PQRS: What You Need to Know and How Therabill Will Help
Physician Quality Reporting System (PQRS)
Federally mandated program that is voluntary for health care providers
Established by Tax Relief and Health Care Act of 2006 (TRHCA)
Implemented by Centers for Medicare and Medicaid Services (CMS) 2007
Incentives of 0.5% increase in payment for covered Medicare Part B charges through 2014 for “Eligible Providers” (EPs)
Penalties (“payment adjustments”) for EPs who are not participating in this program by 2015
Toward an Evidence-Based Medical Reimbursement System
According to the Agency for Healthcare Research and Quality (AHRQ),
“…Evidence-based medicine: the movement to evaluate the safety, effectiveness, and cost of medical practices using tools from science and social science and to base clinical practice on such knowledge.” This was first addressed by the 2006 Tax Relief and Health Care Act, which linked reimbursement to “quality measures”. CMS established their Physician Quality Reporting System (PQRS) based on these quality measures utilized in the treatment of Medicare beneficiaries. Types of measures include:
Structural, efficiency or cost-of-care measures
Quality measures consist of a denominator (eligible cases within a defined demographic of patients who are being evaluated or treated for a particular condition, or who have achieved a particular outcome), and a numerator (the clinical action performed to treat or evaluate that condition or achieve that outcome). According to the “2013 Physician Quality Reporting System (PQRS): Implementation Guide – Claims Based Reporting for Incentive”:
“ The measures in 2013 PQRS address various aspects of care, such as prevention, chronic-and-acute-care management, procedure-related care, resource utilization, and care coordination…At a minimum, the following factors should be considered when selecting measures for reporting:
Clinical conditions usually treated
Types of care typically provided – e.g. preventive, chronic, acute
Settings where care is usually delivered
Quality improvement goals for 2013…
Eligible Professionals (EPs) should not choose individual measures that do not or infrequently apply to services provided to Medicare patients by the eligible professional/practice. EPs may choose to report on measures groups if all the measures within the group are applicable to services provided to Medicare patients by the EP. “ For example, Therapists who treats Medicare patients for back pain may report the “Back Pain Measures Group”:
Measure #148: Back Pain; Initial Visit
Measure #149: Back Pain; Physical Exam
Measure #150: Back Pain: Advice for Normal Activities
Quality-Data Codes are non-revenue (information only) Healthcare Common Procedure Coding System (HCPCS) codes consisting of G-codes and/or CPT II codes defined by Centers for Medicare and Medicaid Services (CMS) for the express purpose of reporting quality measures. According to the AMA 2013 PQRS Implementation Guide for claims-based reporting,
1.) “QDCs must be reported:
On the claim(s) with the denominator billing code(s) that represents the eligible Medicare Part B PFS (Physician Fee Schedule) encounter
For the same beneficiary
For the same date of service (DOS)
By the same eligible professional (individual rendering NPI) who performed the covered service, applying the appropriate encounter codes (ICD-9-CM, CPT Category I or HCPCS codes). These codes are used to identify the measures denominator.”
2.) “QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed.
The submitted charge field cannot be blank
The line item charge should be $0.00
If the system does not allow a $0.00 line-item charge, a nominal amount (e.g. $0.01) can be substituted – the beneficiary is not liable for this nominal amount.
Entire claims with a zero charge will be rejected.
Whether a $0.00 charge or a nominal amount is submitted to the carrier or A/B Medicare Administrative Contractor (MAC), the PQRS code line will be denied but will be tracked in the National Claims History (NCH) for analysis.”
3.) “When a group bills, the group NPI is submitted at claim level; therefore, the individual rendering/performing physician’s NPI must be placed on each line item, including all allowed charges and quality-data line items. Solo practitioners should follow their normal billing practice of placing their individual NPI in the billing provider field (#33 on the CMS-1500 form or the electronic equivalent).”
“Note: Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. If a denied claim is subsequently corrected through the appeals process to the Carrier or A/B MAC, with accurate codes that also correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be included in the submitted claim as instructed in the measures specifications.”
The denial code on the remittance advice (RA) or explanation of benefits (EOB) states: “This procedure is not payable. It is for reporting/information purposes only” and is an indicator that the QDC codes were received, but does nor guarantee the QDC is correct or applied to incentives. It is recommended that you keep track of all reported QDCs for the purpose of verifying them against RAs and/or EOBs received for applicable claims.
The Organizations who Develop Quality Measures:
PCPI (Physician Consortium for Performance Improvement) led by the AMA (American Medical Association) is the main group involved in the development of measures.
NQF (National Quality Forum), open to any government or other parties interested in quality issues in health care delivery, reviews measures and makes adoption recommendations.
AQA Alliance consists of physician and consumer groups and insurers and reviews measures and makes recommendations on whether they should be adopted. Members include:
AAFP (American Academy of Family Physicians)
ACP (American College of Physicians
AHIP (American Health Insurance Plans
AHRQ (Agency for Health Care Research and Quality (This group relies on the recommendations of PCPI and NQF (described above))
Therabill members who qualify as Eligible Providers (EPs):
Clinical Social Worker
Reporting PQRS Measures; Three ways to Report:
1) Claims based: to CMS on Medicare Part B claim form
2) Registry based: to a qualified PQRS registry
3) Via a certified EHR system or qualified PQRS data-submission vendor
Claims Based Physician Quality Reporting
Step 1: Complete claim with codes for reimbursement
Step 2: Reference measure specifications to ensure accurate application of denominator and numerator codes:
CPT codes for covered services
QDC (quality data codes) submitted with a line item charge of 0.00) at the time the associated covered service is performed.
Step 3: Review claim for accuracy:
Charge field for QDC cannot be blank (line item charge of 0.00)
Line item containing QDC should only reference one diagnosis from the base claim.
Documentation must support covered service
Step 4: Submit claim to Medicare
Step 5: Review ERA/EOB for denial code N365. This code indicates the PQR codes were received into the National Claims History.
Analysis of PQRS Data: Reporting Frequency (Measure Tag) and Performance Timeframes
Reporting Frequency (from the AMA 2013 PQRS Implementation Guide):
“Patient-Process: report a minimum of once per reporting period per individual EP (NPI)
Patient- Intermediate: Report a minimum of once per reporting period per individual EP (NPI)
Patient-Periodic: Report once per timeframe specified in the measure for each individual EP (NPI) during the reporting period.
Episode: Report once for each occurrence of a particular illness/condition by each individual EP (NPI) during the reporting period.
Procedure: Report each time a procedure is performed by the individual EP (NPI) during the reporting period.
Visit: Report each time the patient is seen by the individual EP (NPI) during the reporting period.
A measure’s performance timeframe is defined in the measure’s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, outlines the timeframe in which the clinical action described in the numerator may be completed.”
Registry Based Physician Quality Reporting
Speech Language Pathologists are eligible to report eight outcome measures pertaining to Medicare beneficiaries being treated for late effects of cerebrovascular disease (CVD). These measures must be reported to a registry:
1) #209: Functional Communication Measure - Spoken Language Comprehension
2) #210: Functional Communication Measure - Attention
3) #211: Functional Communication Measure - Memory
4) #212: Functional Communication Measure - Motor Speech
5) #213: Functional Communication Measure -Reading
6) #214: Functional Communication Measure - Spoken Language Expression
7) #215: Functional Communication Measure -Writing
8) #216: Functional Communication Measure – Swallowing
The registry ASHA recommends for Speech Language Pathologists to report PQRS to is NOMS (National Outcomes Measurement System).
Therabill is developing a data collection system that will simplify the process of incorporating PQRS reporting and other changes effective January 1, 2013, making it possible to achieve incentive bonuses (a 0.5% increase) for reporting PQRS in 2013 and 2014, and avoid “payment adjustments” (deductions of 1.5%) in 2015.