Physician Quality Reporting System (PQRS) & Physician Value-Based Payment Modifier (VBM) FAQ

PQRS & VBM

 2015 Performance Year

By way of background, this year CMS will stop issuing bonuses for PQRS and continue penalizing for not participating or failing the PQRS measures.  The penalty is potentially 2-6% of your Medicare reimbursement in 2017 if you fail the measures or fail to report.  The below tips should help you to pass for 2015 to avoid a 6% adjustment or penalty.  The average doc stands to lose $1500- $4000 depending on their population (based on the 2012 Medicare database).  While the Name will change from PQRS to MIPS after the SGR fix when through, the concepts, rewards and penalties will stay the same.

 

For a succinct summary of PQRS, click this link from the ACEP Quality Committee.  http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/PQRS%20Flyer%20MAV%20Update.pdf

 

What are the different incentive and penalty quality programs?  

PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs). The program provides an incentive payment to practices with EPs, who are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. There are now only two distinct PQRS programs for the 2015 performance year.     

Two Distinct PQRS Programs

2015 Performance Year (PY):

1. Traditional PQRS Incentive

No incentive payment

2. PQRS MOC Incentive

No incentive payment

3. PQRS Penalties For Failure to Report

-2.0% in 2017

4. Value-Based Modifier (VBPM) 

* For Failure to Report PQRS*

Up to -4.0%in 2017

5.  Total Penalties

Up to -6.0% in 2017

How many measures are needed to meet requirements?  Emergency Medicine EP’s may report utilizing the 3 measures from the Emergency Care Cluster plus one cross cutting measure OR may report 9 measures across 3 domains and one cross cutting measure.  

Claims-Based Reporting Mechanisms Via Cluster 4

Can Report using Emergency Care Cluster 4 to avoid the PQRS and VBM penalties

To Avoid the Penalties:

3 Measures from the Emergency Care Cluster #4 for at least 50% of applicable Medicare patients.

Plus 1 cross cutting measure.

Physicians participating in a group practice, which is part of an Accountable Care Organization (ACO), must report via the Group Practice Reporting Option (GRPO) registry option. Group practices may register to participate and be analyzed as a group, or at the TIN level. Reporting via the GPRO can also satisfy the reporting requirements for the Value-based Payment Modifier (VM). Satisfactorily reporting through the GPRO using the EHR-based reporting method, the Web Interface, or the enhanced Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS in combination with EHR-based reporting or the Web Interface will satisfy the clinical quality measures (CQM) component of the Medicare EHR Incentive Program. Currently there are 33 measures ACO’s are required to report on.

Which measures can emergency EPs report on?

Emergency physicians and emergency department providers reporting as individuals should report on the following measures in the 2015 performance year in order to avoid a 2-6% penalty to their 2017 Medicare reimbursements. This list is used in MAV process to assess whether or not a sufficient number of measures were reported and is referred to as Cluster 5. 

 

2015 Performance Year

Core Quality Measures for Emergency Care Cluster # 4

Physician Quality Reporting System (PQRS) & Value-Based Payment Modifier (VBM)

PQRS Measure Number

Codes Included

Measure Title

NQS Domain

Reporting Mechanism

Measure Applicability Validation Cluster

#54

ED, CC

Emergency Medicine: 12-Lead ECG Performed for Non-Traumatic Chest Pain

Effective Clinical Care

Claims, registry

Claims Cluster #4

#254

ED, CC

Ultrasound Determination of Pregnancy Location for Pregnancy Patients with Abdominal Pain

Effective Clinical Care

Claims, registry

Claims Cluster #4 not assigned to registry cluster

#255

ED, CC

Rhogam for Rh-Negative Pregnancy Women at Risk of Fetal Blood Exposure

Effective Clinical Care

Claims, registry

Claims Cluster #4 not assigned to registry cluster

#317

Cross Cutting Measure

Preventative Care and Screening:  Screening for High Blood Pressure and Follow-Up Documented

Community/ Population  Health

Claims, registry EHR, GPRO Web Interface, Measures Group

Basics of performing and documenting the four Emergency Care measures:

The big one is Measure 317: High blood pressure screening and follow up

  • Population: Medicare patients with patients with pre-hypertension defined as BP120-139/ 80-89 or hypertension BP > 140/90   (Note definitions based upon JNC 7, not updated with JNC 8 yet)
  • Blood pressure must be documented and if hypertensive or pre-hypertensive, documentation of referral to a PCP or other provider for follow up in < 4 weeks for hypertension and <1 year for pre-hypertension.
  • Admission to the hospital would count as follow up documentation.
  • Exclusions: 
    • Normal blood pressure- less than 120/80
    • Patient to urgent or emergent to allow for follow up recommendations(admission, to OR/cath lab) or immediate blood pressure treatment undertaken, such as hypertensive crisis, hypotension
    • Patient refuses blood pressure reading
    • Pre-existing hypertension documented
  • Fail if:
    • Blood pressure not documented and reason not given for not being documented
    • Blood pressure taken and abnormal but reason for no follow up not documented

Next up Measure 54:  12 Lead EKG performed for Non-Traumatic Chest Pain

  • Population: Patients 40 or older with discharge diagnosis of non-traumatic chest pain
  • Must document 12 Lead EKG performed or reason you didn’t
  • Exclusions:
    • Patient refused
    • Document medical reason why not done
  • Fail if no EKG documented and no exclusion documented

Lastly, the pregnant Medicare patient measures.

Measure 254:  Ultrasound determination of pregnancy location in pregnant patients with abdominal pain.

  • Population: Medicare patients age 14-50 with chief complaint of abdominal pain or vaginal bleeding
  • Must document trans-abdominal or trans-vaginal ultrasound performed or why you didn’t
  • Exclusions: 
    • Document patient already has documented IUP
    • Document patient has multiple visits in the last 72 hours
  • Fail if No ultrasound and no reason documented why not. 

Measure 255:  Rhogam ordered for Rh-negative patients at risk of Fetal blood exposure

  • Population:  Medicare patients age 14-50 at risk for fetal blood exposure who are Rh negative
    • At risk patients may include  
      • Abdominal trauma
      • Vaginal bleeding
      • Ectopic pregnancy
      • Threatened or spontaneous Ab  
  • Must document Rhogam ordered for all Rh-negative patients
  • Exclusions:
    • Prior documented Rhogam ordered within 12 weeks
    • Patient refusal
  • Fail if not ordered and not documented why 

Are there other measures that CAN be reported?

Yes, please see below a table of 12 “other” quality measures, which could possibly be reported. Please note that if reporting on just one additional measure outside of the above Cluster, then the MAV process would subject a provider to reporting on additional measures within that clinical cluster.  

2015 PQRS Performance Year

Other Reportable Quality Measures

 

PQRS

Measure

Number

Codes

Included

Measure Title

NQS Domain

Reporting Mechanism

Measure Applicability Validation

Cluster

Notes

#1

ED, CC

Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Effective Clinical Care

Claims, registry

Claims Cluster #3;

Registry Cluster #2

The performance period for this measure is 12 months from date of encounter

#65

ED

Appropriate Treatment for Children with Upper Respiratory Infection (URI)

Efficiency & Cost Reduction

Registry only

Registry Cluster #15

Needs information on three days after the visit

#66

ED

Appropriate Testing for Children with Pharyngitis

Efficiency & Cost Reduction

Registry only

Registry Cluster #15

Needs information 30 days prior to visit for measure

#76

ED, CC

Prevention of Catheter-Related Bloodstream Infections (CRBSI): CVC Insertion Protocol

Patient Safety

Claims, registry

Not included in any MAV process

Patient Safety satisfies an additional NQS domain of care

#91

ED

Acute Otitis Externa (AOE): Topical Therapy

Effective Clinical Care

Claims, registry

Claims Cluster #8

Registry Cluster #16

Each unique occurrence is defined as a 30-day period from onset of AOE

#93

ED

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

Communication & Care Coordination

Claims, registry

Claims Cluster #8

Registry Cluster #16

Each unique occurrence is defined as a 30-day period from onset of AOE

#116

ED

Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use

Efficiency & Cost Reduction

Registry only

Not included in any MAV process

Registry Only; need data 3 days after visit

#117

ED, CC

Diabetes: Eye Exam

Effective Clinical Care

Claims, registry

Claims Cluster #3;

not included in registry MAV process

Requires documentation of eye exam in the measurement year or a negative exam in year prior

#119

ED, CC

Diabetes: Medical Attention for Nephropathy

Effective Clinical Care

Claims, registry

Claims Cluster #3;

Registry Cluster #2

Requires documentation of nephropathy screening test in the measurement year

#163

ED, CC

Diabetes: Foot Exam

Effective Clinical Care

Claims, registry

Claims Cluster #3;

not included in registry MAV process

Requires documented foot exam during the measurement year

#187

CC

Stroke & Stroke Rehabilitation: Thrombolytic Therapy

Effective Clinical Care

Registry only

Registry Cluster #28;

not included in claims MAV process

Registry only

#317

ED

Preventive Care and Screening: Screening for High Blood Pressure

Community/ Population Health

Claims, registry

Claims Cluster #1;

not included in registry MAV process

The documented follow up plan must be related to the current BP reading

 What are the National Quality Strategy domains?

  1. Person and Caregiver-Centered Experience
  2. Patient Safety
  3. Communication and Care Coordination
  4. Community and Population health
  5. Efficiency and Cost Reduction
  6. Effective Clinical Care

What counts as successfully reporting on a measure? For either a group or individual physician, depending on the reporting mechanism, reporting on at least 50% of the Medicare Part B Fee for Service patients to which a PQRS measure applies. Measures with a performance of 0% do not count as successfully reporting that measure.

What are the reporting options for emergency physicians, emergency PAs, and emergency NPs?

  1. Claims-based and qualified registry for individual eligible professionals:
  • What are the requirements for an eligible professional (EP) to report claims-based measures as an individual? To earn the incentive the EP must successfully report on 9 measures across 3 NQS domains. If they do not meet this requirement, then they must report on at least 3 measures for at least 50% of Medicare Part B Fee for Service patients to whom the measure applies in order to avoid the penalty. If the EP does not meet the 9 measures across 3 NQS domains, they will also undergo the MAV process to see if they may earn the incentive. As for avoiding the "adjustment", an EP reporting less than 3 measures will likewise be subjected to the MAV process, which allows CMS to determine whether an EP should have reported quality data codes for additional measures and/or covering additional NQS domains. Measures with a 0% performance rate will not be counted. 
  • How are groups (TINs) with >2 EPs that do not elect to participate in GPRO evaluated for VBM? To avoid the 2017 VBM penalty, the TIN must have at least 50% of their individual EPs either earn the 2015 PQRS incentive or avoid the adjustment.  (subject to the Measure-Applicability Validation process).
    • What about part-time staff? Even just one claim for the calendar year qualifies that NPI as an EP under your TIN for purposes of the "50% threshold."
    • What about PAs/NPs? Even just one claim for the calendar year qualifies that NPI under your TIN for purposes of the "50% threshold."
    • Is the 50% threshold also good for the PQRS? No the 50% requirement applies to the VBM.EPs reporting as individuals for PQRS will avoid the penalty or receive the negative 2% adjustment as an individual.
    • If 51% of the TIN meet the criteria for reporting 2015 PQRS quality measures what happens to the other 49% who do not? The other 49% (or whichever percent do not satisfactorily report PQRS), would still receive a -2% PQRS penalty in 2017 from Medicare on all of their individual Medicare Part B FFS reimbursement.
    • For the VBM adjustment, does every EP in the TIN receive the same adjustment? For the VBM, if at least 50% of the TIN EPs successfully report (avoid the adjustment) 2015  PQRS, then all physicians  in the TIN will be subject to the same VBM adjustment (down, neutral) regardless of the individual EP's PQRS performance.
    • Will the PQRS penalty, VBM penalty, and VBM adjustment be levied for non-physician clinicians (PAs/NPs)?All providers reporting as individuals will be subject to same PQRS incentives and penalties. The VBM adjustments will only be applied to physicians. 

    2. Qualified Registry (QDR) Group Practice Reporting Option (GPRO):

  •  If the group reports via GPRO using a registry, is the requirement for 9 measures across 3 NQS domains at the TIN level or EP level? A group may report as a GPRO at the TIN level (as opposed to the individual level). To successfully report via registry, the TIN must report on 9 measures across 3 NQS domains for at least 50% of their Medicare Part B Fee for Service patients. Measures with a reported 0% performance rate do not count as successfully reported.
  • What if a TIN group reports through GPRO registry and 1 member of the group fails the MAV process, is the whole TIN affected and loses bonus or receives penalty? The measure for successful reporting through this mechanism is at the TIN level only, where the TIN must report on at least 50% of the beneficiaries that fall into 9 measures across 3 NQS domains. Any MAV process through GPRO registry is at the TIN level and not EP level.
  • If the TIN successfully reports on 9 measures across 3 NQS domains do all EPs in the TIN earn the incentive, avoid the penalty and receive the same VBM adjustment? Yes
  • Through GPRO are PAs/NPs considered as part of the TIN? Yes, they are considered EPs for the purpose of PQRS and VBM.
  • How can my group report via a GPRO qualified registry? Groups who elect to report via GPRO registry can select a registry vendor from among the CMS qualified PQRS registry vendors to report. The 2014 CMS qualified data registry vendors are posted to the CMS website here.  There is not yet an updated 2015 list of approved vendors though many of the current vendors will continue to be eligible for 2015. 

    3. Web-Interface GPRO:

  • If your TIN is a multi-specialty group practice that also include primary care office visits or your group participates in the Shared Savings Program as Accountable Care Organizations (ACOs), then your group can register with CMS to report measures through the GPRO Web Interface for program year 2015. For groups electing this method of reporting, CMS will pre-populate the Web Interface with a sample patient population. Successful completion of the 22 Web Interface measures for the required number of patients will determine PQRS incentive eligibility and performance rates for the measures. To avoid the 2017 PQRS payment adjustment, group practices taking part in PQRS GPRO via the Web Interface must meet the requirements for satisfactory reporting. 

    4. How does my group elect a GPRO?

  • Group practices must register to participate in PQRS GPRO. Registration must be completed through the online Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System by June 30, 2015. The PV-PQRS Registration System is a web-based application that serves the PV and PQRS programs. During registration, group practices must indicate their reporting method though they may change this method at any time prior to the June 30, 2015 deadline. Groups who register for the 2015 PQRS GPRO will not be able to withdraw their registration. Prior to signing up for your PQRS reporting mechanism, group practices will need to register for a CMS IACS account if they do not already have an IACS. For more information see the CMS handout on http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_GPRO_Criteria.pdf
  • GPRO election is an annual requirement and requires active registration. Prior year status (i.e. reporting as an individual or GPRO) is not carried forward. 
  1. If my group decides to submit claims-based measures as individuals, do we have to elect this?
  • If your group intends to report on individual claims-based measures, then they are not required to register for a GPRO, however, ACEP strongly encourages all groups to sign up for their IACS account, so that they may obtain their Quality and Resource Use Report (QRUR), which contains important information on their group's performance for prior years. This information will be essential to determine how your group will fare under the VBM quality-tiers in future years.
  • Authorized representatives of groups can access the QRURs and IEP PQRS Performance Reports at https://portal.cms.gov using an Individuals Authorized Access to the CMS Computer Services (IACS) account.
  • Authorized representatives of groups must sign up for a new IACS account or modify an existing account at https://applications.cms.hhs.gov . Quick reference guides that provide step-by-step instructions for requesting each PV-PQRS System role for new or existing IACS account are available here.

Are providers who assigned benefits to the facility for billing considered EPs in 2015? Yes, in the past those EPs that assigned benefits to the facility for billing were not considered EPs however for 2014 and going forward providers that billed Medicare Part B and/or Traditional Railroad on a 1500 claims for or electronic equivalent, under their individual NPI and facility TIN are eligible to participate in the PQRS program. Also beginning in 2014, professionals who reassigned benefits to a Critical Access Hospital (CAH) that billed professional services at a facility level, such as CAH Method II billing, now participate (in all reporting methods except for claims-based). To do so, the CAH must include the individual provider NPI on their Institutional (FI) claims.

If the EP/TIN does not successfully report on 9 measures across 3 NQS domains on at least 50% of the beneficiaries to which the measures apply then what happens?  The EP/TIN undergoes the Measure Applicability Validation (MAV) Process, which allows CMS to determine whether an EP should have reported quality data codes for additional measures and/or covering additional NQS domains. 

    1. Claims Based Reporting  

  • How does the MAV Process work? The MAV is a two-step validation process:

1.    a “clinical domain relation” test, and

         2.    a “minimum threshold” test. 

  •  What is the clinical domain relation test? CMS evaluates the clinical domains or “cluster(s)” the measure(s) the EP reported on fall into. If the EP could have reported on additional measures within the same “cluster(s)” that the EP reported at least one measure on, then the EP may fail the MAV process
  • What is the minimum threshold test? The minimum threshold is 15 beneficiaries (or encounters). An EP must submit quality data codes for any measure within a clinical cluster, if there were at least 15 patient encounters to which the measure applies.
  • What happens if the EP fails the MAV process? The EP may be subject to the 2% PQRS penalty. If <3 measures are reported, the MAV process is applied to determine whether or not the EP would avoid the PQRS adjustment. An EP would not count towards the VBM 50% threshold for their TIN if the EP failed to avoid the adjustment. 
  • Does the EP count towards the 50% threshold for their TIN if they do not satisfactorily report on 9 measures across 3 NQS domains, but passes the MAV process because CMS determines that the EP could not have reported on additional measures? Yes, if the EP passes the MAV process (for avoiding the adjustment), then the EP counts towards the TINs 50% threshold.
  • Would a group of emergency physicians who successfully report as individuals via claims on measures in Cluster #4 (Emergency Care) but do not report on additional measures in different clusters that they could have reported on, still pass the MAV process?  Yes. For the vast majority of emergency medicine EP's, measures #254 and 255 will not need to be reported assuming that the EP had fewer than 15 pregnant Medicare patients in 2015 to which these measures may have applied (i.e. possible ectopic or Rhogam need). However, reporting on any additional measures (other than those in Cluster 4), for example PQRS #91, will trigger the MAV process to be applied to an additional Cluster(s). For more information on the MAV process, please see the Claims based link
  • ( http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/2015_PQRS_MAV_ProcessforClaimsBasedReporting_01152015.pdf) or this one for Registry reporting.(http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/2015_PQRS_MAV_ProcessforRegistryBasedReporting_01152015.pdf) of individual measures. 
  1. GPRO Registry Reporting  
  • How does the MAV Process work? CMS evaluates the "cluster(s)" the measure(s) the TIN reported on fall into. If the TIN could have reported on additional measures within that cluster then the TIN would fail the MAV process.
  •  Are there a minimum number of beneficiaries that the TIN must submit claims on within a measure before CMS will view it as the TIN should have reported on it? Yes, 15 beneficiaries.
  •  Are the clusters for registry reporting different from the clusters for claims reporting? Yes. The CMS website provides the listing for registry clusters.
  • What happens if the TIN fails the MAV process? The TIN and every EP within that TIN would not earn the incentive. The MAV process would then evaluate the eligibility as far as avoiding the incentive. The entire group  is subject to the PQRS incentive, adjustment avoidance or penalty, and the TIN would be subject to the VBM penalty.

What is the relationship between the PQRS and the Value Modifier?

The 2014 Value Modifier and the Physician Quality Reporting System (PQRS)

PQRS & VBM Reporting Skeleton 2015

How is CMS going to calculate the TINs VBM adjustment amount? The Value-Based Payment Modifier is calculated on a split with 50% based on Quality Composite Score and 50% on Cost Composite Score as illustrated below. 

PQRS RVU Flow Chart 2015

Do all TINs have to quality tier?

  • For 2015, TINs with any number of EPs are required to quality tier going forward and may be adjusted down, or remain neutral.

How much is financially at risk with quality tiering? For the 2015 performance year for the 2017 VBM 4% is the maximum amount at risk.

What is the difference between the Total Cost Per Beneficiary (TCPB) and the Medicare Spending Per Beneficiary (MSPB) and how will each of these cost measures be attributed?

  1. Total Costs Per Beneficiary (TCPB) – overall annual and condition specific with primary care E/M Codes used to determine plurality of primary care:
    • CMS will first identify beneficiaries who have received at least one physician primary care service from a primary care physician who is part of a particular group/TIN. If this condition is met, the beneficiary will be assigned to the group if the allowed charges for primary care services furnished by primary care physicians in the group are greater than the allowed charges for primary care services furnished by primary care physicians outside of the group/TIN.
    • For beneficiaries who have not received any primary care services from a primary care physician, the beneficiary is assigned to a group/TIN only if he or she has received at least one primary care service from any physician (regardless of specialty) in the group/TIN and if the allowed charges for primary care services furnished by professionals in that group/TIN (including specialist physicians, NPs, and PAs) are greater than the allowed charges for primary care services furnished by professionals in other groups/TINs.
    • The specific HCPCS/CPT codes that CMS will use to define primary care services includes some urgent care codes, nursing home, and home health codes as follows:  

Attribution Methodology E&M Codes for Total Costs Measures and Outcomes Composite

99201-99205

new patient, office or other outpatient visit

99211-99215

established patient, office or other outpatient visit

99304-99306

new patient, nursing facility care

99307-99310

established patient, nursing facility care

99315-99316

established patient, discharge day management service

99318

established patient, other nursing facility service

99324-99328

new patient, domiciliary or rest home visit

99334-99337

established patient, domiciliary or rest home visit

99339-99345

new patient, home visit

99347-99350

established patient, home visit

G0402

initial Medicare visit (welcome to Medicare visit)

G0438

annual wellness visit, initial

G0439

annual wellness visit, subsequent

         Will ED codes be considered for the plurality of primary care? No, the ED E/M codes are not included; however, urgent care and office based E/M codes are included.   

   2. Medicare Spending Per Beneficiary (MSPB) – 3 days before through 30 days after an index admission   

    • This measure is attributable to the plurality of Part B services delivered to the beneficiary during an inpatient admission. 
    • Will ED providers be assigned these beneficiaries? It is unlikely that ED providers will be assigned these beneficiaries, however in rare circumstances where they may be delivering significant services during an inpatient code, possibly they might be assigned a beneficiary.
    • Does MSPB attribution apply to OBS or just admissions? The plurality of Part B services have to be delivered during an inpatient admission, so if they are considered admitted (observation for 2 midnights) and no other eligible professional submitted claims for more Part B services, then that attribution will occur.   

If cost measures are attributed to any/some NPIs in the TIN (consider multi-specialty group with ED docs, hospitalists and primary care), are those cost measures then applied to all EPs in the TIN for the purposes of quality tiering?  Yes, the cost composite and quality composite is at the TIN level and is applied to all physician NPI’s in the TIN.

What if less than 20 beneficiaries are attributed to the TIN for the cost measures? For those cost measures with a sample size of less than 20 beneficiaries they will not count toward the cost composite and the TINs cost will be considered “Average”.  

Can a TIN still receive a penalty under the VBM if the TINs cost composite is “average”? Yes, if the TIN’s “quality” composite is in the “worst 10%” (defined as greater than one standard deviation from the mean benchmark) then the TIN would be eligible for a 2% penalty, even if their cost is average.  

Will performance be publically reported?

  • Currently Physician Compare identifies individuals and group practices that have satisfactorily reported under PQRS, e-prescribing, or Medicare EHR incentive programs.
  • In 2015, CMS will publicly report 2014 PQRS performance data for individual physicians and/or physician groups for all claims, EHR, or registry reported measures. 
  • CMS will provide a 30-day preview period prior to any publication of any quality data.

 Updated 06/29/2015

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