2014 PQRS for LTC Physicians

RodBairdBeatings will continue until morale improves

By Rod Baird

According to CMS, only 25% of eligible professionals participate in PQRS. CMS has a strategy to improve this dismal level of enthusiasm to 40% – triple the number of Quality Measures required for successful participation. Here is the quote from the Final 2014 Physicians Fee Schedule (emphasis added):

For the commenters who urge us not to raise the satisfactory reporting criteria for the PQRS until participation in PQRS increases, we understand that, as discussed in this final rule below and in the 2011 PQRS and eRx Reporting Experience, participation in the PQRS has fluctuated around 25 percent among those eligible to participate in the PQRS. Indeed, it is one of our major goals to increase participation in the PQRS. While increasing the satisfactory reporting threshold for the 2014 PQRS incentive may deter or discourage some eligible professionals from participating, we believe that this increase to the satisfactory reporting threshold will not significantly deter eligible professionals from participating in the PQRS.

Providers who fail to satisfy minimum participation requirements in 2014 will suffer Medicare Part B payment reductions in 2016. The magnitude of those reductions depends on group size.

  • All eligible providers are subject to a 1.5% penalty if they fail to meet minimum participation levels. The minimum reporting level for LTC is satisfactorily reporting on three individual measures for 50% of eligible patients.
  • Providers wishing to achieve the +0.5% incentive for successful reporting must report on nine PQRS measures for 50% of eligible patients across three domains of care, or on one measures group.
  • If you work in a medical group with 10 or more providers you are subject to an additional penalty of 2.0% under Value Based Purchasing (VBP) if you (or your group) don’t report at least three PQRS measures for 50% of eligible patients. This VBP penalty will apply to every eligible provider in 2015 under the current rules.
  • The two penalties for nonparticipation are additive; that means large groups will have their 2016 Medicare Part B reimbursement cut -3.5% in 2016 if they fail to satisfy the 2014 PQRS and VBP reporting requirements.

Let’s assume you become more motivated to participate, now that it is up to three times more difficult to succeed (nine measures vs. three measures prior to 2014). What strategy should you employ?

Last month, CMS conducted a national call to review the 2014 Medicare Physician Fee Schedule. You can view the slide deck for the call here. The call covered many of the 2014 changes that affect EHR and Quality Reporting. Starting on Slide 45, CMS lists the reporting options available for individuals and groups to satisfactorily report PQRS. I count 26 different choices to report. The best option depends on whether you are simply avoiding the -2% penalty, or trying to achieve the +0.5% incentive payment.

Obviously larger groups have a compelling imperative to avoid the cumulative 3.5% reduction in 2016 payments.

Basic recommendations to avoid penalties

  • Select at least three 2014 PQRS measures to use for the year.
    • We’ve prepared a list of all 2014 PQRS measures that apply to typical LTPAC CPT code families (90791, 90792, 99304-99310, 99324-99334). That list of codes based on CMS tables is available here.
      • The individual measures are listed by PQRS number, which is how CMS published the tables. You can find the individual measures, and measures groups, with full descriptions on the CMS PQRS website.
    • Read each measure and determine how you are supposed to document satisfactory participation. Many definitions have changed from 2013 to 2014, so pay attention to verify that past documentation strategies are still compliant.
    • Validate how to report results (claims, registry, etc.). A significant reporting change in 2014 states that all measures groups are only reportable by a qualified registry.
    • Train clinical and office staff on documentation and reporting.
    • Track your progress throughout the year (CMS promises to provide tools by mid-year to verify your status if using claims based reporting. Registries provide the ability to validate data prior to submission in early 2015).

Recommended strategy for both avoiding penalties and earning 0.5% incentive (not using a 2014 certified EHR product)

  • Follow the basic recommendation (above). Select three individual measures for your group to implement.
  • Select an appropriate measures group that applies to LTPAC patients.
    • Report on this measures group for each eligible professional. This requires a threshold of 20 patients or 80% of all eligible patients seen by the provider.
    • In past years we’ve recommended the CAD measures group for PCPs working in LTPAC. Because staff members are familiar with the measures, we will continue with this measures group. This is a list of 2014 measures groups that apply to 99304-99310:
      • Hypertension
      • Parkinson’s disease
      • Dementia
      • Coronary artery disease
      • Heart failure
      • Chronic kidney disease
      • Diabetes

Strategy for groups using a 2014 certified ambulatory EHR and reporting PQRS by use of the EHR’s eCQMs

  • It is critical to verify your EHR is up to date and using 2014 eCQMs. There are several versions of CQMs available, so check with your vendor that the ones you are going to use are certified for 2014 PQRS reporting.
    • WARNING: An eCQM is eligible for use as a PQRS measure, but an individual PQRS measure is not an eCQM.
  • Each EHR is certified for a minimum of nine eCQMs.
    • eCQMs are reported to CMS through your vendor or a special type of registry.
    • eCQMs don’t use CPT codes or CPT II codes as part of their definition. This is what prevents them from being reported like traditional PQRS measures.
  • EHRs can also include PQRS measures which are reported on claims or via registry.
  • Plan your reporting strategy. You have to report on at least 50% of all eligible patients for the year.
    • If you don’t start using your 2014 EHR early in the year, you may miss hitting the 50% threshold. That is particularly problematic for the influenza measure, which only counts patients seen from Oct. 1, 2013 through March 31, 2014.
    • Meaningful Use only requires reporting for 90 consecutive days during the year. That is a different threshold than PQRS.
  • Remember that you have to have at least one patient in the eCQM, and you have to demonstrate satisfactory performance on one patient to use it as a PQRS measure.

About the Author:  Rod Baird is founder and president of Geriatric Practice Management (GPM) and gEHRiMed. Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. He also was chosen to be a part of the Centers for Medicare and Medicaid Services’ (CMS) Innovation Advisors Program.  Originally posted on LTC Management with permission to syndicate.