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2016 PQRS and VBMfor Radiology

Table of Contents

Summary 1PQRS 1 Definitions 2 PQRSBasics 2 MAV 2 Claims-basedvs.Registry-based Reporting 3RadiologyPQRSmeasuresfor2016 3Value-BasedPaymentModifier(VBM) 5

SUMMARY

RadiologyPQRSreportingrequirementsfor2016aresimilartothosein2015butwiththeadditionofthreenewmeasures. If2016PQRSisnotreported,ornotreportedaccurately (acommonproblem),radiologistsingroupsof10ormoreproviderswillseea-6%adjustmenttoMedicarepaymentsin2018.Thoseinsmallergroupswillseea-4%adjustment.

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

PQRSresultsalsoshowupon“PhysicianCompare”andproposedchangeswillmapPQRSperformanceintoa5starratingsystemforconsumersbycomparingresultsacrossproviders.

PQRS

ToavoidpenaltiesfornotreportingPQRSandVBM,radiologistsmustmeettheBasic Reporting Requirements: -Individualsorgroupswhoreportindividualmeasuresmustcompleteninemeasuresforat

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

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

However,theserequirementsdonotmatchwellwithmanyradiologistssincecross-cuttingmeasuresmaynotapplyand9measuresmaynotapplytoeveryradiologist.Inthesecircumstances,radiologistsaresubjecttothe“MAV”audit,describedbelow.

PQRSissettoexpireafterthisyear(the2016PQRSreportingyearaffects2018Medicarepayments)andbereplacedbytheMerit-BasedIncentivePaymentSystem(MIPS)in2017(whichwillaffect2019

AT A GLANCE:

-PQRS/VBMpenaltiesare-4%to-6%

-Registryreportingisstronglyrecommended

-Thereare3newmeasuresfordiagnosticradiologyin2016



2016 PQRS and VBM for Radiology 1


payments).MIPSismandatedbyMACRA(theMedicareAccessandCHIPReauthorizationActof2015).MACRA eliminated the annual SGR payment reductions and, among other items, replaces PQRS,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

-There isno incentivepayment forreportingPQRSmeasures in2016. However,bonuspayments may be earned via the Value Based Modifier Program (which starts withPQRSdata).

-EPswhodonotsuccessfullyparticipatein2016willreceivea-2%PQRSpaymentadjustmentanda-2%or-4%VBMadjustmentontheir2018Medicarepayments.

-WhiletherearehundredsofPQRSmeasures,only12orfewertypicallyapplytodiagnosticradiology,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.

-Forat least50%ofMedicarepatients,CMSrequiresreportingon9measures,at leastoneofwhichisaso-called“cross-cuttingmeasure”.Butmanyradiologists,donothave9applicablemeasures,inwhichcasetheMAVapplies(seebelow).

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

MAV

For those who report fewer than nine measures or fewer than three domains, the MeasureApplicabilityValidation(MAV)Auditapplies.MedicarecomparesyourPQRSdatatoitsmeasurespecificationstoidentifyothermeasureswhichcouldhavebeenreported,butwerenot.Whilethemeasurestheyidentifymaynotseemrelevant,iftheymeetMedicare’sdefinition,theydirectlyaffectyourPQRScompliance.



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Claims-based vs. Registry-based Reporting

Inthispaper,wefocusprimarilyonclaimsandregistry-basedreportingsincemanyradiologygroupsdonothavetheabilitytouseanEHRforEHR-basedreporting(andmanyEHRsdonothavethenecessaryCEHRTcertification to report themeasures).QCDR isabroader topicas that reportingmethodtypicallyrequiresadditionalqualitymeasuresbeyondthoseinPQRS.

WithPQRSpenaltiesnowsignificant (-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,thosewhousedclaims-basedreportingspentcountlesshourstryingtodeterminewhatdataCMSactuallyhad.Andevenwhenbaddatawasappealed,penaltieswerestillapplied.Registryreportingprovidesongoingfeedbackand,importantly,providesfeedbackonhowanEPorgroupwillfareinaMAVAudit.Inaddition,witharegistry,PQRSdatacanbeupdatedorevenreplaced,somethingthatisimpossiblewithclaims-basedfiling.Asaresult,usingaregistryeliminatesMAVandPQRSpenaltyrisks.

RADIOLOGYPQRSMEASURESFOR2016

The2016PQRSmeasuresforDiagnosticRadiology,asidentifiedbytheACRareshownhere.Thelast3inthetablearenewfor2016.TheCMSlistforradiologywhichincludesmeasuresforInterventionalRadiologycanbefoundhere.Notethatthesearethepossiblemeasures,buteachEPandgroupneedstodeterminewhichapplytotheircircumstances:



Percentageoffinalreportsforproceduresusingfluoroscopythatdocumentradiationexposureindices,orexposuretimeandnumberoffluorographicimages(ifradiationexposureindicesarenotavailable)

Percentageoffinalreportsforscreeningmammogramsthatareclassifiedas“probablybenign”

NuclearMedicine:CorrelationwithExisting ImagingStudies forAllPatientsUndergoingBoneScintigraphy:Percentageoffinalreportsforallpatients,regardlessofage,undergoingbonescintigraphythatincludephysiciandocumentationofcorrelationwithexistingrelevantimagingstudies(e.g.,x-ray,MRI,CT,etc.)thatwereperformed

Percentageoffinalreportsforcarotid imagingstudies(neckmagneticresonanceangiography[MRA], neck computed tomographyangiography [CTA],neck duplexultrasound, carotidangiogram)performedthatincludedirectorindirectreferencetomeasurementsofdistalinternalcarotiddiameterasthedenominatorforstenosismeasurement

Percentageofpatientsundergoingascreeningmammogramwhoseinformationisenteredintoaremindersystemwithatargetduedateforthenextmammogram

http://www.acr.org/~/media/ACR/Documents/P4P/2016%20PQRS/DX/Diagnostic%20Radiology%20Measure%20Specifications_Table.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/Radiology_Specialty_Measure_Set.pdf

265

322

323

324

405

(newfor2016)

406

(newfor2016)

436

(newfor2016)




Percentageofnewpatientswhosebiopsyresultshavebeenreviewedandcommunicatedtotheprimarycare/referringphysicianandpatientbytheperformingphysician

Percentage of stress single-photon emission computed tomography (SPECT) myocardialperfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomographyangiography(CCTA),orcardiacmagneticresonance(CMR)performedinlowrisksurgerypatients18yearsorolderforpreoperativeevaluationduringthe12-monthreportingperiod

Percentage of all stress single-photon emission computed tomography (SPECT) myocardialperfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomographyangiography(CCTA),andcardiovascularmagneticresonance(CMR)performedinpatientsaged18yearsandolderroutinelyafterpercutaneouscoronaryintervention(PCI),withreferencetotimingoftestafterPCIandsymptomstatus

Percentageofallstresssingle-photonemissioncomputedtomography(SPECT)myocardialperfusionimaging(MPI),stressechocardiogram(ECHO),cardiaccomputedtomographyangiography(CCTA),andcardiovascularmagneticresonance(CMR)performedinasymptomatic,lowcoronaryheartdisease(CHD)riskpatients18yearsandolderforinitialdetectionandriskassessment

Percentageoffinalreportsforabdominalimagingstudiesforasymptomaticpatientsaged18yearsandolderwithoneormoreofthefollowingnotedincidentallywithfollow-upimagingrecommended:-Liverlesion≤0.5cm-Cystickidneylesion<1.0cm-Adrenallesion≤1.0cm

Percentageoffinalreportsforcomputedtomography(CT)ormagneticresonanceimaging(MRI)studiesofthechestorneckorultrasoundoftheneckforpatientsaged18yearsandolderwithnoknownthyroiddiseasewithathyroidnodule<1.0cmnotedincidentallywithfollow-upimagingrecommended

Percentageof finalreportsforpatientsaged18yearsandolderundergoingCTwithdocumentationthatoneormoreofthefollowingdosereductiontechniqueswereused:-Automatedexposurecontrol-AdjustmentofthemAand/orkVaccordingtopatientsize-Useofiterativereconstructiontechnique


Inaddition,groupsusingQCDRreportinghavetheoptionof“measuresgroup”reporting.Itrequiresreporting for20patients, themajorityofwhichareMedicare.The“OptimizingPatientExposure toIonizingRadiation”istheonlymeasuresgroupthatappliestoRadiologyfor2016.Itcontains:

-#359 Optimizing Patient Exposure to Ionizing Radiation: Utilization of a StandardizedNomenclatureforComputedTomography(CT)ImagingDescription

-#360OptimizingPatientExposuretoIonizingRadiation:CountofPotentialHighDoseRadiationImagingStudies:ComputedTomography(CT)andCardiacNuclearMedicineStudies

-#361OptimizingPatientExposure to IonizingRadiation:Reporting toaRadiationDoseIndexRegistry

-#362OptimizingPatientExposuretoIonizingRadiation:ComputedTomography(CT)ImagesAvailableforPatientFollow-upandComparisonPurposes

-#363OptimizingPatientExposuretoIonizingRadiation:SearchforPriorComputedTomography(CT)StudiesThroughaSecure,Authorized,Media-Free,SharedArchive

-#364OptimizingPatientExposuretoIonizingRadiation:Appropriateness:Follow-upCTImagingforIncidentallyDetectedPulmonaryNodulesAccordingtoRecommendedGuidelines

DetailsforeachmeasureareavailableintheCMSIndividualMeasuresGuide,availableasadownloadatthisCMS page.

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,etc.Asinpreviousyears,theseprovidersnewtotheprogramarenotsubjecttodownwardadjustments,but



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


thatappliesonlytosoloNPPsorthoseinagroupofonlyNPPs.Solophysiciansandgroupsoftwoormorephysiciansand/orNPPsaresubjecttopaymentadjustments(upordown)basedontheirratioofqualitytocostascomparedtootherprovidersintheMedicareprogram.

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



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