use program in 2014 will not be able to use the PQRS option for meeting the CQM requirements, because they will need to report CQM values to CMS during attestation prior to October 1, 2014 in order to avoid the 2015 Meaningful Use payment penalty. Providers in their first year of MU can still report CQMs for PQRS via the EHR e-submission method, but it will not count towards MU requirements.
  • If you would like to report via a registry, a list of CMS-approved PQRS registries is available on the CMS PQRS website under Registry Reporting.
  • If you would like to report via a registry, a list of CMS-approved PQRS registries is available on the CMS PQRS website under Registry Reporting.
  • We will now answer some questions submitted by you all during the course of the presentation.
  • We are nearing the end of our webinar session. On the screen now is a brief list of PQRS resources that may be helpful for providers who want to know more about PQRS participation. For links to these resources and more information, please visit the Practice Fusion PQRS blog post. A link will be sent to all webinar participants following today’s presentation.Thank you all for joining!
  • PQRS Claims-based Reporting in 2014

    1. 1. PQRS CLAIMS BASED REPORTING IN 2014 The materials in this presentation, or prepared as part of this presentation, are provided for informational purposes only and do not constitute legal advice or legal opinions. You should not act or rely on any information contained in this presentation, or any materials prepared for this presentation, without first seeking the advice of a qualified and independent attorney. Created by: Emily Richmond Senior Manager, Health Care Quality Practice Fusion, Inc.
    2. 2. PQRS is a CMS reporting program that uses a combination of incentive payments and penalties to promote reporting of quality data Who is eligible for PQRS? + Providers who see Medicare Part B patients and are reimbursed under the Medicare Physician Fee Schedule (PFS). + This includes physicians, chiropractors, dentists, PAs, NPs, and other eligible practitioners and therapists. What services are PQRS eligible? + Under PQRS, covered professional services are those paid under or based on the Medicare PFS. + Those services are eligible for PQRS incentive payments and/or payment adjustments. What is the Physician Quality Reporting System?
    3. 3. Your PQRS participation in 2014 determines both your potential payment incentive and possible adjustment penalties that will affect future Medicare reimbursements: PQRS Participation in 2014 Year Year Data Collected to Inform Payment/Penalty Bonus/Adjustment Incentive Payment 2014 2014 +0.5% Payment Adjustment 2015 2013 -1.5% 2016 2014 -2.0% 2017+ 2015 -2.0% Year Year Data Collected to Inform Payment/Penalty Bonus/Adjustment Incentive Payment 2014 2014 +0.5% Payment Adjustment 2015 2013 -1.5% 2016 2014 -2.0% 2017+ 2015 -2.0%
    4. 4. + To qualify for the 2014 PQRS incentive, you must use one of the following reporting options. + Note that completing requirements to earn the 2014 PQRS incentive automatically results in avoiding the 2016 PQRS payment penalty. Earning the 2014 PQRS Incentive Claims-Based Reporting Registry Reporting Qualified Clinical Data Registry (QCDR) Reporting Group Practice Reporting Option (GPRO) Reporting EHR Reporting
    5. 5. To avoid the 2016 PQRS payment adjustment of 2% without completing the PQRS incentive requirements, you must use one of the following reporting options: Avoiding the 2016 PQRS Payment Penalty Claims-Based Reporting Registry Reporting Qualified Clinical Data Registry Reporting Group Practice Reporting Option (GPRO) Reporting
    6. 6. + To be eligible for the 2014 PQRS incentive payment if reporting individual measures via claims, report:  At least 9 measures, covering at least 3 of the National Quality Strategy (NQS) domains, AND  Report each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. + Note: Measures with a 0% performance rate will not be counted. Incentive Payment Claims Reporting Requirements Beginning in 2014, measures groups can ONLY be reporting via the registry reporting option. When reporting via claims, you MUST choose individual measures.
    7. 7. CMS Incentive Payment Claims Based Decision Tree
    8. 8. + To avoid the 2016 payment adjustment report at least 3 measures covering 1 National Quality Strategy domain or be subject to the Measure-Applicability Validation (MAV) process. + If less than 9 measures apply to your practice, then you must:  Report 1-8 measures over at least one NQS domain for which there is Medicare patient data AND  Report each measure for at least 50% of your Medicare Part B FFS patients seen during the reporting period to which the measure applies. Avoiding the Payment Penalty Reporting Requirements
    9. 9. CMS Avoiding the Penalty Claims Based Decision Tree
    10. 10. How Do I Prepare for Claims-Based PQRS Reporting? • Read through the steps in this slide deck to understand if PQRS claims-based reporting is right for you. • Download and/or print the necessary documentation from CMS. • Work with your practice medical biller or billing partner to make sure they are aware that you are participating in PQRS reporting.
    11. 11. 1. Determine which individual measures best fit your practice. 2. Review the specific criteria in order to satisfactorily report.  Remember that the criteria for earning the incentive is different from the criteria for simply avoiding the payment penalty.  You should decide which your practice wants to achieve in 2014. 3. Select which measure or measures group you want to report on. 4. Learn how to read the measure specifications and prepare your staff and practice workflow to report on those measures. Reporting for PQRS Using Claims-Based Reporting Make sure that the measures you choose to report are related to your scope of practice.
    12. 12. What are the key parts of a PQRS measure specification? • Tells you an overview of the measure. • Great for deciding if the measure fits your scope of practice. Description • Tells you how often to report the measure and if it can be reported via claims or registry. • For avoiding the PQRS penalty, it’s OK if you do not report for an entire year. Instructions • Describes the patient population that this measure reports to. • Make sure that your practice regularly sees patients that meet the denominator. Denominator • Describes the clinical action you must take to meet the measure requirementsNumerator • Lists the different QDCs or G-Codes that you must report for this measure depending on which actions are taken. Numerator Quality-Data Coding Options for Reporting Satisfactorily
    13. 13. Measure #130 (NQF 0419)Documentation of Current Medications in the Medical Record
    14. 14. Measure #130 (NQF 0419)Documentation of Current Medications in the Medical Record
    15. 15. Measure #130 (NQF 0419)Documentation of Current Medications in the Medical Record
    16. 16. Measure #130 (NQF 0419)Documentation of Current Medications in the Medical Record
    17. 17. Measure #130 (NQF 0419)Documentation of Current Medications in the Medical Record
    18. 18. Mr. Jones, age 65, presents for office visit (99213) with Dr. Thomas Scenario 1 Dr. Thomas attests to documenting Mr. Jones’ current medications to the best of his knowledge and ability Code: G8427 Scenario 2 Dr. Thomas attests that Mr. Jones is not eligible for medication documentation Code: G8430 Scenario 3 Dr. Thomas does not document Mr. Jones medications and a reason is not given Code: G8428 Satisfactorily Reporting Scenario for PQRS Measure #130
    19. 19. How to Report PQRS on a CMS 1500 Claim Form Make sure the Dx code listed is contained in the specifications of the measure you want to report Include procedures, services CPT/HCPCS modifiers as needed These are the claim line-items QDCs should be submitted with a line- item of $0.00 or $0.01 – DO NOT LEAVE BLANK The beneficiary is not liable for nominal amounts ($0.01) if it must be charged for the QDC. Make sure to include the NPI number of the individual EP who performed the service used to meet the PQRS measure The NPI of the billing provider goes here. This could also be a group NPI if applicable.
    20. 20. + QDCs must be reported:  On the claim(s) with the denominator billing code(s) that represents the eligible Medicare Part B encounter  For the same beneficiary  For the same date of service (DOS)  By the same eligible professional (individual NPI) who performed the covered service, applying the appropriate encounter codes (ICD-9-CM, CPT Category I or HCPCS codes). Principles for Reporting Quality Data Codes
    21. 21. + QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed.  The submitted charge field cannot be blank  If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted  Entire claims with a zero ($0.00) charge will be rejected  Whether a $0.00 charge or a nominal amount is submitted to the Carrier or A/B MAC, the PQRS code line will be denied but will be tracked in the National Claims History for analysis by CMS Principles for Reporting Quality Data Codes
    22. 22. + The individual NPI of the solo practitioner must be included on the claim as is the normal billing process for submitting Medicare claims. + If multiple providers in your practice share a TIN, the NPI will be used to determine which provider is getting PQRS credit on each claim. + The QDC must be included on the claim(s) representing the eligible encounter that is submitted for payment at the time the claim is initially submitted in order to be included in PQRS analysis. Solo NPI Submission This means that each individual provider in your practice must submit PQRS individually. Make sure you are reporting PQRS for all providers in your practice, if applicable.
    23. 23. + The RA/EOB denial code N365 is your indication that the PQRS codes were received by CMS.  N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.”  The N365 denial code is just an indicator that the QDC codes were received. It does not guarantee the QDC was correct or that incentive quotas were met.  However, when a QDC is reported satisfactorily (by the individual eligible professional), the N365 can indicate that the claim will be used for calculating incentive eligibility. + Keep track of all cases reported so that you can verify QDCs reported. Each QDC line-item will be listed with the N365 denial remark code. Remittance Advice (R/A) & Explanation of Benefits (EOB)
    24. 24. + Claims processed by the Carrier or A/B MAC must reach the national Medicare claims system data warehouse by February 28, 2015 to be included in the analysis. + Claims for services furnished toward the end of the reporting period should be filed promptly. + Remember: claims that are resubmitted only to add QDCs will not be included in the analysis. Submitting On Time in Key
    25. 25. + Practice Fusion is not able to offer individual guidance on choosing PQRS measures. + If you have questions regarding individual measures or how PQRS requirements apply to you, please reach out to the CMS QualityNet Help Desk. Need Individual Help with PQRS? 25 CMS QualityNet Help Desk Phone: 866-288-8912, TTY: 877-715-6222 Email: qnetsupport@sdps.org
    26. 26. How do I find out if I am eligible for PQRS? A. Most health care providers who are reimbursed under the Medicare Physician Fee Schedule are eligible for PQRS. For additional details and a list of eligible PQRS providers go to: http://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment- Instruments/PQRS/How_To_Get_Started.html Frequently Asked Questions
    27. 27. Can I resubmit claims for purposes of PQRS reporting or for correcting Quality Data Codes? A. Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. If a denied claim is subsequently corrected through the appeals process to the Carrier or A/B MAC, with accurate codes that also correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be included on the resubmitted claim as instructed in the measure specifications Frequently Asked Questions
    28. 28. I’m participating in Meaningful Use this year, will there be penalties if I don’t also participate in PQRS? A. PQRS is a separate and distinct program from Meaningful Use. Providers who do not report for PQRS in 2014 will be subject to a 2% payment penalty – regardless of whether or not they successfully participate in Meaningful Use. Frequently Asked Questions
    29. 29. For more information on PQRS, include links to CMS resources and other Practice Fusion PQRS materials, go to: http://www.practicefusion.com/blog/resource s-and-faqs-on-cqms-and-pqrs/ 29

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