1. PQRS 2013

2. PQRS
What
The quality reporting program for Medicare Part B (traditional fee for service)
Who
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)
Why
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)

3. PQRS Reporting: Getting Started

4. Determine reporting method
Getting Started
Select measures
Determine reporting method
Educate staff
Begin reporting
Audit success

5. 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:

6. Measure Type: Individual vs 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%

7. Getting Started: Reporting Method and Participation
Choose a reporting method
Claims versus registry
Talk to you billing provider
Qualified registries
Choose reporting participation
Individual versus group (GPRO)

8. Reporting Method Claims vs 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%

9. Reporting Participation: Individual vs 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

10. 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
Checklists for billing staff

11. 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

12. PQRS Reporting: Case Examples

13. PQRS Process PQRS Audit Interim Quarterly Dashboard Reports
Final 2013 Feedback Report- Fall 2014
Source: CMS Open Door Forum 3/22/2011

14. Case Example: Individual Measures
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

15. Case Example: Measure #130
Percentage 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/dietary [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

16. Case Example: Measure #131
Percentage 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 Required
G8731: Pain assessment documented as negative, no follow-up plan required
Patient not Eligible for Pain Assessment for Documented Reasons
G8442: Documentation that patient is not eligible for a pain assessment

17. 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 documented
AND
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)
1100F: 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 Documented
1101F 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

18. 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

19. Case Example: Individual Measures

20. Additional Resources APTA: Case studies Podcasts on specific measures
Successful reporting requirements