GIQuIC: A Qualified Clinical Data Registry for 2014 PQRS ...giquic.gi.org/docs/GIQuIC_QCDR_FAQs.pdfTo earn the .5% incentive payment for 2014, an eligible professional must successfully

GIQuIC: A Qualified Clinical Data Registry for 2014 PQRS Reporting Current as of 7/1/2014

GI Quality Improvement Consortium (GIQuIC)

In May 2014, the Centers for Medicare and Medicaid Services (CMS) announced that GIQuIC was approved as a qualified clinical data registry (QCDR) for 2014 reporting to the Physician Quality Reporting System (PQRS). This reporting option allows eligible providers to report on measures that are meaningful to their specialty practice and will foster improvement in the quality of care provided to patients while being in compliance. Thirteen GI-specific measures within GIQuIC were approved for reporting; click here to view them. To view an informational webinar on GIQuIC as a QCDR option, click here. GIQuIC has received many questions regarding its useas a QCDR option. For your convenience, the Q&A is grouped by the following topics:

GIQuIC as a QCDR

Physician Participation Eligibility

Mid-level Provider Participation Eligibility

Data Submission Requirements

Provider versus Facility-level Reporting and the Medicare ASC Quality Reporting Program

PQRS and the Value-Based Modifier

Meaningful Use Please contact GIQuIC – [email protected] – with any additional questions you may have relative to using GIQuIC as a QCDR to fulfill physician reporting to PQRS or visit our website at www.giquic.org. Please contact CMS directly at (866) 288-8912 or at [email protected] to address your questions about PQRS reporting (other than how to use GIQuIC as a QCDR), the value-based payment modifier, or other public quality reporting programs.

http://giquic.gi.org/docs/GIQuIC_Measure_Submission.pdf

http://giquic.gi.org/qcdr.asp

mailto:[email protected]

http://www.giquic.org/




Following are two FAQ’s from CMS regarding the eligibility for PQRS: Q: Who is eligible for PQRS? A: Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of eligible medical care professionals considered eligible to participate in PQRS is available. Read this list carefully, as not all entities are considered “eligible professionals” because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS). Q: If an eligible professional provides care and submits claims under multiple Taxpayer Identification

Numbers...

A: The analysis of satisfactory reporting will be performed at the individual eligible professional level within each TIN, using individual-level National Provider Identifier (NPI) to identify each professional's services and quality data. Incentives earned by individual professionals will be issued to the TIN under which he or she earned an incentive, based on the Physician Fee Schedule (PFS) professional services claims submitted under the TIN, aggregating individual eligible professionals' incentives to the TIN level. For eligible professionals who submit claims under multiple TINs, CMS groups claims by TIN for analysis and payment purposes. As a result, a professional who submits claims under multiple TINs may earn a Physician Quality Reporting incentive under one of the TINs and not the other(s), or may earn an incentive under each TIN. The financial incentive earned by any individual professional under a given TIN, based on the claims associated with that TIN, will be included in that TIN's aggregate Physician Quality Reporting incentive payment.

Please contact CMS directly at (866) 288-8912 or at [email protected] to address your questions

about PQRS reporting (other than how to use GIQuIC as a QCDR).

http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf

https://questions.cms.gov/faq.php?id=5005&faqId=2133

https://questions.cms.gov/faq.php?id=5005&faqId=2133




GIQuIC as a QCDR 1. Q: If we are already using GIQuIC, is there an additional fee to use it for PQRS reporting?

A: No, for 2014 reporting there is no additional fee for using GIQuIC to submit data for PQRS.

2. Q: Given that the PQRS reporting period is from January 1 - December 31, 2014, if we did not start GIQuIC until March, can we still use it for the PQRS? PQRS has a 365 day reporting period.

A: The CMS requirement is that at least 50% of the eligible provider’s patients in the 2014

reporting year be submitted for each measure reported to CMS. Therefore, if a provider elects to have their measure data submitted to CMS via the GIQuIC QCDR option, then the provider would need to ensure at least 50% of his/her patients are captured in GIQuIC for 2014.

3. Q: I do not find in the list of reports in the GIQuIC registry some of the measures referred to in the Webinar. Is there something I need to do to have them added?

A: The data fields for these measures are already included in your procedure records. We are

adding these as measure reports in the near future.



Physician Participation Eligibility 4. Q: Our unit is set to become a large entity (32 providers) in September of this year. We

currently have six providers. Will we still be allowed to use GIQuIC as a QCDR? A: PQRS is applicable to every provider who is paid under the Medicare Physician Fee

Schedule. The size of the group does not impact a provider’s participation requirement.

There are multiple reporting mechanisms for PQRS. The QCDR option supports reporting by individual eligible providers. The Group Practice Reporting Option (GPRO) is not available for QCDR reporting; however, all providers in a group can choose to do individual reporting using GIQuIC as a QCDR.

5. Q: If our ASC has 10 or more members but these members are from three different GI practices (each of which has less than 10 members), can this qualify for GIQuIC?

A: An endoscopy center of any size can participate in GIQuIC, and in turn, any individual

provider participating in GIQuIC can choose to participate in the QCDR option for 2014 PQRS reporting to CMS.

6. Q: We are a five-physician group with a separately owned endoscopy center. Is our group required to submit data to PQRS since we have less than 10 physicians?

A: All eligible professionals who are paid under the Medicare Physician Fee Schedule are

required to participate in PQRS in calendar year 2014 or be faced with a negative payment adjustment of 2.0% for all of their Medicare Part B services for the 2016 payment year. PQRS is a provider-level program so it would be applicable to every provider who is paid under the Medicare Physician Fee Schedule, and the provider would need to participate in PQRS for each tax identification number (TIN) for which he/she submits claims. Group size is not a determining factor in PQRS participation.

7. Q: If we are only a seven-physician group but participate in a Medicare Shared Savings Plan Accountable Care Organization that has over 25 eligible providers, then are all 25 eligible providers judged together for PQRS reporting and VBPM since they have to report via GPRO?

A: Your ACO governing board should be reporting PQRS on your behalf. Please direct your

question to your ACO or to QualityNet.

8. Q: We are a group of 30 physicians and seven mid-level providers operating under two TINs - one for our physician practice and the other for our endoscopy center. Do we need to submit PQRS data for both TINs? Can we report for both TINs via GIQuIC?

A: If an eligible professional submits claims to Medicare under multiple tax identification

numbers, the professional must participate in PQRS under each TIN to avoid the payment adjustment or to receive a payment incentive. If the eligible professional is participating in PQRS to only avoid the payment penalty, they will need to successfully report three measures for each TIN. Eligible professionals can use different reporting mechanisms for each TIN; however, they can only use one reporting mechanism per TIN. For example, a physician may participate in GIQuIC under the TIN at his/her ASC and in claims-based reporting under the TIN at his/her office.

9. Q: Do anesthesiologists need to complete PQRS for 2014?



A: PQRS is applicable to every eligible provider who is paid under the Medicare Physician

Fee Schedule.

10. Q: We do not have any NPs or PAs, only eight physicians. Are we candidates to participate in this specific program to receive the incentive monies?

A: PQRS should not be confused with the requirements for the physician value-based

modifier. PQRS is a provider-level program; practice setting or size is not a factor when determining participation. Eligible providers who are paid under the Medicare Physician Fee Schedule and choose not to participate in PQRS will face a 2.0% payment reduction on all Medicare Part B claims submitted to Medicare during the 2016 payment year. All eligible providers who successfully report three measures will avoid the payment reduction. To earn the .5% incentive payment for 2014, an eligible professional must successfully report nine measures covering at least three National Quality Strategy Domains (NQS). For eligible professionals using a QCDR to report, one of the nine measures must be an outcome measure.

11. Q: Is the October deadline for submitting a Provider Consent form to sign up for GIQuIC or to authorize GIQuIC to submit data to PQRS?

A: The October 15, 2014 deadline to submit a Provider Consent Form is to authorize GIQuIC

to submit data to CMS on your behalf for participation in the PQRS program. There is no deadline to register for GIQuIC; however, CMS requires that the provider report at least nine measures covering at least 3 National Quality Strategy domains and report each measure for at least 50% of patients seen during the reporting period to which the measure applies (January 1- December 31, 2014). This is to obtain the .5% incentive. Three measures are required in order to avoid the 2.0% payment reduction. For the QCDR reporting option, CMS requires reporting of all patients, regardless of payer. Therefore, if a provider elects to have his/her measure data submitted to CMS via the GIQuIC QCDR option, then the provider would need to ensure at least 50% of their patients, for which the measures apply, are captured in GIQuIC for 2014.

12. Q: If the hospital employs more than 10 physicians of various specialties and only one GI physician, and that physician elects to participate in GIQuIC and PQRS, then can he/she avoid the cut?

A: Yes, if the physician successfully submits data on at least three measures. But in this

specific instance, it would be advised that the provider confirm whether the hospital is submitting to PQRS on his/her behalf.



Mid-level Provider Participation Eligibility

13. Q: I have four physicians and three mid-level providers (MLPs). Can I meet PQRS for my physicians with GIQuIC as a QCDR, and another reporting mechanism for my MLPs?

A: Yes, individual eligible providers within the same practice can use different PQRS

reporting mechanisms.

14. Q: Is there a suggested solution for mid-level providers who do not perform endoscopy if we are using GIQuIC QCDR option for physicians?

A: There are other PQRS reporting options - claims, CMS-qualified registry, or EHR

reporting. We recommend you contact QualityNet for further questions regarding these other reporting options.



Data Submission Requirements

15. Q: Did I understand correctly that if you are a new participant in GIQuIC, you need to go back and submit all data starting from January 1st?

A: The requirement for reporting PQRS measures via the QCDR option is that at least 50% of

applicable patients be reported for at least nine measures, with at least one outcome measure, covering at least three National Quality Strategy domains in order to qualify for the .5% incentive, or report at least three measures to avoid the 2.0% payment reduction on all Medicare Part B Services for CY 2016. “Applicable patients” for this purpose means 50% of the individual provider’s endoscopy cases that fit into GIQuIC’s QCDR measures. Therefore, a provider would need to ensure that at least 50% of his/her patients are submitted to the registry for the 2014 reporting year.

16. Q: What if less than 50% of our procedures are done at an ASC that participates in GIQuIC? The majority are done in a hospital setting that does not participate in GIQuIC. Can we still use GIQuIC for 2014 PQRS reporting?


applicable patients be reported for at least nine measures, with at least one outcome measure, covering at least three National Quality Strategy domains in order to qualify for the .5% incentive, or report at least three measures to avoid the 2.0% payment adjustment for CY 2016. Therefore, at least 50% of the eligible provider’s patients would need to be submitted to the registry for the 2014 reporting year. Note that an eligible professional cannot use multiple reporting mechanisms for PQRS under a single TIN.

17. Q: We are planning to join GIQuIC mid-year. Can you advise me of the required reporting period for PQRS? If we have only a partial year of data on your system, can we still use GIQuIC for PQRS for 2014 reporting?

A: The requirement is that data for at least 50% of the eligible professional’s patients seen

during the reporting period to which the measures apply be sent to CMS, and in this case, the reporting period is the calendar year 2014.

18. Q: If my provider works at two locations, one which submits data to GIQuIC and one that does not, will he still meet the 50% reporting requirement even though he does not see a majority of his patients at the GIQuIC location?


applicable patients be reported. Therefore, if the provider does not meet this threshold with the % of cases reported to the GIQuIC registry, then he should consider another PQRS reporting option where the requirements can be met.

19. Q: Is PQRS reporting for all patients or only for Medicare patients? A: The QCDR option requires reporting to occur on all patients - Medicare and private

payers. Requirements using other reporting mechanisms vary. For example, providers using claims-based reporting must only report on Medicare Part B Physician Fee Schedule patients.



20. Q: If I work in a hospital, should I send in my own PQRS information or will the hospital send in appropriate information for physicians in other areas? I am not sure if I should be contacting someone in the hospital with my information.

A: We encourage you to check with your hospital to clarify expectations. Data from an

eligible provider cannot be reported via two separate PQRS reporting mechanisms for one tax identification number.

21. Q: Do the physicians need to report to PQRS under each office/facility in which they practice?

A: If the physician submits claims to Medicare under different tax identification numbers

(TIN’s) for each office/facility, then the professional must participate in PQRS under each TIN to avoid the payment adjustment or to receive a payment incentive. If the eligible professional is participating in PQRS to only avoid the payment penalty, he/she will need to report three measures for each TIN. Eligible professionals can use different reporting mechanisms for each TIN; however, they can only use one reporting mechanism per TIN. For example, a physician may participate in PQRS via the QCDR option of GIQuIC under the TIN at his/her ASC and in claims-based reporting under the TIN at his/her office.

22. Q: I thought only 20 patients need to be reported if using a registry and not 50%. Is that correct?

A: The 20-patient minimum relates to PQRS reporting a measures group via a registry.

Measures Group reporting is not an option through QCDRs. QCDR reporting is applicable only for individual measures and for that there is requirement of at least 50% of patients.

23. Q: If a physician in our ASC is using GIQuIC to report his/her measures, can the physician’s office also use GIQuIC to report PQRS?

A: Unless endoscopy is provided in the office, there are no office-based encounters that

would be collected in the GIQuIC registry. If the physician submits claims under a different tax identification number (TIN) for the ASC and the office, then he/she is required to submit to PQRS for every unique TIN. If he/she submits claims under only one TIN, he/she could only participate in PQRS via one reporting method.

24. Q: Our hospital outpatient surgery department submits data to GIQuIC for our physicians through ProVation. Are we able to use this for our office for PQRS or Meaningful Use?

A: See the above answer to Q #23. Unless the office conducts office-based endoscopy,

there are no office-based encounters that would be collected in the GIQuIC registry. If the physicians submit claims under different tax ID’s for the outpatient surgery department at the hospital and the office, then they are required to submit to PQRS for every unique TIN. If they submit claims to only one TIN, they could only participate in PQRS via one reporting method. Meaningful Use is a separate program and would still need to be met outside of meeting PQRS via the GIQuIC QCDR option. Contact QualityNet to learn more about requirements for the Meaningful Use/EHR Incentive Program.



25. Q: We have a six physician practice and I have been reporting to PQRS for the office practice. My physicians want to know if they report through GIQuIC and don't satisfactorily report some of the measures; can they combine measures to make the requirements? Also, if they are performing procedures at multiple sites, are they required to report from there as well?

A: With the PQRS program, a physician can report his/her measures through one option

only for each unique TIN for which they submit claims. So they cannot report some through GIQuIC and some through another reporting option (via claims or via another registry/EHR reporting) for the same TIN.

If they are reporting all of their colonoscopies to GIQuIC and have been for the entire year and continue to do so, then they should be able to select at least three of the GIQuIC measures approved by CMS for the QCDR reporting option in order to avoid the - 2.0% payment adjustment. Click here for a list of those measures. As far as reporting from other sites, it would depend on whether at least 50% of their procedures are done at the center that is participating in GIQuIC, and if they submit claims under the same TIN for each site. If they operate under one TIN, they must submit at least 50% of their procedures in total per that TIN.

26. Q: If any of the nine reported measures have a zero denominator, then is it correct that the physician would not receive the incentive and/or would not avoid the penalty?

A: Measures with a 0 percent performance rate will not count. You will not get credit for

reporting this measure. However, the provider could still avoid the payment adjustment. To earn the .5% incentive, a provider must successfully report at least nine individual measures covering at least three National Quality Strategy (NQS) domains. For eligible professionals using a QCDR to report, one of the nine measures must be an outcome measure. To avoid the 2.0% adjustment, a provider must successfully report at least three individual measures.

27. Q: Does GIQuIC pull data from an ASC’s EMR or do you need to collect data manually and then input into GIQuIC?

A: Data can be uploaded directly from a certified endowriter or manually entered into the

GIQuIC registry website.

The following are certified vendors:

Amkai

CORI

eMerge Health Solutions

EndoSoft

gMed

MD-Reports

Olympus (version 7.4)

Pentax (endoPRO iQ)

ProVation (version 5.0)

Summit Imaging

http://giquic.gi.org/docs/GIQuIC_Measure_Submission.pdf



28. Q: MD-Reports stated they were not certified with PQRS. Are you sure they have a method of collecting the necessary data in the system?

A: MD-Reports is a certified vendor with the GIQuIC registry. This means that data can be

collected in MD-Reports and then submitted to the GIQuIC registry. GIQuIC would then submit your applicable measure data to CMS on your behalf, in order to meet the 2014 PQRS reporting requirements.

29. Q: Will we be able to use GIQuIC even if we have Greenway for our EMR? A: Yes, regardless of how your data is entered into GIQuIC - whether it is uploaded from a

certified vendor or manually entered - once it is there, it will be passed on to CMS for the PQRS program should a provider consent for GIQuIC to do this on his/her behalf.

30. Q: If we use GIQuIC as QCDR, will the workflow for collecting and uploading the data remain the same or will there be additional steps?

A: The workflow will stay the same. You should continue to submit data on all cases, and

include all data fields for each case.

31. Q: During the webinar on 5/20/14, it was recommended that we start capturing the insurance information in the GIQuIC registry if we were not already doing so. How do I go about making sure this is captured and how do I find out if we are doing this?

A: If you capture procedure data first in an endowriter that is certified with GIQuIC, you

would want to make sure this is being captured in that system first before the cases are transferred to GIQuIC. If you need help with this part of the documentation in the procedure record, please contact your endowriter.

If you are manually entering case data into the GIQuIC registry website, then there is a data field in the first tab of the patient form where this data field can be captured. In order to see if insurance information has been captured, you could run a report and filter by insurance type.

32. Q: Can insurance become a required field in GIQuIC? A: We are not able to make this change (at this time). This would require a specification

change in which our certified vendors would need to make as well.



Provider versus Facility-level Reporting and the Medicare ASC Quality Reporting Program

33. Q: If the physicians do not report PQRS data, does the facility receive the 2% penalty or does that only apply to the practice?

A: PQRS is a provider-level program, not a facility-level program. Eligible professionals who

do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2% payment adjustment to their Medicare PFS amount for services provided in 2016.

34. Q: For the ASC quality data reporting, is it correct that we cannot submit this data via a registry?

A: The only mechanism to report to the Medicare ASC Quality Reporting Program is through

the QualityNet website. Please contact QualityNet to discuss further reporting to this program.

35. Q: I only have three providers at the endoscopy center. Am I still reporting my PQRS Measures 09 and 10 through the QualityNet while GIQuIC will report all other value-based modifiers?

A: Measures 09 and 10 in the ASC Quality Reporting Program mirror two GI measures in

PQRS, specifically 185 and 320. While they are the same measures, the ASC Reporting and PQRS programs are distinct as are the reporting mechanisms. ASC Quality Reporting Program measures 09 and 10 can only be reported through QualityNet.

PQRS 2014 reporting ties to the Value-Based Payment Modifier for groups of physicians of ≥ 10.

36. Q: When do you anticipate there being a single reporting mechanism, such as GIQuIC as a QCDR, for the ASC Quality Reporting Program and PQRS?

A: GIQuIC’s sponsoring societies ACG and ASGE continue to advocate for alignment across

public quality reporting programs to decrease the reporting burden.



Value-Based Payment Modifier (VBPM)

37. Q: Who is affected by the Value-Based Modifier and how does PQRS affect it? A: For the 2014 reporting, or performance year, the VBPM applies to physicians who are

part of a group with 10 or more eligible providers. Even though group size is based on all eligible professionals, the modifier is applied only to physician payments. By law, all physicians will be subject to the VBPM starting with the 2017 payment year. While this is a separate program from PQRS, the VBPM is linked to successful PQRS participation. For more information on the VBPM program, contact QualityNet.

38. Q: Does the Value-Based Payment Modifier apply to endoscopy centers? A: It would depend on whether the endoscopy center has a single tax identification number

under which 10 or more eligible providers submit claims. CMS specifies the following: “Physicians in group practices of 10 or more eligible professionals who participate in Fee-For Service Medicare under a single tax identification number will be subject to the value modifier in 2016, based on their performance in calendar year 2014.” Note that the modifier is applied to physician Part B reimbursement, not ASC facility payments.

39. Q: Would office-based nurse practitioners in a practice still need to complete traditional non-endoscopic PQRS measures to make a practice of 10 or more eligible for VBPM?

A: Application of the VBPM hinges on successful PQRS participation. If the practice is

participating in PQRS through the Group Practice Reporting Option (GPRO), then the practice would need to satisfy the requirements for the GPRO to avoid a negative VBPM. If the practice does not participate in the GPRO, then at least 50% of the group’s eligible professionals must successfully report (avoid the 2016 PQRS penalty) in PQRS as individuals. In the latter case, depending upon the composition of the practice, an NP(s) may need to report for the practice to avoid a VBPM adjustment. Please contact QualityNet for further questions regarding the Value-Based Payment Modifier.

Meaningful Use

40. Q: If we choose #6 in our menu set for Meaningful Use, will we automatically meet this measure because we use GIQuIC to participate in PQRS?

A: In order to attest to Meaningful Use Menu Objective #6: “Report specific cases to a

specialized registry”, cases must be submitted to GIQuIC via a certified electronic health record technology (CEHRT). A list of CEHRT can be found here at the following link. We recommend confirming that your EHR is on this list before making an attestation. http://oncchpl.force.com/ehrcert?q=chpl

http://oncchpl.force.com/ehrcert?q=chpl

Documents

GIQuIC: A Qualified Clinical Data Registry for 2014 PQRS ...giquic.gi.org/docs/GIQuIC_QCDR_FAQs.pdfTo earn the .5% incentive payment for 2014, an eligible professional must successfully