2011 CMS Physician Quality Reporting System (PQRS): Teaching Doctors of Chiropractic How to Report on Measures Related to Quality Patient Care by Tony Hamm, American Chiropractic Association
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2011 CMS Physician Quality Reporting System (PQRS)
Teaching Doctors of Chiropractic How to Report on Measures Related to Quality Patient Care
Presentation for the National University of Health Sciences
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• Public/private focus on quality care• Why participate in the PQRS (formerly called PQRI) • Information about the 2011 PQRS and measures• How to report on measures applicable to DCs• How you can help improve quality in the chiropractic
• “Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser” – Centers for Medicare and Medicaid Services 2007– Current Medicare Physician Fee Schedule
based on quantity and resources consumed, NOT quality or value
• Value = Quality / Cost– Incentives can encourage higher quality and
avoidance of unnecessary costs to enhance the value of care
• Health outcomes in the United States can be improved by a reduction in medical errors and stronger reliance on evidence-based practice (IOM)
• To address the need for better quality health care, Congress passed the 2006 Tax Relief and Healthcare Act establishing the Physician Quality Reporting Initiative
Help focus attention on quality of care--Need to determine best practices, collect data, report results, set targets, align incentives, & improve systems
PQRI reauthorized in 2007 by the Medicare Extension Act, in 2008 under the Medicare Improvements for Patients and Providers Act and in 2010, under the Patient Protection and Affordable Care Act. PPACA made PQRI a permanent program. When the program was made permanent, its name was changed to the Physician Quality Reporting System.
• A voluntary program in 2011• NPI required for participation• 2011 program includes 3 INDIVIDUAL quality measures applicable
to DCs– Pain Assessment Prior to Patient Therapy– Functional Outcome Assessment in Chiropractic Care– Health Information Technology Adoption/Use of EHRs
• Reporting periods: January 1-December 31 and July 1-December 31
• Law requires CMS to use sampling or other means to validate whether quality measures apply to the services that have been reported
– The Agency is NOT looking at documentation of E/M services, rather it is evaluating documentation of a G-code and/or quality data code related to quality measure reporting
• Determinations of successful reporting are excluded from formal administrative or judicial review
• This measure is to be reported for each visit occurring during the reporting period for all patients aged 18 yrs & older
• Percentage of patients aged 18 yrs and older with documentation of a pain assessment (if pain is present, including location, intensity and description) through discussion with the patient including the use of a standardized tool i.e. McGill Pain Questionnaire, on each visit prior to initiation of therapy and follow-up including a reassessment of pain and documentation of a future appointment, education, referral, notification of primary care provider, etc.
• 65-year old male complains of 2 week history of lower back pain. Pain is located over the right lower back and buttocks. The pain is described as sharp, constant and 6/10 VAS.
• A CPT service code is required to identify patients to be included in this measure – CMT codes (98940-98942) included
• If pain assessment prior to patient therapy was provided, document one of the G-code descriptors– G8440 (pain assessment AND follow-up plan documented)– G8442 (pain not assessed; document exclusion)– G8441 (no documentation of pain assessment)– G8508 (pain assessed but no follow-up plan documented;
document exclusion)– G8509 (pain assessed but no follow-up plan documented)
• This measure is to be reported for each visit occurring during the reporting period for all patients aged 18 yrs & older
• Percentage of patients aged 18 yrs and older with documentation of a functional outcome assessment using a standardized tool (i.e. Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI)) AND documentation of a care plan based on identified functional outcome deficiencies
• 65-year old male complains of 2 week history of lower back pain. Pain is located over the right lower back and buttocks. The pain is described as sharp, constant and 6/10 VAS. Patient completed low back disability index and results are attached to the file.
What will you need to report under this functional outcome assessment measure?
• Whether or not you assessed the patient’s current functional outcome using a standardized tool and documented a care plan, if deficiencies have been identified
– Functional outcome deficiencies are defined as impairment or loss of physical function related to neuromusculoskeletal capacity, including but not limited to, restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms and legs, and headaches.
What if process/outcome of care is not appropriate for your patient?
• There will be times when it is not appropriate to assess the patient’s current functional outcome– Documented reasons (e.g., patient refuses to participate; patient
unable to complete questionnaire)
• In these cases, you will need to indicate that a documented reason applies, and specify
• Office/billing staff will report the G-code that represents these valid reasons (exclusions)
• A CMT code is required to identify patients to be included in this measure – CMT codes (98940-98942)
• Quality codes for this measure include: – G8539 (current functional outcome assessed AND care plan
documented)– G8540 (current functional outcome not assessed; document exclusion)
This measure requires that the functional outcomes assessment tool be utilized at a minimum of every 30 days. Because reporting is required on every visit, you should report G8540 for visits between each 30 day functional outcome assessment.
– G8542 (current functional outcome assessed but no care plan documented; document exclusion)
– G8541 (current functional outcome not assessed)– G8543 (current functional outcome assessed but no documentation of a
• This measure is to be reported at each visit occurring during the reporting period for all patients; reported by clinicians who have adopted and are using HIT
• Documents whether provider has adopted/uses HIT; to qualify must adopt a qualified EHR
The EHR must be certified by an Authorized Testing and Certification Body or
Be on CMS’ list of PQRS qualified EHRs (list available at: www.cms.gov/pqri)
If not certified as delineated above, the system must have the ability to manage a medication and problem list, enter and store laboratory results in a searchable fashion and have basic privacy and security elements.
• While many performance measures are considered to be “process” measures, the future trends are expected to be more focused on “outcome” measures
• We should anticipate that today’s performance measurements, which have been described as “low bar,” will become tomorrow’s indicators of essential care or clinical necessity.
• PQRS represents a “reward system” today but will be required in 2015.