MSMA New PQRS Regulations


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MSMA New PQRS Regulations

  1. 1. PQRS: Prepare Now for 2013! MSMA December 2012 Sandy Pogones, Program ManagerPublication MO-12-31-PREV December 2012This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with theCenters for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contentspresented do not necessarily reflect CMS policy
  2. 2. Who is Primaris Founded in 1983 by the Missouri State Medical Association and Missouri Association of Osteopathic Physicians and Surgeons Federally-designated Quality Improvement Organization (QIO) for the state of Missouri.
  3. 3. ObjectivesIdentify 2013 quality reporting programs under CMSDiscuss how the Physician Quality Reporting System(PQRS) and Value-Based Payment Modifier will impactpracticesExamine reporting optionsDevelop a plan and action steps for quality reporting
  4. 4. Center for Medicare and Medicaid Services (CMS) Quality Reporting Programs Meaningful Use Incentives & Penatlies ACOs/Shared Value-Based Savings Bonus Modifier Bonus & Penalties & Penalties PQRS Patient Medical Public Homes Reporting Incentives PQRS Incentives & PenaltiesContent on this page is subject to the Notice on the title page of this presentation.
  5. 5. What is PQRS? A ―system‖ to report clinical quality data to Centers for Medicare & Medicaid Services (CMS) Allows multiple mechanisms of reporting Provides variety of clinical measures Dynamic system, continually updated with new/revised/discontinued measures
  6. 6. Who is eligible? An eligible provider includes – Physicians (MD, DO, dentists, podiatrists, chiropractors) – Practitioners (NP, PA, APN, clinical nurse specialists, psychologists, clinical social workers) – Therapists (PT, OT, speech, audiologist) Incentives and payment adjustments based on Medicare Part B PFS allowable charges
  7. 7. What Applies to Me in 2013?Program Incentive if reporting in 2013 Payment adjustment if not reporting in 2013PQRS All EPs. Incentive = 0.5% All EPs. Penalty -1.5% applied in 2015Value-Based Groups with 100+ EPs. If report Groups with 100+ EPs. If don’t report PQRSModifier PQRS as a group, then VBM = as a group then VBM = -1.0% applied in 0% (Unless elect quality tiering) 2015Meaningful All EPs. Bonus under Medicare All EPs. If don’t reach MU, -1.0% applied inUse/EHR or Medicaid. Incentive depends 2015 (-2.0% if subject to e-RX penalty inIncentive on year and program—$8000 - 2014) $21,500)E-Prescribe All EPs. Incentive =0.5% unless All EPs. Penalty = -2.0% in 2014 unless you earned a MU EHR incentive meet hardship exemption. Report 10 cases under Medicare, then 0% Jan-June 2013 or 25 cases in 2012 to avoid.
  8. 8. Performance Improvement=Team Sport “Social and collaborative activities account for most workplace learning.” – Informal Survey of Importance of Sources of Learning, Centre for Learning Performance Technology, 2012
  9. 9. Mechanisms of PQRS Reporting •3 measures, or 1 Measures Group Claims •Submit Quality Data Codes on Bill daily •3 measures or 1 Measures Group Registry •EP sends data to Registry; Registry submits after year-end •3 measures EHR-Direct •EP generates files from EHR, Uploads to CMS after year-endEHR-Data Submission •3 measures Vendor •Data electronically shared, DSV submits after year-end •17 measuresAdministrative Claims •EP elects, No need to send any data, CMS calculates GPRO Web-based •22 measures Interface •Group elects, CMS assigns patients, Group submits year-end
  10. 10. How to Choose a PQRS Submission Method Practice size Individual or group Specialty Your EHR Participation Cost
  11. 11. Satisfactory Reporting for Individuals - 2013
  12. 12. Satisfactory Reporting for Groups - 2013
  13. 13. Successful Strategies Scenario 1: Provider in a five-provider practice, Practice Management System, no EHR. – The VBM does not apply in 2013 – Provider does not have an EHR, so will incur a Meaningful Use Penalty of -1.5% effective in 2015 – Provider can participate in PQRS using Claims, Registry, or Administrative Claims – Measures Group good choice
  14. 14. Measures Groups Reportable through Claims and RegistryClaims and Registry Registry OnlyDiabetes Mellitus (DM) Measures Group Coronary Artery Bypass Graft (CABG)Chronic Kidney Disease (CKD) Measures Measures Group Group Coronary Artery Disease (CAD) MeasuresPreventive Care Measures Group GroupRheumatoid Arthritis (RA) Measures Group Heart Failure (HF) Measures GroupPerioperative Care Measures Group HIV/AIDS Measures GroupBack Pain Measures Group Inflammatory Bowel Disease (IBD) Measures GroupHepatitis C Measures Group Sleep Apnea Measures GroupIVD Measures Group Parkinson’s Disease Measures GroupAsthma Measures Group Hypertension (HTN) Measures GroupCOPD Measures Group Cataracts Measures GroupDementia Measures Group Oncology Measures GroupCardiovascular Prevention Measures Group
  15. 15. Qualified Registries2013 Listing Available by Spring of 2013 Instruments/PQRS/Registry-Reporting.html
  16. 16. ―Getting Started with Measures Groups‖(Cardiovascular Measures Group)
  17. 17. Claims-Based Individual Measures and Measure Groups Review the Reporting Guides and Specifications: – Individual Measures – s/ – Measures Groups – s/2013-PQRS-MeasuresGroupsSpecs-ReleaseNotes- AMA Participation Tools Billing system PQRS reporting features
  18. 18. Start Reporting Insert codes for each measure in the Group on the bill Submit the Claim Watch for N365 notice on Remittance Advice Repeat for at least 20 patients, mostly Medicare Part B
  19. 19. Examples of Successful Strategies Scenario 2: Providers works in a group practice of 30 providers with an EHR that is PQRS Qualified in 2013. The providers participate in Meaningful Use and PCMH. – The VBM does not apply in 2013 – Meaningful Use Bonuses – Individual Providers can participate in PQRS using Claims, Registry, EHR, EHR Data Submission Vendor, or Administrative Claims
  20. 20. Qualified Direct EHR CMS will qualify EHRs in 2013. By 2014 all Certified EHRs must be able to submit PQRS. 2013 Listing of Qualified EHRs Available Now Instruments/PQRS/Downloads/2013QualifiedEHRDirectVendors.pdf
  21. 21. Put a plan in place Identify your Identify Engage with team-who, what,measures and Vendor Customer when, where,specifications Support how Initiate Update system Run monthly improvement and submit after reports processes 12/31
  22. 22. Example of Successful Strategies Scenario #3: Specialty practice, 30 cardiologists and NPs. Use an EHR, but it is not qualified to report PQRS in 2013. Participate in the ACC Pinnacle Registry. $8 Million Medicare Part B billings. – Upload Data – Feedback reports – Data submission vendor submits to CMS
  23. 23. Qualified EHR Data Submission Vendor CMS will qualify in 2013, but not in 2014 2013 Listing Available Summer/Fall 2013 Instruments/PQRS/Downloads/2012QualifiedDSVs.pdf
  24. 24. Successful StrategiesScenario 4: TIN with 150 providers. Multispecialty, use differentEHRs, some have participated in PQRS in past, some veryresistant. $30 Million Medicare Billings Option Group Reporting Availability Qualified Registry 2+ EPs, 2013 and beyond GPRO Web-based tool 25+ EPs, 2013 and beyond Administrative Claims 2+ EPs, 2013 only, no incentive Certified EHR/DSV Not Avail in 2013; Avail for 2+ EPs in 2014 and beyond Claims Not available Measure Groups Not available
  25. 25. A Few Other Points about Group Reporting Must self-nominate by 10/15/2013 and be accepted by CMS. If Group elects to report PQRS as a Group using Registry or GPRO web-based interface: – All members use the same reporting mechanism; – All members report on the same measures; – Providers can not participate individually. If group has >100 providers and wish to report PQRS as individuals to earn PQRS incentive, then MUST elect Administrative Claims option to avoid VBM penalty
  26. 26. PQRS Administrative Claims Option for 2013 New in 2013 & only available in 2013 to avoid the 2015 payment adjustment Requires providers to ―elect‖ by notifying CMS via the Communications portal – Portal open December 1, 2012 – January 31, 2013, then again from July – October 15, 2013 No incentive payment!!!
  27. 27. Avoid Penalties Simply by ParticipatingIndividual Providers •Report 1 PQRS measure through Claims, Registry or EHR, --OR-- •Elect Administrative ClaimsGroups: •Self-nominateas a Group, and Elect and Report 1 PQRS measure via Registry or Web-Based Interface, --OR-- •Self-nominate as a Group and Elect Administrative Claims
  28. 28. Summary: How will PQRS Data Be Used? PQRS Incentives (0.5% in 2013 and 2014) PQRS Payment Adjustments (1.5% based on 2013 Reporting, Assessed in 2015; 2.0% thereafter) Calculate VBM for Groups of 100+ EPs based on 2013 & 2014 reporting; for all physicians thereafter Clinical Quality Measure to meet Meaningful Use Requirements (2014 and beyond) and as part of current pilot Quality data reported through a Medicare Shared-Savings Program/ACO to meet PQRS/VBM/MU CQM requirements Physician Compare
  29. 29. ResourcesRecordings of National Provider Calls held by CMS: websites: and Primaris.orgPQRS CMS Website: Questions--QualityNet Help Desk (866)-288-8912, Open 7:00–7:00 CST , M-F, or
  30. 30. Resources (cont)CMS Communication Support Page (Self-nominate as Group& Elect Administrative Claims Option) Compare: Payment Modifier: Modifier Questions: ;
  31. 31. Resources (cont) QRUR Reports for Groups 25+ to help you see how you might compare in VBM calculations: AMA PQRS Participation Tools: http://www.ama- improvement/clinical-quality/
  32. 32. Questions? Sandy Pogones Program Manager 573-673-4531