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PQRS 2013

PQRS

• The quality reporting program for Medicare Part B (traditional fee for service)What

• Eligible providers (PT’s) who bill under the physician fee schedule (part B)• Includes private practices• Excludes facility based providers (SNF, OP

hospital, CORF, etc)Who

• In 2015, practitioners will receive payment adjustments (-1.5%) in their Medicare part B reimbursement if they to not participate in the program (adjustments will be based on CY2013 data)

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PQRS REPORTING: GETTING STARTED

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Getting Started

Select measures

Determine reporting method

Educate staff

Begin reporting

Audit success

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Getting Started: Measure Selection

• Decide which measures best fit for your Medicare population– Choose 3 or more applicable individual

measures OR the group measure• What conditions do you usually treat?• What types of care or interventions are provided in

the clinic?

– Information on the measures is under the 2013 PQRS Measure Details section of the webpage: www.apta.org/PQRS

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Measure Type: Individual vs Group

Individual Group

# Required for Successful Reporting

3 measures per therapist 1 measure per therapist

Measure Focus Variable Condition or disease specific

Reporting Threshold (# of patients)

No threshold 15+ unique patients per 12 month reporting period (CY); 8+ per 6 month reporting period

Intent to Report Code

N/A Must be reported once per reporting period per practitioner

Success Rate via Claims (CY2010)

Individual measures 63% Group measures 51%

Success Rate via Registry (CY2010)

Individual measures 87% Group measures 94%

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Getting Started: Reporting Method and Participation

• Choose a reporting method– Claims versus registry

• Talk to you billing provider• Qualified registries

https://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp

• Choose reporting participation– Individual versus group (GPRO)

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Reporting Method Claims vs Registry

Claims Registry

Cost None Variable

QDC Selection

Each practitioners is responsible for choosing and submitting the QDC’s

Each practitioners is responsible for entering data into the registry ; QDC’s generated based on the data

Updating Annual measure updates must be monitored by the facility

Registry monitors and incorporates annual measure updates

Reporting Requirements

Data must be submitted on +50% of all eligible Medicare patients

Data must be submitted on +80% of all eligible Medicare patients

EHR N/A EHR and registry can be linked

Auditing Each facility must establish an auditing process to ensure successful reporting

Registry provides participants with feedback reports throughout the year

Success Rate (CY2010 data)

Individual measures 63%Group measures 51%

Individual measures 87%Group measures 94%

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Reporting Participation: Individual vs GPRO

Individual GPRO

Registration required

No Yes

Data analysis Analyzed at the individual (NPI) level; looks are the reporting rate of each professional on the selected measures

Analyzed at the group (TIN) level; looks are the cumulative reporting rate of the group on the selected measures

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Getting Started: Staff Education

• Educate staff about the measure specifications and billing procedures– Create processes that support PQRS

implementation• Flow charts or algorithms for clinicians

– AMA tool for 2013 updates typically posted by February

http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system-2012.page

• Checklists for billing staff

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Getting Started: Auditing Your Success

• Plan an auditing process to evaluate your success– Billing audit for claims submission

• Use billing data and N365 remittance advice code on EOB

– Quality Net quarterly dashboard reports– Registry feedback reports – Chart review for content

• Documentation must support the clinical quality action as indicated by the chosen QDC

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PQRS REPORTING: CASE EXAMPLES

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PQRS Process

Source: CMS Open Door Forum 3/22/201113

PQRS Audit

Interim Quarterly Dashboard Reports

Final 2013 Feedback Report- Fall 2014

Case Example: Individual Measures

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Mrs. S is a new

patient she presents for her initial

evaluation on with

adhesive capsulitis

of the shoulder

The therapist performs the initial evaluation and completes the measures:• Ensure

patient is eligible for the measure

• Select the corresponding G-Code or CPT II modifier

• Document to support the quality activities

The administrative staff submits the bill for processing• Ensure

the claim is accepted and check the EOB for the N365 remittance advice code

Case Example: Measure #130Percentage of patients aged 18 years and older with a list of current medications

(includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) documented by the provider, including drug name, dosage, frequency

and route

Current Medications with Name, Dosages,

Frequency and Route Documented

G8427: List of current

medications (includes

prescription, over-the-counter,

herbals, vitamin/mineral/diet

ary [nutritional] supplements)

documented by the provider, including

drug name, dosage, frequency

and route

Current Medications with Dosages not

Documented, Patient not Eligible

G8430: Provider documentation that

patient is not eligible for medication assessment

Current Medications with Name, Dosages,

Frequency, Route not Documented, Reason

not Specified

G8428: Current medications

(includes prescription, over-

the-counter, herbals,

vitamin/mineral/dietary [nutritional]

supplements) with drug name,

dosage, frequency and route not

documented by the provider, reason

not specified

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Case Example: Measure #131Percentage of patients aged 18 years and older with documentation of a pain

assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

Pain Assessment Documented as Positive

G8730: Pain assessment

documented as positive utilizing a standardized tool AND a follow-up

plan is documented

G8509: Documentation of

positive pain assessment; no

documentation of a follow-up plan,

reason not specified

Pain Assessment Documented as

Negative, No Follow-Up Plan RequiredG8731: Pain assessment

documented as negative, no follow-

up plan required

Patient not Eligible for Pain Assessment for

Documented ReasonsG8442:

Documentation that patient is not

eligible for a pain assessment

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Case Example: Measure #154

Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months

Risk Assessment for

Falls Completed

3288F: Falls risk

assessment documente

dAND

1100F: Patient

screened for future fall risk;

documentation of two or more falls in

the past year or any

fall with injury in the past year

Risk Assessment for

Falls not Completed for

Medical Reasons

3288F with 1P:

Documentation of

medical reason(s)

for not completing

a risk assessment for falls (i.e.,

reduced mobility,

bed ridden, immobile,

confined to chair, etc)

AND1100F: Patient

screened for future fall risk

If patient is not eligible for this

measure because patient

has documentation

of no falls or only one fall without injury the past year, report: Patient not at Risk for

Falls

1101F: Patient

screened for future fall risk;

documentation of no

falls in the past year or only one fall

without injury in the past year

If patient is not eligible for this

measure because falls status is not documented, report: Falls Status not

Documented1101F with 8P: No

documentation of falls

status

Risk Assessment for

Falls not Completed, Reason not Specified

3288F with 8P: Falls

risk assessment

not completed, reason not otherwise specified

AND1100F: Patient

screened for future fall risk

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Case Example: Measure #155

Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months

Plan of Care Documented

0518F: Falls plan of care

documented

Plan of Care not Documented for Medical

Reasons

0518F with 1P: Documentation of medical reason(s) for no plan of care

for falls

Plan of Care not Documented, Reason

not Specified

0518F with 8P: Plan of care not

documented, reason not

otherwise specified

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Case Example: Individual Measures

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Additional Resources

• APTA:– Case studies– Podcasts on specific measures– Successful reporting requirements

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