Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014

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This webinar, Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014, goes over which reporting options are available, what the incentives and penalties are for participating, reporting requirements, and how to choose quality measure for reporting.

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  • The Physician Quality Reporting System, or PQRS, is a CMS quality improvement 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 eligible professional services that are paid under or based on the Medicare Physician Fee Schedule.
  • Your PQRS participation in 2014 determines both your potential payment incentive and possible adjustment penalties that will effect future Medicare reimbursements. Note that 2014 is the last year to earn a PQRS incentive payment, and payment penalties will continue to compound at 2% starting with participation this year.
    As you can see, reporting in 2014 can result in either a 0.5% payment incentive or a 2.0% payment adjustment that would be applied in 2016.
    Note that starting this year, the payment penalty increases to 2.0% of your Medicare Part B reimbursements each year moving forward.
  • PQRS is very complex - PQRS requirements vary based on the reporting mechanism that you choose. The complexities are good in that you have more options, but it also means that you need to become familiar specific requirements that apply to the option that you are using.
    PQRS requirements are specific to each calendar year – eligible PQRS measures, G-codes, reporting requirements, etc. may change from year to year, so make sure you refer to 2014 resources and materials
    PQRS actions don’t roll-over – You may have acted last year for PQRS, but that doesn’t mean you can get out of taking action this year. Reporting this year applies to 2016 reimbursements, reporting last year will be applied to 2015 reimbursements.

    PQRS is a quality reporting program, which measures to participate you will need to report data for certain quality measures that you choose. With over 300 measures available for PQRS, choosing the right measures can be difficult. Before we dive into the different reporting mechanisms that are available, lets spend some time talking about the basic characteristics of a PQRS measure and how to choose the right quality measures for PQRS reporting.
  • The measures in 2014 PQRS address various aspects of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. Measure selection should begin with a review of the 2014 Physician Quality Reporting System (PQRS) Measures List to determine which measures, associated domains, and reporting option(s) may be of interest to the practice and applicable to the EP or group practice. Please note, not all measures are available under all of the PQRS reporting options. EPs or group practices should avoid individual measures that do not or may infrequently apply to the services they provide to Medicare patients. The measures list is available as a downloadable document from the Measures Codes section of the CMS PQRS website.

    The following factors should be considered when selecting measures for reporting:
    • Clinical conditions usually treated
    • Types of care typically provided – e.g., preventive, chronic, acute
    • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
    • Quality improvement goals for 2014
    • Other quality reporting programs in use or being considered
  • As reflected in the 2014 Medicare Physician Fee Schedule final rule, which went into effect on January 1, 2014, CMS has greatly increased the reporting requirements for providers who wish to earn the 2014 PQRS payment incentive. To qualify for the 2014 PQRS incentive, you must use one of the following reporting options and report the required number of measures as described:
    Claims-Based Reporting involves reporting quality data codes, or g-codes, on Medicare claims.
    Registry-based reporting is used when a provider registers or connects with a data registry.
    Qualified Clinical Data Registry reporting - New for 2014, the QCDR method provides a new standard to satisfy PQRS requirements based on satisfactory participation. A QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries. A QCDR is different from a qualified registry in that it is not limited to measures within PQRS. A QCDR may submit measures used by boards or specialty societies, and measures used in regional quality collaborations. Practice Fusion is not a qualified clinical data registry.
    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 and reporting is done via a web interface tool or providers can report via a registry as a group. Providers who report via GPRO will have their PQRS measure results posted publically on the CMS Physician Compare website.
    EHR Reporting option is available to providers using an EHR that has been certified to the most recent versions of the quality measures. Practice Fusion’s EHR has been certified to the most recent version of the CQMs, so any of the current CQMs can be used for PQRS if you meet the reporting requirements. Group reporting is not available using the EHR reporting option.

    Beginning in 2014, most PQRS reporting options require an EP or group practice to report 9 or more measures covering at least 3 National Quality Strategy (NQS) domains for incentive purposes. After making a selection of potential measures, review the specifications for the selected reporting option for each measure under consideration and select those measures that apply to services most frequently provided to Medicare patients by the EP or group practice. Individual EPs or group practices participating in GPRO should review each measure’s denominator coding to determine which patients may be eligible for the selected PQRS measure(s). These eligible patients or denominator would be appropriate to report the selected measure(s) clinical action or numerator.

    Measures with a 0 percent performance rate would not be counted. For an eligible professional who reports fewer than 9 measures via the claims-based reporting mechanism, the eligible professional would be subject to the Measures Applicability Validation (MAV) process, which would allow CMS to determine whether an eligible professional should have reported quality data codes for additional measures.

    Not all providers may want to put in the effort required to achieve the 2014 PQRS payment incentive. However, all providers must act in 2014 if they want to avoid the 2016 PQRS payment penalty.
  • If a provider isn’t interested in completing the additional requirements needed to earn the 2014 PQRS incentive, there are lesser requirements for simply avoiding the 2016 PQRS payment penalty. While there are fewer measure reporting requirements for avoiding the penalty, there are also fewer reporting options available. To avoid the 2016 payment penalty, a provider can choose to report measures via claims-based reporting, registry reporting, qualified clinical data registry reporting, or using the group practice reporting option mechanism.

    Now that we have outlined the available reporting mechanism, let’s dive deeper into the reporting requirements for each reporting option.
  • Claims Reporting Criteria
    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 and measures groups containing a measure with a 0% performance rate will not be counted.
    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 the eligible professional, then the EP must report 1-8 measures over 3 NQS domains OR if 9 or more measures apply over less than 3 NQS domains for which there is Medicare patient data AND report each measure for at least 50% of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. The eligible professional would be subject to registry-based MAV.

    Claims based reporting for PQRS can be very complex. Practice Fusion will offer additional detailed webinars in the future for several of the PQRS reporting options, including claims based reporting.
  • EPs can earn a 2014 PQRS incentive by meeting one of the following criteria for satisfactory reporting:
    1. Report on at least 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50
    percent of the EP’s Medicare Part B FFS patients.
    2. Report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of
    20) must be Medicare Part B FFS patients.

    EPs can avoid the 2016 PQRS payment adjustment by meeting one of the following criteria:
    1. Satisfactorily report and earn the 2014 PQRS incentive.
    2. Report at least 3 measures covering one NQS domain for at least 50 percent of the EP’s
    Medicare Part B FFS patients.
    EPs that submit quality data for one or two PQRS measures for at least 50 percent of their patients or encounters eligible for each measure will be subject to MAV.
  • New for 2014, the QCDR method provides a new standard to satisfy PQRS requirements based on satisfactory
    participation. A QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that
    collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in
    the quality of care furnished to patients. The data submitted to CMS via a QCDR covers quality measures
    across multiple payers and is not limited to Medicare beneficiaries.
    A QCDR is different from a qualified registry in that it is not limited to measures within PQRS. A QCDR may
    submit measures from one or more of the following categories with a maximum of 20 non-PQRS measures
    Allowed including Measures used by boards or specialty societies, and Measures used in regional quality collaborations
  • A “group practice” under 2014 Physician Quality Reporting System (PQRS) consists of a
    physician group practice, as defined by a single Tax Identification Number (TIN), with 2 or more
    individual eligible professionals (EPs), as identified by individual National Provider Identifier or
    NPI, who have reassigned their billing rights to the TIN. As required by section 1848(m)(3)(C)(iii)
    of the Act, an individual EP who is a member of a group practice participating in PQRS group
    practice reporting option (GPRO) is not eligible to separately earn a PQRS incentive payment
    as an individual EP under that same TIN (that is, for the same TIN/NPI combination). Once a
    group practice (TIN) registers to participate in the GPRO, this is the only PQRS reporting
    method available to the group and all individual NPIs who bill Medicare under the group’s TIN
    for 2014.

    (Press enter) Each of the first three GPRO reporting options requires reporting of at least 9 measures that cover at least 3 national Quality Strategy domains.
  • EPs can earn a 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment by meeting the following criteria for satisfactory reporting:
    Using a direct EHR product that is Certified EHR Technology (CEHRT) or EHR data submission vendor that is CEHRT, report on at least 9 measures covering 3 National Quality Strategy (NQS) domains
    If the EP’s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. An EP must report on at least 1 patient for which there is Medicare patient data.

    If an EP satisfactorily reports for 2014 PQRS using the EHR-based reporting option, (s)he will also satisfy the CQM component of the EHR Incentive program; however, EPs will still be required to meet the other Meaningful Use objectives through the Medicare EHR Incentive Program Registration and Attestation System. Using the 2014 EHR reporting mechanism for PQRS and for MU will result in MU incentive payments being delayed until after the PQRS measures are reporting to CMS in 2015.
  • We will now answer some questions submitted by you all during the course of the presentation.
  • We will now answer some questions submitted by you all during the course of the presentation.
  • We will now answer some questions submitted by you all during the course of the presentation.
  • Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014

    1. 1. Understanding Physician Quality Reporting System (PQRS) Requirements in 2014 Presented By: Emily Richmond, MPH Senior Manager, Health Care Quality www.PracticeFusion.com
    2. 2. What is the Physician Quality Reporting System? PQRS is a CMS quality improvement 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.
    3. 3. PQRS Participation in 2014 Your PQRS participation in 2014 determines both your potential payment incentive and possible adjustment penalties that will affect future Medicare reimbursements: Year Year Year Data Collected to Inform Payment/Penalty Year Data Collected to Inform Payment/Penalty Bonus/Adjustment Bonus/Adjustment Incentive Payment Incentive Payment 2014 2014 +0.5% 2014 2014 +0.5% Payment Adjustment Payment Adjustment 2015 2013 -1.5% 2016 2014 -2.0% 2017+ 2015 -2.0% 2015 2013 -1.5% 2016 2014 -2.0% 2017+ 2015 -2.0%
    4. 4. Important PQRS Facts + PQRS is very complex - PQRS requirements vary based on the reporting mechanism that you choose. The complexities are good in that you have more options, but it also means that you need to become familiar specific requirements that apply to the option that you are using. + PQRS requirements are specific to each calendar year – Eligible PQRS measures, G-codes, reporting requirements, etc. may change from year to year, so make sure you refer to 2014 resources and materials. The 2014 PQRS reporting period is January 1, 2014-December 31, 2014. + PQRS actions don’t roll-over – You may have acted last year for PQRS, but that doesn’t mean you can get out of taking action this year. Reporting this year applies to 2016 reimbursements, reporting last year will be applied to 2015 reimbursements. 4
    5. 5. Understanding PQRS Measures + PQRS measures consist of two major components: 1. A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure’s numerator) 2. A numerator that describes the clinical action required by the measure for reporting and performance + Each component is defined by specific clinical codes described in each measure specification along with reporting instructions. + For measures eligible for EHR reporting, Practice Fusion has implemented the measure according to very specific guidelines (including how data must be collected and how the measure is calculated). 5
    6. 6. PQRS Measure Selection Considerations Measure selection should begin with a review of the 2014 PQRS Measures List to determine which measures, associated domains, and reporting option(s) may be of interest to and applicable to your practice. Not all measures are available under all of the PQRS reporting options. Avoid individual measures that do not or may infrequently apply to the services you provide to Medicare patients. 6 The following factors should be considered when selecting measures for reporting:  Clinical conditions usually treated  Types of care typically provided – e.g., preventive, chronic, acute  Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite  Quality improvement goals for 2014  Other quality reporting programs in use or being considered
    7. 7. Earning the 2014 PQRS Incentive + 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. Claims-Based Reporting Registry Reporting Qualified Clinical Data Registry (QCDR) Reporting Group Practice Reporting Option (GPRO) Reporting EHR Reporting
    8. 8. Avoiding the 2016 PQRS Payment Penalty To avoid the 2016 PQRS payment adjustment of 2% without completing the PQRS incentive requirements, you must use one of the following reporting options: Claims-Based Reporting Registry Reporting Qualified Clinical Data Registry Reporting Group Practice Reporting Option (GPRO) Reporting
    9. 9. Claims-Based Reporting for PQRS + Claims-based reporting for PQRS involves submitting certain Quality Data Codes (QDCs) or “G-Codes” on your Medicare claims for applicable patients and select measures. + Measures with a 0% performance rate, meaning measures with a value of zero (0) in the denominator and/or numerator, will not be counted. 9 • 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 your Medicare Part B FFS patients seen during the reporting period to which the measure applies. Earn the PQRS Incentive • Report at least 3 measures covering 1 National Quality Strategy domain or be subject to the Measure-Applicability Validation (MAV) process. Avoid the PQRS Penalty
    10. 10. Registry Reporting for PQRS + The list of 2014 PQRS qualified registries will be posted during the summer of 2014 on the PQRS website under the Registry Reporting page. 10 • Report on at least 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50% of your Medicare Part B FFS patients. • Report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients. Earn the PQRS Incentive • Report at least 3 measures covering one NQS domain for at least 50% of your Medicare Part B patients • EPs that submit quality data for one or two PQRS measures for at least 50 percent of their patients or encounters eligible for each measure will be subject to Measure Applicability Validation Process. Avoid the PQRS Payment Adjustment
    11. 11. Qualified Clinical Data Registry (QCDR) Reporting for PQRS New in 2014 + A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients.  The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries. 11 Providers can earn a 2014 PQRS incentive by meeting the following criteria: • Report on a minimum of 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50 percent of applicable patients seen during the 2014 participation period. • At least 1 of the 9 measures submitted must be an outcome measure (containing denominator data fulfilling both exceptions and exclusions, as well as numerator data) Providers can avoid the 2016 payment adjustment by meeting one of the following criteria: • Satisfactorily participate and earn the 2014 PQRS incentive • Report at least 3 measures covering 1 NQS domain for at least 50 percent of applicable patients seen during the 2014 participation period
    12. 12. Group Practice Reporting Option (GPRO) for PQRS + A “group practice” under 2014 PQRS consists of a group of 2 or more eligible professionals who have reassigned their billing rights to a single Tax ID number (TIN). + Providers interested in reporting PQRS as a group practice must register with CMS by September 30, 2014 using the PV-PQRS Registration system. + Group practices must meet requirements as outlined in the CMS 2014 PQRS GPRO Requirements Guide and can report under any of the following reporting options, depending on the size of the group:  Qualified Registry (2 or more providers)  EHR Reporting (2 or more providers)  GPRO Web Interface Reporting (25 or more providers)  CMS-Certified Survey Vendor (25 or more providers) 12 Each of these GPRO reporting options requires reporting of at least 9 measures that cover 3 NQS domains
    13. 13. EHR Reporting for PQRS Providers can earn a 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment by meeting the following criteria for EHR satisfactory reporting: + Using a EHR product that is Certified EHR Technology (CEHRT), report on at least 9 measures covering 3 National Quality Strategy (NQS) domains + If the certified EHR does not contain patient data for at least 9 measures covering at least 3 domains, then report the measures for which there is Medicare patient data.  Providers must report on at least 1 patient for which there is Medicare patient data. + If a provider reports for 2014 PQRS using the EHR-based reporting option, it will also satisfy the CQM component required for Meaningful Use – assuming the other MU objectives have been met. 13
    14. 14. Practice Fusion and PQRS EHR Reporting + Practice Fusion will be acting as a Direct EHR Vendor (EHR Direct), which will allow our providers to use Practice Fusion to directly submit their PQRS measures data to CMS in the CMS specified format on their own behalf. + PQRS reporting for the EHR reporting mechanism will occur in January 2015 since the PQRS measurement period runs from January 1, 2014-December 31, 2014. 14
    15. 15. Need Individual Help with PQRS? + 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. 15 CMS QualityNet Help Desk Phone: 866-288-8912, TTY: 877-715-6222 Email: qnetsupport@sdps.org
    16. 16. PQRS Frequently Asked Questions 16
    17. 17. 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
    18. 18. I reported G-codes on my e-prescriptions last year, will that be enough to meet PQRS requirements in 2014? A. The CMS eRx Incentive Program also uses G-codes, which are submitted via e-prescriptions. The G8553 code submitted for the eRx incentive program cannot be used to meet PQRS requirements. PQRS has unique G-codes for each measure, so you must use the applicable codes and submit them on Medicare claims. Note that the eRx Incentive Program ended in 2013, so there is no need to report G-codes for e-prescribing in 2014.
    19. 19. Practice Fusion’s CQMs don’t apply to my specialty, how will I participate in PQRS? A. PQRS offers over 300 quality measures, which can be reporting using various reporting mechanisms (although not all measures are available for all reporting options.) If you wish to use Practice Fusion, you only have the measures we support available to use f or PQRS reporting. You may report less than 9 measures if you meet the other EHR reporting criteria, but you will be subject to the Measure Applicability Validation process which means you may not earn the incentive (although you could avoid the payment). Practice Fusion recommends that continue to monitor and record patient data in the EHR if you believe the measures apply to you to see how your CQM values adjust over the next few months, If you are a specialty provider who wants to report PQRS measures that are not available for EHR reporting, we suggest looking into how to reporting using other mechanisms (claims, etc.)
    20. 20. 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.

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