By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS
The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.
Incentives: The Good, the Bad, and the Ugly
The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.
An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.
The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).
The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.
Subtle Changes to Traditional Reporting
The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).
The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.
Individual EP Reporting of Individual Measures
EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.
As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:
- Qualified direct electronic health record (EHR)
- Qualified EHR data submission vendor
Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.
Aligning Quality Initiatives
There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.
“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule
In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.
As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.
An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.
Individual EP Reporting of Measures Groups
EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).
There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:
- Diabetes Mellitus
- Chronic Kidney Disease
- Coronary Artery Bypass Graft (CABG)
- Preventive Care
- Rheumatoid Arthritis
- Perioperative Care
- Back Pain
- Coronary Artery Disease (CAD)
- Heart Failure
- Ischemic Vascular Disease (IVD)
- Hepatitis C
- Chronic Obstructive Pulmonary Disease (COPD)
- Sleep Apnea
- Irritable Bowel Disease (IBD)
- Cardiovascular Prevention
CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.
Group Practice Reporting
CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.
Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.
Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).
Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.
Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.
If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.
As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PhysicianReview-ICN904144.pdf).
There’s Still Time to Act
Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).
Avoiding the PQRS Negative Adjustment
CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.
If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.
CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:
- Satisfactorily report and earn the 2013 incentive of 0.5 percent.
- Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
- Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.
The Push for Better Care and Outcomes
CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”
Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.
April 1st, 2013