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Laura W. Groshong, LICSWDirector, Government Relations
April 26, 2014, 12-1 pm EDT
PQRS for LCSWs
Disclaimer CSWA has done its best to collect accurate
information on the information provided in this webinar. There will undoubtedly be changes to the Physician Quality Reporting System going forward, which will modify the information presented here in the future. CSWA will provide additional information as it becomes available.
Get Ready for a Wild RideLearning about the new concepts which will
anchor mental health and health care reimbursement will revise many concepts we have worked by for decades
Areas to be Covered
Business Plans for LCSWs as Context
Physician Quality Record Systems (PQRS)
Changes to Health Care
The End of the World as We Know It?
Therapists considering dropping out of solo practice to join groups: “The increasing complexity of running a practice has meant more therapists are taking down their shingles or forming groups with other therapists to share the burden, executives at national mental health groups say. Others have joined large medical groups that offer mental health services as part of comprehensive care.” (NPR.org, 10/24/13) http://www.npr.org/blogs/health/2013/10/24/234737302/therapists-explore-dropping-solo-practices-to-join-groups?goback=%2Egde_4267431_member_5799134027814297601#%21
Biggest Health Care Changes
Massive changes in health care delivery
‘Out of network’ reimbursement likely to end in next 5 years; instead in-network, new risk sharing systems (ACOs, health homes) or private pay
In 5-10 years LCSWs working with third-party payers are likely to be required to do record keeping through interoperable electronic systems
Impact of Affordable Care Act and
Mental Health Parity Act“Integrated care” in ACA likely to lead to
LCSWs working in virtual clinic-like organizations in capitated systems
Cost of hiring billers and/or buying EHRs may make joining groups more appealing to cover administrative costs
Parity will make mental health more integrated into medical care, but up to LCSWs to explain what mental health treatment needed
More marketing necessary for clinicians who want to remain in private pay system
From FFS to P4P –Underlying Goal
Medicare goal to end fee-for-service (FFS) payment, go to pay for performance (P4P) – likely to be adopted by private insurers
Less treatment and better outcomes lead to higher reimbursement rates
Role of insurers unclear as ACOs/health homes roll out
For now, LCSWs need to learn how to explain mental health treatment needs, esp. long-term
LCSWs and Overall Changes to Health Care Reimbursement
We feel that we are being locked into systems which are at odds with being in control of our own practices
Unlock the Changes:New Business Plans for LCSWs
Business plan good base for all new health service delivery changes
Courses offered by SAMHSA: Strategic Business Planning; Third-party Billing and Compliance; Eligibility and Enrollment; Third-party Contract Negotiation; and Meaningful Use of Healthcare Technology (not for clinicians at this time)
Go to http://bhbusiness.org/Special-pages/Home.aspx to register!
New Business Plans for LCSWs (cont.)
Another option for learning to navigate new business models:
Behavioral Health First Aid at http://bhbusiness.org/Special-pages/Home.aspx
Consultants on Clinical Business Practices
Rob Reinhardt, LPC – EHRs – www.tameyourpractice.com
Steve Walfish, PsyD – business practices - Financial Success in Mental Health Practice: Essential Tools and Strategies for Practitioners (2008); Earning a Living Outside of Managed Mental Health Care: 50 Ways to Expand Your Practice (2010) - http://thepracticeinstitute.com/the-tpi-team
On to Physician Quality Reporting System (PQRS)
Climbing the PQRS mountains…..
PQRS is Part of MedicareLCSWs are automatically part of the Medicare
provider network HOWEVERTo become eligible for reimbursement, LCSWs
must “opt in” through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf
LCSWs Can Opt Out of Medicare
If an LCSW decides not to become part of the Medicare provider network, the LCSW must do two things:
- The LCSW must send an “Opt Out Form” to the Medicare Administrative Center (MAC) that oversees the LCSW’s region (see CSWA website)
- The LCSW must send an exact copy of the “Medicare Private Contract” that the LCSW will use with any Medicare beneficiary to guarantee that no claims will be submitted by the LCSW or the beneficiary for the LCSW’s services
LCSWs Can Opt Out of Medicare (cont.)
No templates of Opt Out Form or Private Medicare Contract provided by CMS
Editable templates of the Opt Out Form and the Private Medicare Contract can be found in the Members Only Section of the CSWA website: (www.clinicalsocialworkassociation.org)
Go to CSWA Templates to downloadCan join CSWA on website and access
Templates
Physician Quality Reporting System (PQRS)
Started as Physician Quality Reporting Initiative in 2007
Changed to PQRS in 2010PQRS which will provide ‘incentive’ (bonus)
for data submitted in 2013 and 2014 two years later, i.e., 2015 and 2016 of .5%
PQRS will also provide ‘payment adjustment’ (penalties) if reporting threshold is not met
CMS Guidelines for PQRS
“We urge solo practitioners and physicians in smaller groups to participate in the PQRS now, because we will propose in future rulemaking to apply the value-based payment modifier to smaller groups and solo practitioners. (CMS, 2012)” http://www.ama-assn.org/amednews/2012/11/12/gvsa1112.htm
Translation: clinicians do not use PQRS measures by 2015 will see increasing penalties in payments
‘Eligible’ Mental Health Professionals for PQRS
“Eligibility” for PQRS
“Eligibility” actually misnomer – requirement for all “eligible” groups or will have reimbursements penalized
Will have “eligibility” for bonus in 2015 and 2016 – in 2017 will be only penalty (1.5 in 2015 for 2013 data; 2% for 2016 for 2014 data)
Starting in 2017 will only be penalties of 2% per year if PQRS data not submitted
Reason for PQRS PQRS designed to reduce costs of most
expensive disorders, e.g., diabetes, congestive heart failure, major depressive disorder, chemical dependency, to provide assessments and preventive care
HOWEVER:PQRS not lined up with DSM/ICD codes –
must be creative to implement as mental health clinicians (see below)
PQRS and Mental HealthPQRS is not easily applied to chronic disorders,
including mental health, more for assessment
PQRS concept started in Medicare but likely be used by all insurers/health care delivery systems within next 5 years
Most important general document for finding PQRS data that applies to LCSWs: 2013 Physician Quality Reporting System (PQRS) Claims/Registry Measure Specifications Manual (637 pp.)
Mental Health Diagnoses and PQRS
Remember: DSM/ICD Diagnoses not linked to PQRS Measures!
Mainly assessment and prevention measures for LCSW patients, i.e., depression assessment, suicide risk assessment, smoking assessment, substance use assessment, etc., regardless of actual ICD-9 diagnoses
List of codes for LCSWs to follow
PQRS Effect on Medicare Payments
PQRS will affect Medicare reimbursement rates with bonus (.5% in 2015 and 2016) or penalty (1.5% in 2015, 2% in 2016) for 2015 and 2016 claims
PQRS bonuses end in 2016, then only penalties
Must have three QDCs for 50% of Medicare patients to be eligible for PQRS bonus in 2016 (from 2014 data submitted) and be MAV compliant
Six Areas of PQRS Usage
Denominator and Numerator – information that must be included to be PQRS compliant
Measures – 350 areas that are ‘measured’ by Medicare as Denominator and Numerator (9 for LCSWs)
Quality Data Codes (QDCs) – codes entered on CMS-1500 representing the use of a measure
Six Areas of PQRS Usage cont.
Domains – 11 areas that assess the overall reason for including a given measure
Medicare-Applicability Validation (MAV) – validates that there are less than 9 measures available to the provider (applies to LCSWs) and leads to
Clusters – 27 ‘clusters’ of CPT codes that should be included if one is used
PQRS ‘Denominator’Denominator= patient
group/encounter/dx, i.e., CPT and ICD Codes, treatment location, i.e., what LCSWs already submit
ICD-9 Codes for mental health disorders, especially major depressive disorder, AND
CPT Codes for LCSWs: 90791, 90832, 90834, 90837, 90839, 90845, 90846, 90847, 90849, 90853
PQRS ‘Numerator’Numerator = treatment according to
Quality Data Codes (QDCs) using new G-codes and F-codes for measures
Can be submitted if new ‘episode’, i.e., patient not treated for diagnosed condition for at least 4 months
Go to Clinical Social Work Association link for complete list of connected G-codes and F-codes: http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20PQRS%20Options%20for%20LCSWs%20(revised)%20-%209-24-13%20(2).pdf
PQRS DomainsSix general areas which are used to describe
underlying goal of measure: - Efficiency and Cost Reduction (ECR)- Effective Clinical Care (ECC)- Community/Population Health (CPH)- Patient Safety (PS)- Communication and Care Coordination (CCC)- Person/Caregiver-Centered Outcomes (PCCO)Use as many as possible!
PQRS Measures Purpose
PQRS Measures created to ‘measure’ most expensive diagnostic categories and contain costs
Measures reported on CMS-1500 forms as Quality Data Codes once a year for most Measures used by LCSWs
Exception: Measure #130, Documentation of All Medication, must be submitted for each session
List of PQRS Measures
Go to http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs
Then go to “Educational Resources” (left side)
Then go to http://www.cms.gov/2014_PQRS_MeasuresList_12132013.pdf
Change every year!
PQRS Quality Data Codes
PQRS Measures are like general categories, i.e., depression
PQRS Quality Data Codes (QDCs) are like specific categories, i.e., a new specific code
Again, QDCs get reported on CMS-1500!
PQRS Clusters (MAV)
Medicare-Applicability Validation (MAV)
Automatically used when less than 9 measures available, as with LCSWs
27 ‘Clusters’ to make sure all possible measures reported on
PQRS Clusters (MAV) cont.
Based on CPT codes, e.g., 90791, 90834, 90837
If any CPT code used by LCSW in a cluster, all other measures must be reported if in scope of practice
Three clusters for LCSWs: #1 (General Preventive Care); #11 (Depression); #22 (Substance Use Disorders)
PQRS Clusters (MAV) cont.
Cluster 1 (General Preventive Care) = Measures #130 (Medications), #226 (Tobacco Use)
Cluster 11 (Depression) = Measures #106 (Depression Screening), #107 (Suicide Assessment), #134 (Follow Up Plan), #226 (Tobacco Use)
Cluster 22 (Substance Use Disorders) = Measures #130 (Medications), #226 (Tobacco Use), #247 (Treatment for Alcohol Dependence), #248 (Treatment for Depression with Substance Dependence)
Measures Used by LCSWs
The next 9 slides summarize the QDC, Domain, Cluster, and reporting schedule for each measure used by LCSWs
PQRS Measures =Major Depression Evaluation
#106 Adult Major Depressive Disorder Comprehensive Depression Evaluation: Diagnosis and Severity
Domain: ECCQDC: G8930 (for assessment of depression severity at
the initial evaluation)Clusters: #11Report: Once a year or every new episode (must be four
months since end of last treatment for MDD)
PQRS Measures = Suicide Risk
#107 (Suicide Risk Assessment)Domain: ECCQDC: G8932 for suicide risk assessed at the
initial evaluation; 3092F for major depressive disorder in remission; or G8933 for suicide risk not assessed at the initial evaluation
Clusters: #11Report: Once a year or every new episode
(must be four months since end of last treatment)
PQRs Measures - Medications
#130 (Medication Documentation)Domain: PSQDC: G8427: Current Medications
Documented; G8430: Current Medications not
DocumentedClusters: #1 and #22Report: EVERY SESSION
PQRS Measures – Depression Treatment Plan
#134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Domain: CPHQDC: G8431: Positive screen, documented follow-up
plan; G8510: Negative screen, follow-up not
required; G8433: Screening not done, patient not
eligibleClusters: #11Report: Once a year or every new episode (must be
four months since end of last treatment)
PQRS Measures – Unhealthy Alcohol Use
#173 Preventive Care and Screening: Unhealthy Alcohol Use
Domain: CPHQDC: 3016F: Patient screened for unhealthy
alcohol use using a systematic screening method
3016F-1P: unhealthy alcohol use screening not performed,
Clusters: #22Report: Once a year or every new episode (must
be four months since end of last treatment)
PQRS Measures – Elder Maltreatment
#181 Elder Maltreatment Screen and Follow-Up Plan
Domain: PSQDC: G8733: Documentation of a positive
elder maltreatment screen and follow-up plan
G8734: Elder maltreatment screen documented as negative
Clusters: NoneReport: Once a year
PQRS Measures – Tobacco Use
#226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Domain: CPHQDC: 4004F: Patient screened for tobacco use
AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user
1036F: Current tobacco non-user; patient screened for tobacco use and Identified as a non-user of tobacco
Clusters: #1, #22Report: Once a year
PQRS Measures – Alcohol Dependence
#247 Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence
Domain: ECCQDC: 4320F: assessment of psychosocial
and pharmacologic treatment options for alcohol dependence
Clusters: #22Report: Once a year
PQRS Measures – Depression and Substance Dependence
#248 Substance Use Disorders: Screening for Depression among Patients with Substance Abuse or Dependence
Domain: ECCQDC: 1220F: screening for depression among
patients with substance abuse or dependence 1220F-1P: screening for depression among
patients with substance abuse or dependence not completed for medical reasons, documentation required.
Clusters: #22Report: Once a year
Two Ways to Submit PQRS
Claims reporting – through CMS-1500 – most practical way for private practitioners
Must be submitted once a quarter for most QDCs
Easiest way to submit QDCs every time bill
Registries – will collate PQRS information – to use must have 80% of all Medicare cases with 3 measures reported OR a 20 patient sample
PQRS Claims Reporting – CMS-1500 Details
Put G-codes into 24D - right under CPT codesPut in ‘pointer’ for each DSM/ICD diagnosis in
24EBe sure to add $.01 in 24F for each G-codeFor more information on CMS-1500 go to:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf
For sample new CMS-1500 form (02/12), go to:
http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20CMS-1500%20Changes%20-%203-14.pdf
Reactions to Past 20 Slides
PQRS and EHRs
PQRS will be automatically loaded into approved programs
LCSWs not required to use EHRs by 2015, as physicians are, but may be required after 2015 to avoid payment penalties or to even receive third-party reimbursement
No incentives or meaningful use requirements at this time
Important to become ‘literate’ in EHR systems for future
Considerations in Choosing an EHR
EHRs have 18 areas which should be reviewed to make best decision – not all LCSWs will want all functions, which include:
Record keeping (see below)Billing Outcomes toolsInteroperable system
Considerations in Choosing an EHR (cont.)
Business Associate AgreementWebsite IntegrationClient ‘Portal’ for RecordClient FormsView appointmentsSchedule AppointmentsEncrypted Messaging/Emails
Considerations in Choosing an EHR (cont.)
Data PortabilityBill Paying OptionGraphic User InterfaceUser ExperienceTablet FriendlyServer SupportReliability
Problems with EHRs
EHRs were designed to prevent fraud but not successful so far
Privacy still issue – no required auditing of who logs on to records and encryption – breaches exploding (http://www.healthcareitnews.com/news/cms-called-out-ehr-fraud-failings?goback=.gde_4172177_member_5828467181918134276#!)
HHS and CMS trying to address
Online Billing Systems
Hard to find online billing system that is as reliable as direct payment
Currently Paypal, Square, and Intuit most widely used
Be prudent when choosing online billing/payment system
The Future in Mental HealthThere are no absolutes, but here are some
likely changes that LCSWs can expect:
The Future:Personal Health Records
(PHR)
http://www.cms.gov/Medicare/E-Health/PerHealthRecords/downloads/SummaryofPersonalHealthRecord.pdf
Designed to give patients control of health records but not as robust as CMS hoped
May become record model over next 10 years
The Future: Integrated Care
Medicare goal - 'integrated care' systems, i.e., care provided in health homes and ACOs which operate on capitated cost management
Integrated care systems will promote communication between medical professionals working with a patient
LCSWs may see better communication with other health care professionals
The Future: New Medicare Rate Formula
Sustainable Growth Rate (SGR) ties Medicare reimbursement to Consumer Price Index, long been seen as flawed
Implementation has been delayed 17 times since it was established in 1996, as potential cuts rose to 27%
Congress delays at last minute (currently delayed until March 31, 2015)
New formula for reimbursement needed to replace ‘doc fix’
The Future: Health (Medical) Homes
New systems which provide capitated funding for integrated care
Mainly connected to Medicaid in Affordable Care Act
Require balancing mental health costs with medical costs
The Future:Accountable Care
Organizations
Accountable Care Organizations – identify high cost conditions and assure that steps are taken to treat conditions early
Must be approved by the Office of National Certification (ONC) and oversee 5000 Medicare or Medicaid beneficiaries – currently @200 ACOs
The Future: ACOs
Will seek clinicians in next 2-5 years
ACOs will look something like Cleveland Clinic, except will have capitation, profit-sharing/loss-sharing
Go to http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2013-04-09-MSSP-NPC.pdf to get information on becoming a provider for ACOs
The Future: Outcome Tools
Outcome Tools (2-5 years)PQRS data tip of the iceberg in terms of
required outcome data of all kindsProvide a baseline for what kinds of
treatment work with what kinds of treatment goals
CSWA hopes to offer guidance about the way to integrate outcome tools into our practices in the near future.
Many QuestionsHow do we choose our practice model,
private practitioner or group practice?How do we choose to have a private pay or
third-party pay?What is the right way forward for each
LCSW?
Difficult But Necessary Choices –
Time Frame
All choices likely to be necessary in next five years
Mental health world different from todayPossible changes will be:- inclusion of LMHCs and LMFTs in Medicare; - national licensure standards (already true
in military); - decisions about working in ‘clinic’ systems
and/or privately
Difficult But Necessary Choices - PQRS
If we choose to work in Medicare after 2015, LCSWs will need to incorporate PQRS and EHRs into our practices to avoid reimbursement penalties
May be necessary for private insurers as well
ACOs/health homes may be a useful option in terms of administering the new requirements for health care reimbursement
Difficult But Necessary Choices –
Interoperable Record-Keeping
Interoperable electronic record keeping systems will be required for third-party reimbursement
May be provided by ‘clinic’ systems which pay ‘salary’ based on outcomes, possible bonus/penalty
Systems must be certified by ONC
Difficult But Necessary Choices –
Practice Only Record-Keeping
If private practice, may only use practice electronic systems or stay with paper record keeping
Must still have dual record-keeping if want to keep psychotherapy notes private
Probably need to do more branding and marketing to build practice privately
Difficult But Necessary Choices –
Health Care Systems
Move from 3rd party fee-for-service to pay-for-performance
Role of insurers as exist today unclear for reimbursement
In-network systems only – Out-of-network likely to be eliminated in next five years
Difficult But Necessary Choices – Health Care
Systems
For future 3rd party payments, will need to join one or more of following:
- Health/Medical Homes- Accountable Care Organizations - Medicare- Independent Practice Organizations
Be Prepared to EducateLCSWs will need to explain to other health care
professionals why mental health treatment needed as follows:
1) treatment needed for chronic mental health conditions, especially ones like personality disorders and substance abuse, that for decades have been given short shrift in terms of coverage
2) the importance of integrating psychotherapy with medication as a primary treatment, rather than medication alone as a primary intervention
Thanks for Participating! CSWA hopes that this information will
make navigating the new health care delivery changes easier.
Clinical Social Work Association
P.O. Box 10Garrisonville, VA 22463
1-703-522-3866www.clinicalsocialworkassociation.org
