PQRS Individual Measures Data Entry Guide

The deadline to submit PQRS data to New

Jersey Innovation Institute for program

year 2016 is March 10th, 2017

2016 PQRS Individual Measures Data Entry Guide

Purpose of this Guide This guide provides simple, step-by-step instructions to help Eligible Professionals (EPs) satisfy Physician Quality Reporting System (PQRS) requirements for the 2016 program year using NJII’s Qualified PQRS registry. This guide is intended for EPs who are reporting using a Measures Group. If you are reporting using Individual Measures, please see the PQRS Individual Measure Data Entry Guide.

Contents

• Overview

o Individual Measures

o PQRS Requirements

o How to Get Started with NJII’s Qualified Registry

• Step-by-Step Data Entry Guide

o Log In

o Prepare Your PQRS Data

o Enter Your Data

o Review Your PQRS Summary

o Complete Your Final Submission

2016 PQRS Individual Measures Data Entry Guide

Overview Individual Measures With NJII you can mix and match from 198 Individual Measures to report on the best measures that represent the provider the best, allowing more flexibility for measure selection. Individual Measures must be reported for Medicare Part B Fee-For-Service (FFS) patients seen by an Eligible Professional (EP) throughout the full calendar year. EPs must report on at least 9 measures covering at least 3 National Quality Strategy (NQS) domains for >50% of Medicare Part B FFS patients eligible for each measure. The Measures Applicability Validation (MAV) Reporting a Measures Group is a simple option for many reasons: To avoid the -2% penalty in 2017, EPs must:

• Report at least 9 individual measures across at least 3 domains • Report on at least 50% of eligible Medicare Part B FFS patients or encounters for each measure • Report one (1) cross-cutting measure if they had at least one (1) face-to-face encounter with a

Medicare fee-for-service patient during 2016 • For each measure, report a performance of greater than 0% (or less than 100% for inverse

measures, where a lower performance rate indicates better performance) List of 2016 Cross Cutting Measures:

• #1 – Diabetes: Hemoglobin A1c Poor Control • #46 – Medication Reconciliation Post Discharge • #47 – Care Plan • #110 – Preventive Care and Screening: Influenza Immunization • #111 – Pneumonia Vaccination Status for Older Adults • #112 – Breast Cancer Screening • #128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan • #130 – Documentation of Current Medications in the Medical Record • #131 – Pain Assessment and Follow Up • #134 – Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan • #154 – Falls: Risk Assessment • #155 – Falls: Plan of Care • #182 – Functional Outcome Assessment • #226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention • #236 – Controlling High Blood Pressure • #317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented • #400 – One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk: • #402 – Tobacco Use and Help with Quitting Among Adolescents • #431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

2016 PQRS Individual Measures Data Entry Guide

PQRS Requirements To satisfy program year 2016 PQRS requirements for reporting Individual Measures and avoid a –2% payment adjustment in 2018:

1. Choose 9 Measures Group across at least 3 of the NQS Domains that is relevant to your EP. Review the performance numerator criteria for each measure to make sure the measures are relevant to your scope of practice.

TIP: CMS specifications for each Measures can be found on the NJII Portal. On the Getting Started Tab, click the Reporting Individual Measures sub tab, and then click on the link for the Specification Manual.

2. Collect the total number of Eligible Instances per Individual Measure the provider is reporting on. Make sure the patients are Medicare FFS patients (includes Medicare Secondary and Railroad Medicare). To identify eligible patients, search for claims with dates of service during 2015 that have specific patient denominator criteria such as diagnosis, age, and procedure (CPT) code. Most electronic billing software and/or vendors will be able to generate a report of eligible patients using these criteria.

TIP: Use the CMS Specification Sheets on the NJII Portal to review denominator criteria. On the Getting Started Tab, click the Reporting Individual Measures sub tab, and then click on the link for the Specification Manual.

3. Collect data for each individual measure the provider is reporting. The clinical data related to the measures can be documented in either paper, electronic charts, or reports but proof that the reported clinical action was performed must be clearly documented in the patient’s records. Make sure that you can supply this supporting documentation to CMS in the event of an audit.

• Collect the following summary or aggregate data required to report individual measures: • # of Eligible Instances • # of Eligible Instances where performance is met • # of Eligible Instances where performance is excluded • # of Eligible Instances where performance is not met

4. Submit data to NJII’s Qualified PQRS Registry by March 10, 2017.

How to Get Started with NJII’s Qualified Registry If you have not yet registered for program year 2016, please contact a NJII PQRS Specialist at 973-642-4055 or pqrs@njii.com.

2016 PQRS Individual Measures Data Entry Guide

Step-by-Step Data Entry Guide Step1:LogIn

Step2:PrepareYourPQRSData

Users will receive their username and password (in two separate emails) immediately after payment has been received by NJII.

NOTE: If you have previously used NJII’s PQRS Registry (Formerly NJ-HITEC) for reporting, you will receive a new username and password for 2016 Reporting • Visit http://www.mynjii.com/pqrs in a new

browser window • Log in with your myNJII Portal username and

password • If you forgot your password or your password is

incorrect, click on “Forgot Password” to reset it You can skip to Step 3 if you have already collected your patient data

• Click Reporting Individual Measures in the top menu to view 2016 PQRS reporting requirements and download CMS Individual Measures Specification Sheets.

• Use the Reporting Criteria on CMS Individual Measures Specifications Manual to collect data for at least 9 measures across 3 National Quality Strategy (NQS) Domains.

o Collect the following summary or aggregate data required to report Individual Measures: # of

Eligible Instances • # of Eligible Instances where performance is met • # of Eligible Instances where performance is excluded • # of Eligible Instances where performance is not met

2016 PQRS Individual Measures Data Entry Guide

Step3:EnterYourData

Step 3A: Select Individual Measures

• Click the Data Entry tab

• Select a provider by clicking on the corresponding row in the table displayed on the screen

• Verify that the provider’s NPI and Tax ID are correct

• Click under the Reporting Type column

o A “Reporting Type” pop-up window will appear

• Select Individual Measures and click Save

• Scroll to the bottom of the page and click Enter Data in the lower right hand corner

2016 PQRS Individual Measures Data Entry Guide

Step 3B: Select Your Reporting Goal and Measures

• To begin selecting your Individual Measures answer the 2 questions below:

o Has this provider had at least 1 face-to-face encounter with a Medicare patient during 2016?

o Do at least 9 measures across 3 NQS domains apply to this provider? • Click Add Measures in the top right corner • To add a Measure to your Measures List click check box to the left of the Measure #

o To add or remove a Favorite measure, click the star in the Favorites column o Once you have all your Measures Selected, Click Save at the top of the screen

• For inverse measures, a lower performance % is better (Inverse Measures are indicated by

• Hover over column header title for more details

Step 3C: Report Your Measures

• Enter in the data collected for each measure o # of Eligible Instances o # of Eligible Instances where performance is met o # of Eligible Instances where performance is excluded o # of Eligible Instances where performance is not met

2016 PQRS Individual Measures Data Entry Guide

• On the Data Entry screen: • Review your PQRS Measures List to make sure all applicable measures are reported.

o If a measure is incomplete enter in the missing fields • Click Submit in the top right to proceed to the final submission screen

The PQRS Measures List breaks down the reporting rate and performance rate based on CMS guidelines. The reporting rate is the percentage of eligible patients for whom you selected a performance. The performance rate is the number of eligible patients that meet the measure criteria. You need to have a 50% reporting rate to meet the PQRS requirements, and should aim for a high-performance rate to indicate better quality care. The items on the Submission Checklist (at the bottom of the screen) represent the minimum requirements to avoid the 2018 PQRS payment adjustment of -2%. You must meet all goals to successfully submit your PQRS data to NJII’s Registry. The Submit button will only be active when all criteria in the Submission Checklist are met.

Step4:ReviewYourPQRSData

2016 PQRS Individual Measures Data Entry Guide

Step5:CompleteYourFinalSubmission

• Double-check your NPI and Tax ID! o If your NPI and/or Tax ID is incorrect, DO NOT PROCEED with your submission. Call

NJII at 973-642-4055 to update your NPI and/or Tax ID information. • Check the box next to each statement to agree • Complete the Submitter Validation fields • Once you have double-checked your information, click Submit

The deadline to submit PQRS data to New Jersey Innovation Institute for program year 2016 is March 10th, 2017