2012 Physician Quality Reporting System Claims-Based Reporting

1. 2012 Physician Quality Reporting System Claims-Based Reporting The Physician Quality Reporting System (PQRS) is a voluntary Medicare reporting program that provides an incentive payment to practices with eligible professionals who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service beneficiaries. The following professionals are eligible to participate in the Physician Quality Reporting System: Medicare physiciansPractitionersTherapists MD PA Physical Therapist DO NP Occupational Therapist Podiatrist CNS Speech-Language Therapist Optometrist CRNA Oral Surgeon Certified Nurse Midwife Dentist Clinical Social Worker Chiropractor Registered Dietician Nutrition Professional Audiologist

2. 2012 CMS PQRS Reporting Options.

3. Benefits of PQRS Claims-Based Reporting Annual incentive payments 2012 -2014 = 0.5% of allowed Medicare charges Avoid reduced Medicare payments in the future 2015 = 1.5% reduction in allowed Medicare charges 2016 and beyond = 2.0% reduction in allowed Medicare charges Mountain-Pacific Quality Health support and assistance Helpful tools and resources No third party fees

4. 2012 PQRS Claims-Based Reporting Option

5. 2012 Claims-Based Measures Group Reporting: Patient Sample 30 Patient Sample Method – 12-month reporting period 30 unique Medicare Part B FFS patients who meet criteria for a measures group Patient sample may include MSP claims and claims for Railroad Retirement beneficiaries Patient sample may NOT include beneficiaries covered under a Medicare Advantage plan

6. 2012 Claims-Based Measures Groups 22 measures groups have been established for 2012 PQRS reporting. Twelve of the 22 (highlighted in orange) can be reported using the claims-based method: Diabetes MellitusChronic Kidney Disease Preventive Care *Coronary Artery Bypass Graft Rheumatoid ArthritisPerioperative Care Back PainHepatitis C Heart FailureCoronary Artery Disease Ischemic Vascular Disease * HIV/AIDs AsthmaCOPD Inflammatory Bowel Disease Sleep Apnea Dementia Parkinson’s Disease HypertensionCardiovascular Prevention * CataractsCommunity-Acquired Pneumonia * Mountain-Pacific will assist and support providers in reporting these measures groups

7. Claims-Based Measures Groups Participation Strategy Each eligible professional submits clinical data for only one measures group for all 30 patients. Mountain-Pacific has developed data collection templates for three measures groups: Preventive Care, Ischemic Vascular Disease (IVD)and Cardiovascular Prevention All applicable measures within the chosen measures group must be reported at least once for each patient between 1/1/2012 – 12/31/2012 Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group

8. Claims-Based Measures Groups Participation Strategy Intent to report a measures group Intent to report codes G8485 DM G8487 CKDG8486 Preventive Care* G8490 RA G8492 Periop care G8493 Back Pain G8545 Hepatitis CG8547 IVD*G8546 CAP G8645 AsthmaG8898 COPDG8905 Cardiovascular Prevention* * Mountain-Pacific Supported Measures Submit a measures group-specific intent G-code on one claim for a covered professional service. This submission serves as the indication the eligible professional is choosing to report on a measures group and will initiate measures group analysis

9. Claims-Based Measures Groups Participation Strategy Report Quality-Data Codes (QDCs) on all applicable measures within a measures group for each patient If all quality actions for the applicable measures in a measures group have been performed for the patient, one composite G-code may be reported in lieu of the individual QDCs Composite G-Codes: Diabetes: G8494 CKD: G8495 Preventive Care: G8496 RA: G8499 Perioperative: G8501 Back Pain: G8502 Hepatitis C: G8549 IVD: G8552 CAP: G8550 Asthma: G8646 COPD: G8757 Cardiovascular Prevention: G8764

10. Claims-Based Reporting Principles QDC Reporting Principles A QDC which is represented by either a CPT II or G-code must be reported: On the claim(s) that represents the eligible encounter For the same beneficiary For the same date of service By the same eligible professional (individual NPI) who performed the covered service, normally identified by CPT or HCPCS codes

11. Claims-Based Reporting Principles QDC Reporting Principles – Modifiers CPT II modifiers may be used to report measures by appending the appropriate modifier to a CPT II code as specified for a given measure. Use of these modifiers is unique to CPT II codes and may not be used with other types of CPT codes. Reporting modifiers will alter an eligible professional's performance rate; however, PQRS is a pay-for-reporting model. As such, accurate reporting on all selected measures will count toward incentive, whether the clinical action is reported as complete or not complete (or performance met or not met).

12. Claims-Based Reporting Principles QDC Reporting Principles - Exclusion Modifiers Exclusion modifiers indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. Reasons for appending these modifier fall into one of three categories: 1P Performance measure exclusion modifier due to medical reasons includes: Not indicated (absence of organ/limb, already received/performed, other) Contraindicated (patient allergy history, potential adverse drug interaction, other) Other medical reasons 2P Performance measure exclusion modifier due to patient reasons includes: Patient declined Economic, social, or religious reasons Other patient reasons 3P Performance measure exclusion modifier due to system reasons includes: Resources to perform the services not available (e.g., equipment, supplies) Insurance coverage or payer-related limitations Other reasons attributable to health care delivery system

13. Claims-Based Reporting Principles QDC Reporting Principles – Reporting Modifier Use of the 8P reporting modifier indicates that the patient is eligible for the measure; however, there is no indication in the record that the action described in the measure was performed and the reason is not specified. Eligible professionals can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance. Eligible professionals should use the 8P modifier sensibly for applicable measures they have selected to report. The 8P modifier may not be used freely in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.

14. Claims-Based Reporting Principles QDC Reporting Principles Submit QDCs at the time the associated covered service is performed and billed Report each QDC as a separate line item, if more than one is required for a measure Submit QDC(s) with a line-item charge of $0.00 or $0.01 if system does not allow a zero charge Total charge for the claim cannot be $0.00. QDC line items will be denied for payment with RA remark code N365 with a message that confirms the QDC was passed through the Medicare claims processing system for PQRS analysis N365 does not indicate if the QDC is accurate for the claim or measure the eligible professional is attempting to report. Keep track of all PQRS cases reported in order to verify QDCs reported match RA notices.

15. Claims-Based Reporting Principles Diagnosis Coding Principles Up to 4 (paper claims) or 8 (electronic claims) diagnoses can be reported in box 21 or the header All diagnoses reported on the base claim will be included in PQRS analysis Only one diagnosis can be linked to each line item. For line items containing a QDC, only one diagnosis from the base claim should be referenced in the diagnosis pointer field. To report a QDC for a measure requiring multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim.

17. The following is a claim sample for reporting the Ischemic Vascular Disease (IVD) Measures Group on a CMS-1500 claim. Two samples are included: • Reporting of individual measures for the IVD measures group • Reporting performance of all measures in the group using a composite G-code • The patient was seen for an office visit (99202). The provider reports all measures (#201, #204, #226 and #241) in the IVD Measures Group: • Intent G-code (G8547) was submitted to initiate the eligible professional’s submission of the IVD Measures Group. • Measure #201 (BP mgmt) with QDCs G8588 and G8589 + IVD line-item diagnosis (24E points to Dx 414.01 in item 21); • Measure #204 (Aspirin Therapy) with QDC G8598 + IVD line-item diagnosis (24E points to Dx 414.01 in item 21); • Measure #226 (Tobacco Use) with QDC 4004F + IVD line-item diagnosis (24E points to Dx 414.01 in item 21);

18. If billing software limits the line items on a claim, you may add a nominal amount such as a penny to one of the QDC line items on the second claim for a total charge of $0.01. • Measure #241 (Complete Lipid Panel) with QDCs G8593 and G8597 + IVD line-item diagnosis (24E points to Dx 414.01 in item 21); • Note: All diagnoses listed in Item 21 will be used for Physician Quality Reporting analysis. (Measures that require the reporting of two or more diagnoses on a claim will be analyzed as submitted in item 21.) • NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing.

19. This sample shows reporting performance of all measures in the group using a composite G-code. • The patient was seen for an office visit (99202). The provider reports all measures (#201, #204, #226 and #241) in the IVD Measures Group: • Intent G-code (G8547) was submitted to initiate the eligible professional’s submission of the IVD Measures Group. • Measures Group QDC Composite G-code G8552 (indicating all quality actions related to the IVDE Measures Group were performed for this patient) + IVD line-item diagnosis (24E points to Dx 414.01 in item 21). The composite G-code G8552 may not be used if performance modifiers (1P, 2P, 3P or G-code equivalent) of the 8) reporting modifier apply. • Note: All diagnoses listed in Item 21 will be used for Physician Quality Reporting analysis. (Measures that require the reporting of two or more diagnoses on a claim will be analyzed as submitted in item 21.) • NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing.

20. QUESTIONS? Q: When Medicare is secondary and the QDC code is entered on a claim sent to the primary payer, what should I do if that QDC is stripped before the claim is forwarded to Medicare? A: Because many primary payers may be unable to properly process QDCs, the QDCs must usually be applied to the claim after the primary payer has processed it and prior to its submission to Medicare for secondary payment. Q: I am an employee member of a group and I have assigned my Medicare Part B Physician billing to the group. Can I report and be eligible for the incentive under PQRS? A: If a professional has assigned Medicare Physician Fee Schedule billing to an employer, the eligible professional may participate. The employer, on behalf of the eligible professional, can submit the Physician Quality Reporting clinical measure CPT Category II codes or G-codes on Part B professional services claims and pursue the financial incentive. When the claim is billed, the individual NPI must be in the rendering NPI field to be able to calculate the data at the individual NPI level. In situations where eligible professionals who are employees or contractors have assigned their payments to their employers, the statute requires that any financial incentive earned will be paid to the employers or facilities.

21. QUESTIONS? Q: What is meant by reporting "all applicable" measures? A: Every measure within a measures group must be reported on each patient in the eligible professional's sample to whom the measure(s) applies. In many cases, all the measures in a group will apply to all the patients in the measures group sample, but in some cases only some of the measures in a group will apply to each patient. For example, the Preventive Care measures group includes three measures that apply only to female patients; the eligible professional would be required to report these measures on females in the measures group sample who are within each measure's specific age range. They would not be expected to report a female-specific measure on a male patient or on a female patient outside the measure's specified age range.An eligible professional could choose to report measures that are not applicable to a patient to ensure complete reporting; however, these patients will be ignored in the 30-patient sample count. (For example, there is no penalty for reporting diabetes measures on an 80-year-old patient, but the count for the 30-patient sample will include only patients in the 18-75 year range for the Diabetes Mellitus measures group). Q: How will an eligible professional know when (s)he has reported on all 30 unique patients for measures group reporting for PQRS? A: The eligible professional will need to pay close attention to the PQRS measures-group patient sample criteria, and report on at least 30 unique patients to whom the measures group applies. While there is no immediate feedback as to whether the eligible professional has accurately identified and reported all 30 required unique patients, (s)he can check the Remittance Advice to ensure that quality-data codes reported were processed and denied as indicated by remark code N365 on the EOB.

22. QUESTIONS? Q: When is it appropriate to use the composite G-code and when does the eligible professional need to report the measures within each measures group individually? A: There are two options for reporting quality-data codes (QDCs) for the Physician Quality Reporting measures groups. The individual eligible professional may report QDCs on all individual measures within the measures group OR report one (composite) G-code which indicates the performance (quality action) of all measures in the group were performed.If all of the quality actions for the measures within the measures group were performed at an encounter during the reporting period, the eligible professional could report the composite G-code instead of reporting QDCs for each measure individually. Note that performance exclusion modifiers (i.e., 1P, 2P, 3P or G-code equivalent) and the 8P reporting modifier cannot apply to the reporting of any measure within the measures group if the composite G-code is used for reporting because all of the quality actions for each measure must have been performed and documented.Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group. The recommended clinical quality action must be performed on at least one patient for each measure within the measures group reported by the eligible professional. Performance exclusion quality-data codes are not counted in the performance denominator. If the eligible professional submits all performance exclusion quality-data codes, the performance rate would be 0/0 (null) and would be considered satisfactorily reporting.

23. References Mountain-Pacific Quality Health: www.mpqhf.org Janice Mackensen, Project Manager 1-800-497-8235, Ext: 5843 jmackensen@mpqhf.org Janet Whitmoyer, RN HIT Specialist 1-800-497-8235, Ext: 5876 jwhitmoyer@mpqhf.org Centers for Medicare and Medicaid Services (CMS) PQRS: How To Get Started https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html Getting Started With Measures Groups https://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2012_PhysQualRptg_MeasGroups_Specs_SupportingDoc_121511.zip 2012 PQRS: Claims Reporting Made Simple:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2012PQRS_SatisfRprtng-Claims_Final508_1-13-2012.pdf Help Desk QualityNet Help Desk : 1-866-288-8912 (TTY 1-877-715-6222) or via http://qnetsupport@sdps.org Available Monday through Friday from 7:00 a.m.-7:00 p.m. CST for assistance with program questions, feedback reports, incentive payments, and other concerns. CMS Frequently Asked Questions https://questions.cms.gov/ .