12/20/2011 1 Making Sense of PQRS Making it Simple Physician Quality Reporting System 2012 Presented by Rebecca H. Wartman, O.D. Practice Advancement Committee Member, Clinical and Practice Advancement Group American Optometric Association Disclaimers 1. This presentation is current at the time it was published onto the web. 2. Medicare policy changes frequently so links to the source documents have been provided for your reference. 3. This presentation is prepared as a tool to assist providers and is not intended to grant rights or impose obligations. 4. Every reasonable effort has been made to assure the accuracy of the information. 5. Ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. 6. The American Optometric Association, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. Disclaimers 6. This presentation is general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. 7. The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo on the CMS website. 8. Current Procedural Terminology (CPT) is copyright by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
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12/20/2011
1
Making Sense of PQRS
Making it SimplePhysician Quality Reporting System2012
Presented byRebecca H. Wartman, O.D.Practice Advancement Committee Member,Clinical and Practice Advancement GroupAmerican Optometric Association
Disclaimers
1. This presentation is current at the time it was published onto the web.
2. Medicare policy changes frequently so links to the source documents have been provided for your reference.
3. This presentation is prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
4. Every reasonable effort has been made to assure the accuracy of the information.
5. Ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
6. The American Optometric Association, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
Disclaimers
6. This presentation is general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.
7. The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo on the CMS website.
8. Current Procedural Terminology (CPT) is copyright by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
– Authorizes financial incentive for professionals reporting quality data
• Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)
– Continued authorization for PQRI in 2009-2010
• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
– Expanded bonus payments through 2010 - 2% bonus
• The Affordable Care Act (ACA) of 2010
– Created a 1.0% bonus in 2011 and a 0.5% bonus in 2012-2014. For those who do not report, reduces Medicare payments by 1.5% in 2015 and by 2.0% in 2016 and every year thereafterSqs
PQRS Form and Manner of Reporting
• Claims based
• Registry reporting- no clinical registries specific to optometry– Registry reporting may replace claims-based reporting in future
• Measures groups –no groups appropriate for optometry
• Electronic Health Records Reporting– EHR reporting available
• AOA is: – investigating potential development of clinical eye care registry
– reviewing current registries for reporting some measures by optometry
• CMS Reporting method decision tree https://www.cms.gov/PQRS/Downloads/2012_PhysQualRptg_DecisionTree11-11-2011.pdf
– Electronic based using ASC X 12N Health Care Claim Transaction (Version 5010).
– Must be reported on the same claim as CPT I• Sample CMS 1500 form will be reviewed later tonight
– No registration is required to participate
– Still strictly voluntary for 2012
Satisfactory PQRS ReportingClaims-Based
For satisfactory reporting:Must report at least 3 measures, 50% of time for each measure
This does NOT mean 3 measures on every claim at least 50% of the time.
Choose three measures (or more) and use them when appropriate at least 50% of the time
AOA recommendation: Submit QDC for all reportable cases Frequent reporting will aid in meeting the 50% goal No penalty for more frequent reporting
Reporting Quality Data
• Quality Data Code (QDC) charged at $0.00
(or nominal, such as $0.01)
• Must file with CPT I and other requirements
• PQRS line items denied for payment
• N365: This procedure code is not payable. It is for reporting/information purposes only.
• BUT, sent to National Claims History (NCH) file for PQRS analysis
• MAY NOT resubmit only to add QDC - will not be included in the analysis or counted
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PQRS Reporting Hints
• Track all claims submitted with PQRS
• Each QDC line will have N365 denial code
• Ensure NPI attached to each line item including QDC line items
• Include QDC codes on corrected claims (Cannot re-file only to add QDC)
• Use 8P modifier judiciously
(will discuss later in presentation)
PQRS Bonus Payment
• 0.5% bonus payment for 2012
• Bonus paid on all Medicare allowable 2012 charges
• Includes -TC of diagnostic services
• Bonus paid to holder of TIN
(Tax Identification Number)
Reporting period: January 1,2012- December 31, 2012
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Understanding PQRS Analysis
• For claims bases reporting analysis is by individual NPI under each TIN
– Must have and correctly use individual NPIs
– Requires individual providers identified
– Separate analysis for each TIN
• Must reach the 3 measure-50% threshold
PQRI (S) Feedback Reports
• 2007 PQRI quality reports June 2008• 2008 PQRI quality reports in October 2009• 2009 PQRI quality reports in November 2010• 2010 PQRS quality reports in September 2011• Reports by NPI for each TIN• Access reports via IACS or Contractor/Carrier by NPI
• If report available will be listed at:www.qualitynet.org
2011: very similar so far BUT threshold is 50% so expect more OD earning bonus
2011 PQRSSo far
• Ophthalmology 3,233,738 submitted
87.97% correct
• Optometry 855,532 submitted
85.17% correct
Again most errors are incorrect diagnosis codes
PQRS Participation Considerations
• Physician Compare Website (Medicare.gov)• Listing who successfully reported for 2010
“This professional chose to take part in Medicare's Physician Quality Reporting System and reported quality measure information satisfactorily for the year 2010.”
• Eventually will report performance information, including the measures collected under PQRS
“A physician or other healthcare professional can choose whether to report quality information to Medicare under the Physician Quality Reporting System. Medicare believes that reporting quality information by professionals is an important means to improve the quality of care provided to Medicare beneficiaries.”
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2012 PQRS Measures
• Claims/ Group Reporting: 143 measures• Registry Reporting: 208 measures
– 65 registry only measureshttps://www.cms.gov/PQRS/Downloads/2011_Qualified_Registries_Posting_11-30-2011.pdf
• EHR Reporting: 51 measuresContact your EHR vendor for information
• Measure Group Reporting: 22 groupsNo measure groups appropriate for optometry
Pressure (IOP) by 15% OR Documentation of a Plan of Care
Optometry only needs to be concerned about 7 PQRS measuresNew measures are registry only by patient survey
Cataracts codes are for surgeons (191,192) –registry onlyCataract outcomes by patient reported (303,304)- registry only
2012 PQRS
• 0.5% bonus (total allowed charges for Medicare Part B provided for reporting period)
• Extra 0.5% incentive payment when ABO provides data on Maintenance of Certification Program beyond MOC required by ABOAmerican Board of Optometry one of five fully approved boards accepted by CMSContact ABO for more information
• Claims based reporting threshold reduced– Successful reporting: 3 measure 50% of time– 1 Reporting period for claims based reporting
• 1/1/11-12/31/12• Measure group, registry and EHR reporting rules are different
• Denominator– CPT I codes (E&M; General Ophthalmic codes)
– Any appropriate diagnosis indicated
– Additional factors such as age and frequency
Exceptions Modifiers
What if measure cannot be completed?
• You must still report to be counted or it will count against you
• Use modifiers
– 1P: medical reason
– 2P: patient reason
– 8P: other reason
Physician Quality Reporting SystemPQRS 2012
• Only Three Diagnoses To Think About:–Age Related Macular Degeneration
–Primary Open Angle Glaucoma
–Diabetes: Insulin and Non-insulin Dependent
• ANY OF THESE … THINK PQRS
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Physician Quality Reporting SystemPQRS
• If you report an evaluation & management code
– 99201-99205 or 99212-99215
OR
• If you report a general ophthalmic service code
– 92004,92014, 92002, 92012
• ANY OF THESE CODES - THINK PQRSNo other procedure codes are considered
Nursing Home/Rest Home and other E&M codes eligible as well but will not discuss tonight
Physician Quality Reporting SystemPQRS
If you have the diagnosis and examination code:
The only step left is to add the PQRS code
Must add the PQRS code to every Medicare claim where the diagnosis and examination code is appropriate for the measure
If you do this, you should earn your bonus!
Physician Quality Reporting SystemPQRS
• Rule of thumb:
USE PQRS EVERY TIME YOU HAVE DIAGNOSIS AND ENCOUNTER CODE (with modifiers if needed) OR WILL COUNT AGAINST YOU!
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Physician Quality Reporting SystemPQRS
• Let’s break it down by disease
Age Related Macular Degeneration
• Any of these three diagnoses
– 362.50 Macular Degeneration, NOS
– 362.51 Macular Degeneration, non-exudative
– 362.52 Macular Degeneration, exudative
• Patient age 50 and older
ARMD
• Two PQRS measures to use (#14,#140):
2019F and 4177F
• 2019F:– Dilated view of macula
– Recorded +/- macular thickening and
+/- hemorrhages
You must dilate and record finding, once per 12 month period - once per reporting period
BUT YOU MUST REPORT EVERY TIME USE ARMD DIAGNOSIS CODES
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ARMD Exceptions
• 2019F– 1P medical reason for no dilated macula view
– 2P patient reason for no dilated macula view
– 8P other reason for no dilated macula view
ARMD
4177F:
– Discussed pros and cons of AREDS
– Made proper recommendations for individual
– Documented discussion
You must discuss and record your recommendation, once per 12 month period - once per reporting period for each unique patient … BUT YOU MUST REPORT EVERY TIME you see the patient
ARMD Exceptions
• 4177F
– 8P no reason for not discussing AREDS
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Glaucoma –Primary Open Angle
Two PQRS measures to be used (12,141):2027F 3284F or 0517F+3285F
Will discuss these two measures together• Any of these four diagnoses
– 365.10 Open angle glaucoma, unspecified– 365.11 Primary open angle glaucoma– 365.12 Low Tension Glaucoma– 365.15 Residual Open Angle Glaucoma– 365.70-365.74 (new codes used in conjunction with regular
glaucoma diagnoses)
• Patient age 18 years and older
Glaucoma
• Two different reporting options
– Controlled IOP
• 2027F and 3284F
– Uncontrolled IOP
• 2027F and 0517F & 3285F
Glaucoma Controlled
• 2027F - Viewed optic nerve(With or without dilation)
• 3284F - IOP reduced 15% or more from pre-intervention levels
Once in a 12 month period -per reporting period
Report every time you use diagnosis and exam code
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Glaucoma Controlled Exceptions
2027F
• 1P medical reason for not viewing optic nerve
• 8P no reason for not viewing optic nerve
3284F
• 8P IOP not documented, no reason given
Glaucoma Uncontrolled
• 2027F- Viewed optic nerve
• 3285F- IOP NOT reduced 15% from pre-intervention levels
&
• 0517F- Plan of care to get IOP reduced
Once in a 12 month period or reporting period
Report every time you use diagnosis and exam code
Glaucoma Uncontrolled
• 0517F Plan of care examplesrecheck of IOP at specified time
change in therapy
perform additional diagnostic evaluations
monitoring per patient decisions
unable to achieve due to health system reasons
referral to a specialist
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Glaucoma Uncontrolled Exceptions
2027F
• 1P medical reason for not viewing optic nerve
• 8P no reason for not viewing optic nerve
3285F
• No exceptions – use 3284F 8P if did not measure IOP
0517F
• 8P no plan of care to reduce IOP documented
Diabetes
Three different PQRS measures (18,19,117):2022F or 3072F; 2021F; 5010F+G8397 or G8398
• Diabetes with or without retinopathy2022F or 3072F
• Diabetes with retinopathy2021F
• Communication of macular edema and retinopathy to physician responsible for DM care
5010F and G8397 OR G8398 aloneOnce in a 12 month period - per reporting periodReport every time you use diagnosis and exam code
Diabetes with or without retinopathy2022F or 3072F
• Any of these diabetes diagnoses250.00-250.03, 250.10-250.13, 250.20-250.23,
250.30-250.33, 250.40-250.43, 250.50-250.53,
250.60-250.63, 250.70-250.73, 250.80-250.83,
250.90-250.93, 357.2, 362.01-362.07, 366.41,
648.01-648.04
• Patients age 18-75 years old
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Diabetes with or without retinopathy
2022F Dilated eye exam in diabetic patient
OR
3072F Low risk of DR (normal exam last year)
(two other codes for imaging views of the retina exist for this measure, 2024F and 2026F, but we are making it simple and dilation is the recommended clinical care guidelines)
Diabetes with or without retinopathyExceptions
• 2022F
8P no reason for not performing dilated eye exam
• 3072F
No exceptions for this measure
Diabetes with retinopathy2021F
• Any of these six diagnoses codes– 362.01
– 362.02
– 362.03
– 362.04
– 362.05
– 362.06
• Patient age 18 years and older
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Diabetes with retinopathy
• 2021F
– Documented +/- macular edema and
level of diabetic retinopathy
• Exceptions
1P medical reason for not documenting
2P patient reason for not documenting
8P no reason for not documenting
Diabetes with retinopathy
• 5010FCommunicated presence or absence of macular edema
and the level of DR to physician responsible for the diabetic care
Exceptions
1P medical reason for not communicating
2P patient reason for not communicating
8P no reason for not communicating
Diabetes with retinopathy
G8397 Dilated macular exam performed
OR
G8398 Dilated macular exam not performed
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Diabetes Examples
1. DM –no DR, age 18-75: 2022F
2. DM +DR, age 18-75:2022F, 2021F, 5010F,G8397
3. DM – no DR, over age 75:no PQRS codes
4. DM +DR, over age 75:2021F, 5010F, G8397
Combined Examples
1. ARMD + DM, age 52:
2019F, 4177F, 2022F
2. ARMD + G (controlled), age 35:
2027F, 3284F
3. ARMD + G (uncontrolled) + DM age 72:
2019F, 4177F, 2027F, 0517F, 3285F, 2022F
4. G (uncontrolled) + DM with DR, age 72:
2027F, 0517F, 3285F, 2022F, 2021F, 5010F, G8397
5. ARMD + G (controlled) + DM, age 78:
2019F, 4177F, 2027F, 3284F
PQRS “Rules to live by”
1. Must file at least three different PQRS measures
2. Must file a PQRS measure on at least 50% of the claims whenever the examination code and diagnosis code indicates the need for a measure
3. File PQRS codes on EVERY CLAIM (with modifiers if needed) with the diagnosis code and the examination codes for that measure even if you did not perform the measure on that visit
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PQRS-Other Bits
1. Providing a little more timely feedback reports including interim reports
2. Created informal review for disputes on satisfactory PQRS a. 90 days from the release of report to request informal review through
the Quality Net Help Desk b. response given in writing within 60 daysc. decisions made will be final without further review or appeal
3. Retain claims-based reporting mechanism, the registry-based reporting mechanism, and the EHR-based reporting mechanism in 2012
4. BUT will consider significantly limiting the claims-based mechanism of reporting in future program years
PQRS Future• PQRS incentives through 2014
+0.5% for 2012- 2014
• PQRS payment adjustment beginning 2015
Minus 1.5% payment adjustment for 2015 if not using and
may be based on 2013 performance
Minus 2% payment adjustment for 2016 and up if not using
• AOA continues to fight to retain claims based
reporting, more timely performance reports and for
any penalties to be more closely linked to previous
AOA Website Sections Provide Information RegardingPrivate Insurers and Governmental Health Programs
– Third Party Center http://www.aoa.org/TPC– Clinical & Practice Advancement Group
http://www.aoa.org/CPAG
• Clinical Practice Guidelines• Frequently Asked Questions• Webinars and other online education for doctors and staff• Articles in AOA NEWS and the Journal of the AOA• [email protected]
– Email your questions direct to an expert– Include AOA member’s name and state
– Subscription based resource, including coding information for procedures and diagnoses, accepted combinations of codes, compliance guidelines and reimbursement information specific to the insurers with which your office is contracted
– Popular program offered to AOA members at significant discount
AOA Resources Related to Coding
• Codes for Optometry—Two volumes $125
– AOA Order Department, 1-800-262-2210
• AMA Current Procedural Terminology, and
• AOA Codes for Optometry
– ICD-9 abridged for the eye
– Documentation Guidelines
– Correct Coding Initiatives from Medicare
– HealthCare Common Procedure Coding System (HCPCS) for Coding Materials in Medicare