understanding cms pqrs new pathology measures: how cap ... · report data on physician quality...

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Understanding CMS PQRS New Pathology Measures: How CAP Members Can Participate

Jonathan L. Myles, MD, FCAP Chair, CAP Economic Affairs Committee Pathology Advisor, AMA RUC Emily E. Volk, MD, FCAP Chair, Public Health Policy Committee

Kimberly Schwartz Nurse Consultant, CMS PQRS Program Manager

Webinar Broadcast Date: December 7, 2011 1

College of American Pathologists:

Physician Quality Reporting System

(Physician Quality Reporting)

Kimberly Schwartz, Nurse Consultant Quality Measurement and Health Assessment Group,

Office of Clinical Standards and Quality

December 7, 2011

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Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Agenda

Overview of Physician Quality Reporting System Tips for Successful Participation/Reporting Identifying Applicable Measures for Reporting Questions & Answers

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PHYSICIAN QUALITY REPORTING SYSTEM

Overview of

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Physician Quality Reporting: Incentives & Adjustments Established in 2007, the Physician Quality Reporting System is a pay-for

reporting program that provides a combination of incentives and payment adjustments to eligible professionals and group practices who satisfactorily report data on Physician Quality Reporting System quality measures

The applicable incentive amounts are as follows: 2012: 0.5 percent 2013: 0.5 percent 2014: 0.5 percent The applicable payment adjustment amounts are as follows: 2015: 1.5 percent 2016 and each subsequent year: 2.0 percent The Physician Quality Reporting System will be the basis for the Value-Based

Modifier This final rule sets forth our requirements for the 2012 Physician Quality

Reporting System Website: http://www.cms.gov/PQRS/

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http://www.cms.gov/PQRS/�

Moving Toward Value- Based Purchasing

2011 • ACA, HITECH

• 194 individual measures

• Claims

• 14 Measures Groups

• Registry

• EHRs

• eRx

• GPRO I

• GPRO II

2007 • 74 measures

• Claims-based only


• Claims


• Registry


• Claims


• Registry

• EHR-testing

• eRx

2010 • 175 individual measures

• Claims


• Registry

• EHRs

• eRx

• GPRO

2012 Final in the CY 2012 PFS NPRM:

• 211 measures total

• 79 new individual measures

• Claims

• 8 new Measures Groups

• Registry

• EHRs

• EHR data submission vendor

• eRx

• GPRO (25 or more NPIs)

• EHR incentive program pilot 7

2012 Decision Tree: 12-Month Reporting Options

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Reporting Measures with Claims

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Registry Submission

What is a registry? Captures and stores clinically related data submitted by the eligible

professional (or group practice) Registry submits information on Physician Quality Reporting System

individual measures or measures groups (or eRx measure) to CMS on behalf of eligible professionals (or group practice)

Registries provide CMS with calculated reporting and performance rates at the end of the reporting period Data must be submitted to CMS via defined .xml specifications

CMS qualifies registries annually Current list of Qualified Registries for 2011 Reporting is available at:

http://www.cms.gov/PQRS/Downloads/2011_ Qualified_Registries_Posting_10-04-2011.pdf ◊ 100 registries and 27 EHRs

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http://www.cms.gov/PQRS/Downloads/2011_Qualified_Registries_Posting_10-04-2011.pdf�

http://www.cms.gov/PQRS/Downloads/2011_Qualified_Registries_Posting_10-04-2011.pdf�

http://www.cms.gov/PQRS�

TIPS FOR SUCCESSFUL PARTICIPATION/REPORTING

Examples of

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Participation: Tips for Success

If reporting using claims: Ensure billing software and clearinghouse can capture all

the codes, zero charges (or a nominal amount), and associated modifiers used in Physician Quality Reporting for the measures selected ◊Discuss with vendors if applicable

Review reporting principles and specifications for each measure or measures group selected ◊CMS website is the official source of measures documentation,

with materials updated yearly ◊Be sure to use current program year materials for the reporting

method chosen!

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Participation: Tips for Success (cont.)

If reporting using claims: (cont.)

Establish internal processes to identify and report all applicable patients and codes

Begin reporting on appropriate Medicare Part B FFS patients via CMS-1500 form or electronically ◊Use rendering National Provider Identifier (NPI) under the

Taxpayer Identification Number (TIN) ◊Check Remittance Advice for N365 remark code (confirms

receipt of quality-data codes but not necessarily accuracy)

Consider reporting more than required (i.e., report 35+ applicable patients for 30 patient sample measures group)

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Participation: Tips for Success (cont.)

If submitting through a qualified registry or qualified EHR: Work with selected vendor Follow their specific instructions for data

collection/submission and timeframes Use rendering NPI/TIN Contact the vendor with questions

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IDENTIFYING APPLICABLE MEASURES FOR REPORTING

Tips on

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2011 Quality Measures

Eligible professionals can choose whether to report individual quality measures or a group of related measures (aka “measures groups”)

194 individual measures, including 44 registry-only measures, 20 measures for EHR-based reporting, and 20 new measures

14 measures groups: Diabetes Mellitus, CKD, Preventive Care, CABG, Rheumatoid Arthritis, Perioperative Care, Back Pain, CAD, HF, IVD, Hepatitis C, HIV/AIDS, CAP, and Asthma (new) Registry-only includes: CABG, CAD, HF, & HIV/AIDS Back Pain measures are reportable as a measures group only

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Identifying Applicable Measures

Review the Physician Quality Reporting System Measures List, and determine which measures apply to your practice

To help select measures, search for frequently billed codes: Single Source Master Code Table (claims/registry for individual

measures) Measures Specifications Manual (claims/registry for individual

measures) Measures Groups Specifications (for measures groups) Downloadable Resource Table (EHRs)

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2012 Quality Measures

Eligible professionals can choose whether to report individual quality measures or a group of related measures (aka “measures groups”)

211 individual measures, including 28 new measures 20 measures groups: Diabetes Mellitus, CKD, Preventive

Care, CABG, Rheumatoid Arthritis, Perioperative Care, Back Pain, CAD, HF, IVD, Hepatitis C, HIV/AIDS, CAP, Asthma, COPD, IBD, Sleep Apnea, Dementia, Parkinson’s, Hypertension, Cardiovascular Prevention, and Cataracts

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RESOURCES Physician Quality Reporting

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Resources

CMS Physician Quality Reporting website http://www.cms.gov/PQRS

CMS eRx Incentive Program website http://www.cms.gov/ERxIncentive

2011 eRx Final Rule http://www.gpo.gov/fdsys/pkg/FR-2011-06-01/pdf/2011-22629.pdf

2012 PFS Final Rule http://ofr.gov/OFRUpload/OFRData/2011-28597_PI.pdf

Frequently Asked Questions Medicare and Medicaid EHR Incentive Programs

http://www.cms.gov/EHRIncentivePrograms Physician Compare http://www.medicare.gov/find-a-doctor/provider-search.aspx

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http://www.cms.gov/PQRS�

http://www.cms.gov/ERxIncentive�

http://www.gpo.gov/fdsys/pkg/FR-2011-06-01/pdf/2011-13463.pdf�

http://ofr.gov/OFRUpload/OFRData/2011-28597_PI.pdf�

http://www.cms.gov/EHRIncentivePrograms�

http://www.medicare.gov/find-a-doctor/provider-search.aspx�

Where to Call for Help

QualityNet Help Desk: Portal password issues PQRS/eRx feedback report availability and access IACS registration questions IACS login issues PQRS and eRx Program and measure-specific questions

866-288-8912 (TTY 877-715-6222) 7:00 a.m.–7:00 p.m. CST M-F or [email protected]

You will be asked to provide basic information such as name, practice, address, phone, and e-mail

Provider Contact Center: Questions on status of 2010 eRx/PQRI incentive payment (during distribution

timeframe) See Contact Center Directory at

http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip

EHR-ARRA Information Center: 888-734-6433 (TTY 888-734-6563)

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mailto:[email protected]�

http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip�

QUESTIONS & ANSWERS Thanks!

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cap.org

Pathology Measures PQRS 2012

Jonathan L. Myles, MD FCAP Chair, CAP Economic Affairs

Committee Pathology Advisor, AMA RUC

Emily E. Volk, MD FCAP Chair, Public Health Policy

Committee

December 7, 2011

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Pathology Measure Specifications

• Pathology measures in the 2012 PQRS • 2012 PQRS Reporting • 2012 Measure Specifications • Case studies • Q & A

© 2011 College of American Pathologists. All rights reserved. 24

Pathology measures in the 2012 PQRS

• Breast Cancer Resection Pathology Reporting • Colorectal Cancer Resection Pathology Reporting • Barrett’s Esophagus* • Radical Prostatectomy Pathology Reporting* • Immunohistochemical (IHC) Evaluation of Human

Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer Patients*

*New in 2012


2012 PQRS Reporting

CMS requires eligible professionals (EP) to report on at least three measures to be eligible for the 0.5% bonus in for reporting in 2012.

• EPs with fewer than three applicable measures must report on all measures that apply and will be subject to measure-applicability validation process (MAV) by CMS

• EPs must report on 80% of eligible cases if reporting via registry

• EPs must report on 50% of eligible cases if reporting via claims © 2011 College of American Pathologists. All rights reserved. 26

Measure Specifications

#99 Breast Cancer Resection Pathology Reporting Numerator: Reports that include the pT category, the pN category and the histologic grade Denominator (Eligible Population): All breast cancer resection pathology reports (excluding needle biopsies) ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.7, 174.8, 174.9, 175.0, 175.9

AND CPT service codes: 88307, 88309



Reporting on Breast Cancer Measure Use CPT Category II Codes: 3260F -

• Modify with (-1P) if medical reason documented for not reporting required elements

• Modify with (-8P) if required elements not included on report

3250F-Specimen site other than anatomic location of primary tumor



#100 Colorectal Cancer Resection Pathology Reporting Numerator: Reports that include the pT category, the pN category and the histologic grade Denominator (Eligible Population): All colon and rectum cancer resection pathology reports (excluding biopsies) ICD-9 diagnosis codes: 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.8 AND CPT service codes: 88309



Reporting on Colorectal Cancer Measure (NEW) (NEW) Use G Codes: G8721 - if all required elements are included in the report

• Use G8722 if medical reason documented for not reporting required elements

• Use G8724 if required elements not included on report

G8723-Specimen site other than anatomic location of primary tumor



#249 Barrett’s Esophagus Numerator: Esophageal biopsy reports that document the presence of Barrett’s mucosa and includes a statement about dysplasia Denominator (Eligible Population): All esophageal biopsy reports that document the presence of Barrett’s mucosa ICD-9 diagnosis codes: 530.85

AND CPT service codes: 88305



Reporting on Barrett’s Esophagus Measure Use CPT Category II and G Codes: 3125F – (once per patient per each date of service)

• Modify with (-1P) if medical reason documented for not reporting the finding of Barrett’s mucosa (e.g. malignant neoplasm, absence of intestinal dysplasia)

• Modify with (-8P) if required element is not included on report

G8797-Specimen site other than anatomic location of esophagus



#250 Radical Prostatectomy Pathology Reporting Numerator: Reports that include the pT category, the pN category, Gleason score and statement about margin status Denominator (Eligible Population): Patients with radical prostatectomy pathology reports ICD-9 diagnosis codes: 185

AND CPT service codes: 88309



Reporting on Radical Prostatectomy Measure Use CPT Category II and G Codes: 3267F -

• Modify with (-1P) if medical reason documented for not reporting required elements

• Modify with (-8P) if required elements not included on report

G8798-Specimen site other than anatomic location of prostate



#251 IHC Evaluation of Human Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer patients Numerator: Quantitative HER2 by IHC evaluation consistent with scoring system defined in the ASCO/CAP guidelines Denominator (Eligible Population): All breast cancer patients with quantitative breast tumor evaluation by HER2 IHC ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 175.0, 175.9

AND CPT service codes: 88360, 88361



Reporting on HER2 measure Use CPT Category II Codes: 3394F - Quantitative HER2 by IHC evaluation utilizing scoring system defined in the ASCO/CAP guidelines

• Modify with (-8P) if evaluation on HER2 was not performed using the recommended scoring system

3395F-Quantitative non-HER2 IHC evaluation (e.g. quantitative evaluation of estrogen or progesterone receptors by IHC)


Case Study 1

• A 65-year-old woman developed a 3cm breast mass and a subsequent needle biopsy specimen revealed infiltrating ductal carcinoma. After consultation with her surgeon, oncologist and radiation therapist, the patient elected to undergo a modified radical mastectomy with axillary lymph node dissection. The surgical pathology report from the resection includes pT, pN, and tumor grade. The specimen is sent for HER2 IHC testing and ER/PR IHC testing. The pathologist has been participating in the PQRS for breast cancer specimens.


Case Study 1

Two measures apply in this case- • Breast Cancer Resection Pathology Reporting • Immunohistochemical (IHC) Evaluation of Human

Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer patients


Case Study 1

• The PQRS code 3260F is entered into field 24D of the CMS-1500 hard copy form.

• If the pathologist was participating in PQRS and had

not included pTpN in the surgical pathology report, the case would be coded with the (-8P) modifier.

• In both cases, the pathologist would be considered

as meeting the PQRS requirement for reporting.


Case Study 1

The pathologist would also report on the HER2 measure:

• The PQRS code 3394F is entered into field 24D of the CMS-1500 hard copy form if the measure is met.

• If the pathologist was participating in PQRS and had

not used the ASCO/CAP scoring system, the case would be coded with the (-8P) modifier.

• In both cases, the pathologist would be considered as

meeting the PQRS requirement for reporting


Case Study 1

• If ER/PR was also done at the same time and billed on the same claim, 3395F would also be added to the CMS-1500 hard copy form

• If ER/PR was also done but on billed on a separate claim, 3395F would be added to the CMS-1500 hard copy form on which the ER/PR evaluation was billed.


Case Study 2

A 68 year old man with a history of Barrett's mucosa underwent endoscopic evaluation of the esophagus. During the procedure, multiple endoscopic biopsies were obtained and placed in a total of 6 specimen containers representing different sites within the esophagus. Five of the six specimens demonstrated Barrett's mucosa. Two of those five specimens demonstrated high grade dysplasia, while dysplasia was not identified in the other three specimens. The CMS 1500 form indicated 530.85 as a primary ICD9 code in the case. The pathologist is participating in PQRS. What is the correct way to code this case for PQRS?


Case Study 2

Answer:

A pathologist choosing to report on the Barrett’s Esophagus measures would enter CPT Category II (PQRS) code 3125F into field 24D once on the CMS-1500 hard copy form if a statement about dysplasia was included.

For this measure, the PQRS code is entered once per patient per each date of service.


Case Study 2

If the pathologist was participating in PQRS and had not included a statement on dysplasia, the case would be coded with the (-8P) modifier appended to the 3125F CPT II code.

For biopsies at other sites in Barrett’s patients use:

G8797-Specimen site other than anatomic location of esophagus


Case Study 3

A 73 year old man presents to his physician with an elevated serum Prostate Specific Antigen. Subsequent prostate biopsies are performed and reveal invasive adenocarcinoma in 3 of 6 core biopsies (Gleason score 4+3=7). The urologist later performs a radical prostatectomy. The prostatectomy specimen is sent to the hospital pathologist who wishes to participate in PQRS. The pathologist includes pT and pN, the Gleason score and the margin status in the final surgical pathology report.

What is the correct way to code this case?


Case Study 3

Answer:

The CMS 1500 form indicated 185 as a primary ICD-9 code in the case for malignant neoplasm of prostate.

CPT code 88309 (level VI surg path, gross and microscopic exam) was listed in field 24D of the CMS-1500 hard copy form.

For a pathologist choosing to report on the Radical Prostatectomy measure one enters CPT Category II (PQRS) code 3267F into field 24D once on the CMS-1500 hard copy form if all four required elements were included on the report.


Measure Specifications Available at:

https://www.cms.gov/PQRS/15_MeasuresCodes.asp


https://www.cms.gov/PQRS/15_MeasuresCodes.asp�

Case Study 4

A 75-year-old man came to his primary care physician for a routine annual visit. History revealed symptoms of fatigue. Physical examination was essentially unremarkable, but fecal occult blood testing was positive, and laboratory examination revealed a microcytic, hypochromic anemia. The patient was referred to a gastroenterologist. Outpatient sigmoidoscopic examination revealed a friable mass in the sigmoid colon. The mass was biopsied, and the specimen was sent to the hospital pathology laboratory, where it was examined and reported as showing infiltrating moderately differentiated adenocarcinoma. The patient was then referred to a surgeon, who performed a sigmoid resection and regional lymph node dissection at the same hospital. This specimen was sent to the same hospital pathology laboratory as the biopsy specimen. The surgical pathology report from the resection includes pT, pN, and tumor grade. The pathologist wishes to participate in the PQRS program.


Case Study 4

• The PQRS code G8721 is entered into field 24D of the CMS-1500 hard copy form for the resection specimen.

• The biopsy specimen is not covered by the measure, no CPT II code would be added for the biopsy specimen.


Case Study 4

For specimens at other sites in this patient use:

G8723 - Specimen site other than anatomic location of colon


Case Study 5

The patient with breast cancer in Case #1 developed elevated liver enzymes one year later. CT scan demonstrated a 2 cm mass in the liver. A needle biopsy of the liver demonstrated metastatic adenocarcinoma. The pathologist wishes to participate in the PQRS program.

When coding the case, a secondary ICD9 code was entered which qualified the case for PQRS.


Case Study 5

• The correct CPT code for this case would be 88307

• The correct code to enter in field 24D on CMS form 1500 would be 3250F.

• The pathologist would be considered as having met the PQRS reporting requirement.


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