2016 pqrs and vbm for anesthesia and pain management · by the merit-based incentive payment system...

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2016 PQRS and VBM for Anesthesia and Pain Management

Table of Contents

PQRS 1 Definitions 2 PQRSBasics 2 MAV 3 Claims-basedvs.Registry-based Reporting 32016PQRSChangesforAnesthesia 3AnesthesiaPQRSmeasuresfor2016 4CareTeamConsiderations 5Value-BasedPaymentModifier(VBM) 5PainManagementin2016 6

SUMMARY

AnesthesiaPQRSreportinghaschangedsignificantlyfor2016vs.2015.Thereareseveralnewmeasuresandonlyoneisavailableforclaims-basedfiling.

Like in2015, if2016PQRSisnotreported,ornotreportedaccurately (acommonproblem),anesthesiologistsingroupsof10ormoreproviderswillseea-6%adjustmenttoMedicarepaymentsin2018.Thoseinsmallergroupswillseea-4%adjustment.

ThereareseveralwaystoreportPQRSmeasuresbutaregistryistheonlypracticalsolutionformostanesthesiologists,sinceCMSisphasingoutclaims-basedreportingandEHRreportingusuallyisn’tpractical.Mostimportant,however,aregistryapproachcaneliminatetheriskofthe-4%to-6%penalty.

PQRSresultsalsoshowupon“PhysicianCompare”andproposedchangeswillmapPQRSperformanceintoa5starratingsystemforconsumersbycomparingresultsacrossproviders.

PQRS

Toavoidpenalties fornot reportingPQRSandVBM,anesthesiologistsandCRNAsmustmeet theBasic Reporting Requirements: -Individualsorgroupswhoreportindividualmeasuresmustcompleteninemeasuresforat

least50%of theeligibledenominator,andthosemeasuresmust include three National Quality Strategy Domains.

-Oneofthosemeasuresmustbe“cross-cutting,”asdefinedbyMedicare:apopulation-widemeasurerequiredforproviderswhoseeatleastonepatientina“face-to-face”encounter.

However,theserequirementsdonotmatchwellwithmostanesthesiologistssincecross-cuttingmeasures

AT A GLANCE:

-PQRS/VBMpenaltiesare-4%to-6%

-Registryreportingisstronglyrecommended

-Mostanesthesiagroupsmustreportviaregistrytoavoidpenalties

-Thereareseveralnewmeasuresin2016foreachofanesthesiaandpainmanagement



2016 PQRS and VBM for Anesthesia and Pain Management 1


mayormaynotapplyandtherearefewerthan9measuresapplicabletomanyanesthesiologists(seebelow).Asaresult,anesthesiologistsaresubjecttothe“MAV”audit,describedbelow.

PQRSissettoexpireafterthisyear(the2016reportingyearaffects2018payments)andbereplacedbytheMerit-BasedIncentivePaymentSystem(MIPS)in2017(whichwillaffect2019payments).MIPSismandatedbyMACRA(theMedicareAccessandCHIPReauthorizationActof2015).MACRAeliminatedtheannualSGRpaymentreductionsand,amongotheritems,replacesPQRS,MeaningfulUseandtheVBM(ValueBasedModifier)programs.

However,whilethenamePQRSwilleventuallydisappear,thequalityreportingcomponentofMIPSwillbeheavilybasedonPQRS,meaningthatworkdonetocomplywithPQRSwilltransitionintotheMIPS environment. Furthermore, non-reporting penalties increase with MIPS, adding additionalincentivetohavegoodqualityreportinginplace.

DEFINITIONS

Thefollowingabbreviationsareusedinthispaper,consistentwithCMSterminology:EP–EligibleprofessionalGP–GroupPracticeEHR–ElectronicHealthRecordQCDR–QualifiedClinicalDataRegistry

PQRSBASICS

-ThereisnoincentivepaymentforreportingPQRSmeasuresin2016.However,incentive/bonuspaymentsmaybeearnedviatheValueBasedModifierProgram.

-EPswhodonotsuccessfullyparticipatein2016willreceivea-2%PQRSpaymentadjustmentanda-4%VBMadjustmentontheir2018Medicarepayments.

-WhiletherearehundredsofPQRSmeasures,onlyasmallnumberapplytoanesthesia,asdescribedbelow.

-PQRScanbereportedviaclaims,registry,EHR,QCDRorGPRO(groupsonly).Thefirst4methodsaretypicallyusedforindividualEPs,evenwhenpartofagroup.However, claims-based reporting is being phased out by CMS so it is recommended to use one of the other methods.

-Foratleast50%ofMedicarepatients,CMSrequiresreportingon9measures,atleastoneofwhichisaso-called“cross-cuttingmeasure”.Butmanyanesthesiologistsdonothave9applicablemeasures,inwhichcasetheMAVapplies(seebelow).

Itisveryimportanttonotethatmeasuresaredefinedonameasure-by-measurebasis,not by specialty.Thatisbecausetwoprovidersinthesamespecialtymaynotperformthesameservices.




MAV

For thosewhoreport fewer thanninemeasuresor fewer than threedomains, theMeasureApplicability Validation (MAV) Audit applies. Medicare compares your PQRS data to its measurespecifications to identifyothermeasureswhichcouldhavebeenreported,butwerenot.While themeasurestheyidentifymaynotseemrelevant,iftheymeetMedicare’sdefinition,theydirectlyaffectyourPQRScompliance.

CLAIMS-BASED VS. REGISTRY-BASED REPORTING

In this paper, we focus primarily on claims and registry-based reporting since many anesthesiagroupsdonothavetheabilitytouseanEHRforEHR-basedreporting(andmanyEHRsdonothavethenecessaryCEHRTcertificationtoreportthemeasures).QCDRisabroadertopicasthatreportingmethodforanesthesiatypicallyrequiresadditionalqualitymeasuresbeyondthoseinPQRS.

With PQRS penalties now significant (-4% to -6% when combined with the VBM penalty), registryreporting is becoming almost essential. This is because claims-based reporting doesn’t provideanyMAVinsight,untilitistoolate.Furthermore,theprocesstoreviewclaims-filedPQRSdataiscumbersome,atbest.In2015,countlesshourswerespenttryingtodeterminewhatdataCMSactuallyhad.Andevenwhenbaddatawasappealed,penaltieswerestillapplied.Registryreportingprovidesongoingfeedbackand,importantly,providesfeedbackonhowanEPorgroupwillfareinaMAVAudit.Inaddition,witharegistry,PQRSdatacanbeupdatedorevenreplaced,somethingthatisimpossiblewithclaims-basedfiling.Asaresult,usingaregistryeliminatesMAVandPQRSpenaltyrisks.

Formanyifnotmostanesthesiaproviders,claims-basedfilingisnotgoingtoworkin2016,asdescribedinthenextsection.

2016PQRSChangesforAnesthesia

Thebiggestchangein2016PQRSisthatmanyanesthesiologistsandCRNAswillnolongerbeabletouseclaims-basedPQRSreporting!ThisisbecauseCMSdeletedMeasure193(warming),andmovedMeasure44(betablocker)toregistryonly,leavingMeasure76(sterileCVC)astheonlyonereportableviaclaims.ButEPswhodon’tinsertcentrallinesorPAcathswillnotbeabletoreportMeasure76.ThismeansthatEPswhodon’tinsertcentrallinesorPAcathsmust report via registry or QCDR to avoid PQRS and VBM penalties![1]

Itisworthnotingthat,inagroup,ifoneproviderdoesinsertcentrallinesorPAcaths,theycanstillreportviaclaimsevenifotherproviderscannotandchoosetousearegistry.Inotherwords,alloftheprovidersinagrouparenotrequiredtousethesamereportingmethod.



1VaughnandAssociates,“PQRSWarning:WhatifYouhaveNoMeasurestoReportviaClaims?”December18,2015.


ThePQRSchangesin2016include: -“Changes to Existing Measure 76.Therequirementstocomplywiththesteriletechniquefor

CVChavechangedfor2016.Code6030Fnowrequiresdocumentationof“sterileultrasoundtechniques”whichisdefinedas“sterilegelandsterileprobecovers.”So,youwillneedtochangeyourMeasure76templatetocapturethefollowing:(1)cap(2)mask(3)sterilegown(4)sterilegloves(5)sterilefullybodydrape(6)handhygiene(7)skinpreparation,andifultrasoundisused(8)sterilegel,and(9)sterileprobecovers.

- Deleted Anesthesia Measure.Measure193(intraoperativetemperaturewarming)wasdeleted because there was 100% compliance. (Ironically, this same basic measure wasaddedtothelistofmeasurestoreportviaregistryasMeasure424.)

-Changed Method of Reporting.Measure44 (BetaBlocker)was removed from the listofavailablemeasurestoreportviaclaims,althoughitcanbereportedviaregistry.

-New Anesthesia Measures.Thereare5newanesthesiameasuresfor2016,butforregistryreportingonly.Theyare:SmokingAbstinence#404(reportableviaregistry),PerioperativeWarming#424,PACUTransferperFormalProtocol#426,ICUTransferperFormalProtocol#427,andPONVTherapyforInhalationGA#430.

-New Cross-Cutting Measures:Thereare3newcross-cuttingmeasuresfor2016.Theyare:UnhealthyAlcoholUse#431;BreastCancerScreening#112;FallsandRiskAssessment#154.

-New Chronic Pain Measures.Forgroupswithachronicpaincomponent,thereare3newopioid related measures, as follows: Opioid Therapy Follow-up Eval #408 (registry only);SignedOpioidTreatmentAgreement#412(registryonly);andInterviewforRiskofOpioidMisuse#414(registryonly).[2]

TheoptionsforrelevantPQRSmeasuresarequitelimitedforsomeanesthesiaproviderswhomayfind they need to report a measure with poor performance. While this may avoid the PQRS andValue-BasedPaymentModifier(VBPM)non-reportingpenalty,itdoesrisktriggeringaVBMpenalty(thoughtheVBMpenaltyis-2%to-4%vs.the-6%non-reportingpenalty.

AnesthesiaPQRSmeasuresfor2016

Asdescribedabove,mostanesthesiagroupswillbereportingviaregistryin2016.Ifso,thesearethepossiblemeasuresidentifiedtodate(eachEPandgroupneedstodeterminewhichapply): -44(BetaBlocker), -76(CVCsteriletechnique), -342(PainBroughtunderControlwithin48Hours;appliesto99231-99233), -404(Smokingabstinence), -424(Perioperativewarming), -426(TransfertoPACU), -427(TransfertoICU), -430(PONV), -1(Hemoglobin),and -47(Careplan).



2VaughnandAssociates,“What’sNewinAnesthesiafor2016?”December21,2015.


Thelast2arecross-cuttingmeasuresthatapplywhereveranEPhasaface-to-faceencounterwithapatient.Measure1[poorhemoglobin]and47[advancecareplan]arereportableifbillingpost-oppainroundsusing99231-99233;severalothermeasuresarereportable ifbillingoutpatientE&Mcodesusing99201-99205or99211-99215).

DetailsforeachmeasureareavailableintheCMSIndividualMeasuresGuide,availableasadownloadatthisCMS page.

CareTeamConsiderations

IncaseswherebothEPsintheCareTeambillMedicare,themeasureinformationforbothshouldbereported.Ifbillingisonlydoneforone,themeasureisonlyreportedforthatEP.IfbillingisdoneusingIndividualNPInumbers,themeasureinformationneedstobereportedusingeachIndividualNPI.Inotherwords,eachtimeabillingcodeissubmittedtoMedicareitisaneligibleinstance.SoifacodeisbeingbilledundertwoseparateNPIsthenbothNPIswouldbeableto(andneedto)reportfortheeligibleinstance.

Value-BasedPaymentModifier(VBM)

LikePQRS,theValue-BasedModifier(VBM)affectsMedicarepaymentswithaone-yeardelay.Hence,performancein2015hasalreadydeterminedPQRSandVBMpaymentadjustmentsfor2017.Andperformanceduringthisyear(2016)willdetermineadjustmentsfor2018payments.

For2015,CMSdescribedtheVBMasfollows:“Inordertobeeligibleforupward,downward,orneutralpaymentadjustmentsundertheValueModifierquality-tieringmethodologyandtoavoidanautomaticnegative twopercent (“-2.0%”) (forphysiciangroupswithbetween2 to9EPsandphysiciansolopractitioners) or negative four percent (“-4.0%”) (for physician groups with 10 or more EPs) ValueModifierpaymentadjustmentinCY2017,EPsingroupsandsolopractitionersMUSTparticipateinthePQRSandsatisfyreportingrequirementsasagrouporasindividualsinCY2015.Quality-tieringismandatoryforgroupsandsolopractitionerssubjecttotheValueModifierinCY2017.Groupswith10ormoreEPsaresubjecttoupward,neutral,ordownwardadjustmentunderquality-tiering,andgroupswithbetween2to9EPsandphysiciansolopractitionersaresubjecttoonlyupwardorneutraladjustmentunderquality-tieringin2017.”

Whilethepreciserulesfor2016arenotclearontheCMSwebsite,itappearsthatgroupsunder10providersarenowsubjecttoa-2%VBMpenalty,andcontinuetobeeligiblefora+2xincentive,basedontheirqualityandcostresults.ButthisassumesthatthegroupreportsitsPQRSmeasures.Anygroupunder10providersthatdoesnotreportPQRSsuccessfullywilldefinitelyseea-4%penalty.

Inaddition,for2016,non-physicianpractitioners(NPPs)areincludedintheVBM:PAs,NPs,CNSs,andCRNAs,etc.Asinpreviousyears,theseprovidersnewtotheprogramarenotsubjecttodownwardadjustments,butthatappliesonlytosoloNPPsorthose inagroupofonlyNPPs.Solophysiciansandgroupsoftwoormorephysiciansand/orNPPsaresubjecttopaymentadjustments(upordown)



https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/measurescodes.html

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html#CY


basedontheirratioofqualitytocostascomparedtootherprovidersintheMedicareprogram.

Tosummarize,theupwardordownwardpaymentadjustmentfactorsandpercentagesfor2016VBMareasfollows: -Forsolophysiciansandgroupsuptonineproviders:+2.0xand-2.0%. -Forgroupswith10ormoreproviders:+4.0xand-4.0%.

PainManagementin2016

Likeallotherspecialties,painmanagementmustreportatleast9measures,coveringatleast3oftheNQSdomainsANDreporteachmeasureforatleast50percentoftheEP’sMedicarepatients.SincepainmanagementproviderstypicallyseeMedicarepatientsinaface-to-faceencounter,theymust report on at least 1 cross-cutting measure. There are 3 new cross-cutting measures for2016:UnhealthyAlcoholUse#431 (reportableviaregistryandmeasuresgroups);BreastCancerScreening#112(reportableviaclaimsandregistry);andFalls:RiskAssessment#154(reportableviaclaimsandregistry).

Asnotedabove, thereare3newChronicPainopioid relatedmeasures:OpioidTherapyFollow-upEvaluation#408(registryonly);SignedOpioidTreatmentAgreement#412(registryonly);andInterviewforRiskofOpioidMisuse#414(registryonly).

PainmanagementgroupsusingQCDRreportinghavetheoptionof“measuresgroup”reporting. Itrequiresreportingfor20patients,themajorityofwhichareMedicare.The“PreventiveCareMeasuresGroup”istheonlymeasuresgroupthatappliestoPainManagementfor2016.Itcontains: -#39ScreeningforOsteoporosisforWomenAged65-85YearsofAge -#48UrinaryIncontinence:AssessmentofPresenceorAbsenceofUrinaryIncontinencein

WomenAged65YearsandOlder -#110PreventiveCareandScreening:InfluenzaImmunization -#111PneumoniaVaccinationStatusforOlderAdults -#112BreastCancerScreening -#113ColorectalCancerScreening -#128PreventiveCareandScreening:BodyMassIndex(BMI)ScreeningandFollow-UpPlan -#134PreventiveCareandScreening:ScreeningforClinicalDepressionandFollow-UpPlan -#226PreventiveCareandScreening:TobaccoUse:ScreeningandCessationIntervention -#431PreventiveCareandScreening:UnhealthyAlcoholUse:Screening&BriefCounseling



2016 pqrs and vbm for anesthesia and pain management · by the merit-based incentive payment system...

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