2011 cms physician quality reporting system - tony hamm

© 2011 American Chiropractic Association

2011 CMS Physician Quality Reporting System (PQRS)

Teaching Doctors of Chiropractic How to Report on Measures Related to Quality Patient Care

Presentation for the National University of Health Sciences

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*The materials and information presented on ACA webinars are independently developed and presented and do not necessarily reflect the opinions or positions of the American Chiropractic Association. All information and comment contained in ACA webinars are provided with the understanding that neither the ACA nor the presenter are engaged in the provision of legal, coding, accounting or other professional advice. Doctors are advised to seek the services of a competent professional in order to obtain such advice.


What we’ll cover

• Public/private focus on quality care• Why participate in the PQRS (formerly called PQRI) • Information about the 2011 PQRS and measures• How to report on measures applicable to DCs• How you can help improve quality in the chiropractic

care setting

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Quality and Value-Based Purchasing

• “Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser” – Centers for Medicare and Medicaid Services 2007– Current Medicare Physician Fee Schedule

based on quantity and resources consumed, NOT quality or value

• Value = Quality / Cost– Incentives can encourage higher quality and

avoidance of unnecessary costs to enhance the value of care

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Quality & CMS PQRS

• Health outcomes in the United States can be improved by a reduction in medical errors and stronger reliance on evidence-based practice (IOM)

• To address the need for better quality health care, Congress passed the 2006 Tax Relief and Healthcare Act establishing the Physician Quality Reporting Initiative

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Quality & CMS PQRS

Help focus attention on quality of care--Need to determine best practices, collect data, report results, set targets, align incentives, & improve systems

PQRI reauthorized in 2007 by the Medicare Extension Act, in 2008 under the Medicare Improvements for Patients and Providers Act and in 2010, under the Patient Protection and Affordable Care Act. PPACA made PQRI a permanent program. When the program was made permanent, its name was changed to the Physician Quality Reporting System.

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Why Participate in PQRS?

• The Patient Protection and Affordable Care Act made participation mandatory beginning in 2015.

• Providers not successfully reporting in 2015 will have payments reduced by 1.5% and by 2% in 2016 and beyond.

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• Likely to turn into the first phase of comparative effectiveness/pay for performance. Lets prove our effectiveness

• Likely that private payers will adopt some portion of PQRS and we want to be included

• May provide supportive documentation when a claim is unfairly denied

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Profession has a duty to our patients to provide and report quality health care

ACA has a responsibility to assist providers with the technical aspects of reporting

Focus attention on the quality of care we provide

EQUATES TO BETTER CARE FOR PATIENTS!

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2011 PQRS

• A voluntary program in 2011• NPI required for participation• 2011 program includes 3 INDIVIDUAL quality measures applicable

to DCs– Pain Assessment Prior to Patient Therapy– Functional Outcome Assessment in Chiropractic Care– Health Information Technology Adoption/Use of EHRs

• Reporting periods: January 1-December 31 and July 1-December 31

• 1% Bonus Financial incentive provided

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Reporting thresholds

• INDIVIDUAL Measures

– Each INDIVIDUAL measure must be reported for at least 50% of the cases in which a measure was reportable

– The reporting periods are January 1, 2011-December 31, 2011 or July 1, 2011-December 31, 2011

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PQRS bonus payment

Participating DCs who successfully report may earn a bonus payment

– 1% bonus calculation based on total allowed charges during the reporting period for professional services billed under the Fee Schedule

– Claims must reach the National Claims History (NCH) file by February 28, 2012

– Bonus payments will be made in a lump sum in October 2012, distributed to holder of Taxpayer Identification Number (TIN)

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PQRS validation and appeals

• Law requires CMS to use sampling or other means to validate whether quality measures apply to the services that have been reported

– The Agency is NOT looking at documentation of E/M services, rather it is evaluating documentation of a G-code and/or quality data code related to quality measure reporting

• Determinations of successful reporting are excluded from formal administrative or judicial review

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Feedback reports

• CMS will provide confidential feedback reports to participating providers

– Enable quality improvement at the practice level– Include reporting and performance rates by

National Provider Identifier (NPI) number for each Tax ID Number (TIN)

– Problems with CMS feedback in previous program year

– PPACA has mandated that CMS provide more timely feedback to participants

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Understanding quality measures under 2011 PQRS

• 194 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims

• 3 INDIVIDUAL measures apply to doctors of chiropractic in 2011

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Construction of measures

Clinical action required for reporting and performance ________________________________

Eligible cases for a measure

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Construction of measures cont.

CPT II Code

Or

Temporary G Code ________________________________

ICD-9-CM

and

CPT Category I Codes

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What are CPT-II codes?

• CPT-II code = quality-data code– Translates clinical actions so they can be captured in

the administrative process• Quality-data codes relay that:

– The measure requirement was met or,– The measure requirement was not met due to

documented allowable performance exclusions

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How to Report on Applicable Measures

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Pain assessment measure description

• This measure is to be reported for each visit occurring during the reporting period for all patients aged 18 yrs & older

• Percentage of patients aged 18 yrs and older with documentation of a pain assessment (if pain is present, including location, intensity and description) through discussion with the patient including the use of a standardized tool i.e. McGill Pain Questionnaire, on each visit prior to initiation of therapy and follow-up including a reassessment of pain and documentation of a future appointment, education, referral, notification of primary care provider, etc.

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Clinical Example

• 65-year old male complains of 2 week history of lower back pain. Pain is located over the right lower back and buttocks. The pain is described as sharp, constant and 6/10 VAS.

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What will you need to report under this pain assessment measure?

• Whether or not you assessed for pain prior to initiation of therapy – Pain assessment may result in either documentation

of the absence of pain OR documentation of pain (including location, intensity and description)

• Whether or not you documented a follow-up plan, if appropriate.

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http://www.ama-assn.org/ama1/pub/upload/mm/pqrs/2011-measure131-worksheet.pdf


Pain assessment coding specs

• A CPT service code is required to identify patients to be included in this measure – CMT codes (98940-98942) included

• If pain assessment prior to patient therapy was provided, document one of the G-code descriptors– G8440 (pain assessment AND follow-up plan documented)– G8442 (pain not assessed; document exclusion)– G8441 (no documentation of pain assessment)– G8508 (pain assessed but no follow-up plan documented;

document exclusion)– G8509 (pain assessed but no follow-up plan documented)

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© 2011 American Chiropractic Association26

Example of Quality-codesCMS-1500 Form

99203

98940

25 GY

AT

G8440


Functional outcome assessment measure description

• This measure is to be reported for each visit occurring during the reporting period for all patients aged 18 yrs & older

• Percentage of patients aged 18 yrs and older with documentation of a functional outcome assessment using a standardized tool (i.e. Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI)) AND documentation of a care plan based on identified functional outcome deficiencies

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Clinical Example

• 65-year old male complains of 2 week history of lower back pain. Pain is located over the right lower back and buttocks. The pain is described as sharp, constant and 6/10 VAS. Patient completed low back disability index and results are attached to the file.

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What will you need to report under this functional outcome assessment measure?

• Whether or not you assessed the patient’s current functional outcome using a standardized tool and documented a care plan, if deficiencies have been identified

– Functional outcome deficiencies are defined as impairment or loss of physical function related to neuromusculoskeletal capacity, including but not limited to, restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms and legs, and headaches.

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What if process/outcome of care is not appropriate for your patient?

• There will be times when it is not appropriate to assess the patient’s current functional outcome– Documented reasons (e.g., patient refuses to participate; patient

unable to complete questionnaire)

• In these cases, you will need to indicate that a documented reason applies, and specify

• Office/billing staff will report the G-code that represents these valid reasons (exclusions)

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Functional outcome assessment measure coding specs

• A CMT code is required to identify patients to be included in this measure – CMT codes (98940-98942)

• Quality codes for this measure include: – G8539 (current functional outcome assessed AND care plan

documented)– G8540 (current functional outcome not assessed; document exclusion)

This measure requires that the functional outcomes assessment tool be utilized at a minimum of every 30 days. Because reporting is required on every visit, you should report G8540 for visits between each 30 day functional outcome assessment.

– G8542 (current functional outcome assessed but no care plan documented; document exclusion)

– G8541 (current functional outcome not assessed)– G8543 (current functional outcome assessed but no documentation of a

care plan)

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Example of Quality-codesCMS-1500 Form

99203

98940

25 GY

AT

G8539

97110 GP GY


Health IT measure description

• This measure is to be reported at each visit occurring during the reporting period for all patients; reported by clinicians who have adopted and are using HIT

• Documents whether provider has adopted/uses HIT; to qualify must adopt a qualified EHR

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Certified EHRs

The EHR must be certified by an Authorized Testing and Certification Body or

Be on CMS’ list of PQRS qualified EHRs (list available at: www.cms.gov/pqri)

If not certified as delineated above, the system must have the ability to manage a medication and problem list, enter and store laboratory results in a searchable fashion and have basic privacy and security elements.

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http://www.cms.gov/pqri


How do I know if I should report this measure?

• Do you have an EHR?

• If the answer is NO, DO NOT report

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What you will need to report for each visit of this measure?

• Whether or not the patient encounter was documented using qualified EHR

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EHR coding specs

• A CMT code is required to identify patients to be included in this measure – CMT codes (98940-98942) included

• Quality codes for this measure include: – G8447 (encounter documented using an EHR

system that has been certified by an Authorized Testing and Certification Body (ATCB))

– G8448 (encounter documented using a PQRS qualified EHR or other acceptable system)

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Quality-code Exclusion ModifiersCMS-1500 Form

98940 739.0

G8448 739.2

AT


Ensuring success in quality reporting

• Start reporting early to increase the probability of achieving an 50 percent rate of reporting during the reporting period

• If you don’t have an EHR, then only report on pain assessment and the functional outcome assessment measure

• Report on as many eligible patients as you can

• Ensure that quality codes are reported on the same claim as the diagnosis or CPT-1 codes (can’t go back and add!)

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Why Quality Reporting?

• While many performance measures are considered to be “process” measures, the future trends are expected to be more focused on “outcome” measures

• We should anticipate that today’s performance measurements, which have been described as “low bar,” will become tomorrow’s indicators of essential care or clinical necessity.

• PQRS represents a “reward system” today but will be required in 2015.

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Linking quality with chiropractic care

• Learning about and participating in quality health care delivery and reporting is simply not optional for the chiropractic profession

• DCs must coalesce around best practices

• Improve patient care!

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PQRS educational resources

• ACA PQRS tool kit available at: www.acatoday.com/pqrs– DC Frequently Asked Questions– Glossary of terms– Hints for successful reporting

• CMS PQRS website contains all publicly available information at: www.cms.hhs.gov/PQRI– Medicare Carrier/Medicare Administrative Contractor (MAC)

inquiry management

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Any questions?

• ACA Dept. of Government Relations

email: [email protected]

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2011 cms physician quality reporting system - tony hamm

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