PQRS 2013

PQRS What The quality reporting program for Medicare Part B (traditional fee for service) Who Eligible providers (PT’s) who bill under the physician fee schedule (part B) Includes private practices Excludes facility based providers (SNF, OP hospital, CORF, etc) Why In 2015, practitioners will receive payment adjustments (-1.5%) in their Medicare part B reimbursement if they to not participate in the program (adjustments will be based on CY2013 data)

PQRS Reporting: Getting Started

Determine reporting method Getting Started Select measures Determine reporting method Educate staff Begin reporting Audit success

Getting Started: Measure Selection Decide which measures best fit for your Medicare population Choose 3 or more applicable individual measures OR the group measure What conditions do you usually treat? What types of care or interventions are provided in the clinic? Information on the measures is under the 2013 PQRS Measure Details section of the webpage: www.apta.org/PQRS

Measure Type: Individual vs Group # Required for Successful Reporting 3 measures per therapist 1 measure per therapist Measure Focus Variable Condition or disease specific Reporting Threshold (# of patients) No threshold 15+ unique patients per 12 month reporting period (CY); 8+ per 6 month reporting period Intent to Report Code N/A Must be reported once per reporting period per practitioner Success Rate via Claims (CY2010) Individual measures 63% Group measures 51% Success Rate via Registry (CY2010) Individual measures 87% Group measures 94%

Getting Started: Reporting Method and Participation Choose a reporting method Claims versus registry Talk to you billing provider Qualified registries https://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp Choose reporting participation Individual versus group (GPRO)

Reporting Method Claims vs Registry Cost None Variable QDC Selection Each practitioners is responsible for choosing and submitting the QDC’s Each practitioners is responsible for entering data into the registry ; QDC’s generated based on the data Updating Annual measure updates must be monitored by the facility Registry monitors and incorporates annual measure updates Reporting Requirements Data must be submitted on +50% of all eligible Medicare patients Data must be submitted on +80% of all eligible Medicare patients EHR N/A EHR and registry can be linked Auditing Each facility must establish an auditing process to ensure successful reporting Registry provides participants with feedback reports throughout the year Success Rate (CY2010 data) Individual measures 63% Group measures 51% Individual measures 87% Group measures 94%

Reporting Participation: Individual vs GPRO Registration required No Yes Data analysis Analyzed at the individual (NPI) level; looks are the reporting rate of each professional on the selected measures Analyzed at the group (TIN) level; looks are the cumulative reporting rate of the group on the selected measures

Getting Started: Staff Education Educate staff about the measure specifications and billing procedures Create processes that support PQRS implementation Flow charts or algorithms for clinicians AMA tool for 2013 updates typically posted by February http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system-2012.page Checklists for billing staff

Getting Started: Auditing Your Success Plan an auditing process to evaluate your success Billing audit for claims submission Use billing data and N365 remittance advice code on EOB Quality Net quarterly dashboard reports Registry feedback reports Chart review for content Documentation must support the clinical quality action as indicated by the chosen QDC

PQRS Reporting: Case Examples

PQRS Process PQRS Audit Interim Quarterly Dashboard Reports Final 2013 Feedback Report- Fall 2014 Source: CMS Open Door Forum 3/22/2011

Case Example: Individual Measures Mrs. S is a new patient she presents for her initial evaluation on with adhesive capsulitis of the shoulder The therapist performs the initial evaluation and completes the measures: Ensure patient is eligible for the measure Select the corresponding G-Code or CPT II modifier Document to support the quality activities The administrative staff submits the bill for processing Ensure the claim is accepted and check the EOB for the N365 remittance advice code

Case Example: Measure #130 Percentage of patients aged 18 years and older with a list of current medications (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) documented by the provider, including drug name, dosage, frequency and route Current Medications with Name, Dosages, Frequency and Route Documented G8427: List of current medications (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) documented by the provider, including drug name, dosage, frequency and route Current Medications with Dosages not Documented, Patient not Eligible G8430: Provider documentation that patient is not eligible for medication assessment Current Medications with Name, Dosages, Frequency, Route not Documented, Reason not Specified G8428: Current medications (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) with drug name, dosage, frequency and route not documented by the provider, reason not specified

Case Example: Measure #131 Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Pain Assessment Documented as Positive G8730: Pain assessment documented as positive utilizing a standardized tool AND a follow-up plan is documented G8509: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not specified Pain Assessment Documented as Negative, No Follow-Up Plan Required G8731: Pain assessment documented as negative, no follow-up plan required Patient not Eligible for Pain Assessment for Documented Reasons G8442: Documentation that patient is not eligible for a pain assessment

Case Example: Measure #154 Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months Risk Assessment for Falls Completed 3288F: Falls risk assessment documented AND 1100F: Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year Risk Assessment for Falls not Completed for Medical Reasons 3288F with 1P: Documentation of medical reason(s) for not completing a risk assessment for falls (i.e., reduced mobility, bed ridden, immobile, confined to chair, etc) 1100F: Patient screened for future fall risk If patient is not eligible for this measure because patient has documentation of no falls or only one fall without injury the past year, report: Patient not at Risk for Falls 1101F: Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year If patient is not eligible for this measure because falls status is not documented, report: Falls Status not Documented 1101F with 8P: No documentation of falls status Risk Assessment for Falls not Completed, Reason not Specified 3288F with 8P: Falls risk assessment not completed, reason not otherwise specified

Case Example: Measure #155 Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months Plan of Care Documented 0518F: Falls plan of care documented Plan of Care not Documented for Medical Reasons 0518F with 1P: Documentation of medical reason(s) for no plan of care for falls Plan of Care not Documented, Reason not Specified 0518F with 8P: Plan of care not documented, reason not otherwise specified

Case Example: Individual Measures

Additional Resources APTA: Case studies Podcasts on specific measures Successful reporting requirements