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PQRS 2013. PQRS. PQRS Reporting: Getting Started. Getting Started. Getting Started: Measure Selection. Decide which measures best fit for your Medicare population Choose 3 or more applicable individual measures OR the group measure What conditions do you usually treat? - PowerPoint PPT Presentation
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PQRS 2013
PQRS
• The quality reporting program for Medicare Part B (traditional fee for service)What
• Eligible providers (PT’s) who bill under the physician fee schedule (part B)• Includes private practices• Excludes facility based providers (SNF, OP
hospital, CORF, etc)Who
• In 2015, practitioners will receive payment adjustments (-1.5%) in their Medicare part B reimbursement if they to not participate in the program (adjustments will be based on CY2013 data)
Why2
PQRS REPORTING: GETTING STARTED
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Getting Started
Select measures
Determine reporting method
Educate staff
Begin reporting
Audit success
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Getting Started: Measure Selection
• Decide which measures best fit for your Medicare population– Choose 3 or more applicable individual
measures OR the group measure• What conditions do you usually treat?• What types of care or interventions are provided in
the clinic?– Information on the measures is under the
2013 PQRS Measure Details section of the webpage: www.apta.org/PQRS
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Measure Type: Individual vs GroupIndividual Group
# Required for Successful Reporting
3 measures per therapist 1 measure per therapist
Measure Focus Variable Condition or disease specific
Reporting Threshold (# of patients)
No threshold 15+ unique patients per 12 month reporting period (CY); 8+ per 6 month reporting period
Intent to Report Code
N/A Must be reported once per reporting period per practitioner
Success Rate via Claims (CY2010)
Individual measures 63% Group measures 51%
Success Rate via Registry (CY2010)
Individual measures 87% Group measures 94%
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Getting Started: Reporting Method and Participation
• Choose a reporting method– Claims versus registry
• Talk to you billing provider• Qualified registries
https://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp
• Choose reporting participation– Individual versus group (GPRO)
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Reporting Method Claims vs RegistryClaims Registry
Cost None Variable
QDC Selection
Each practitioners is responsible for choosing and submitting the QDC’s
Each practitioners is responsible for entering data into the registry ; QDC’s generated based on the data
Updating Annual measure updates must be monitored by the facility
Registry monitors and incorporates annual measure updates
Reporting Requirements
Data must be submitted on +50% of all eligible Medicare patients
Data must be submitted on +80% of all eligible Medicare patients
EHR N/A EHR and registry can be linked
Auditing Each facility must establish an auditing process to ensure successful reporting
Registry provides participants with feedback reports throughout the year
Success Rate (CY2010 data)
Individual measures 63%Group measures 51%
Individual measures 87%Group measures 94%
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Reporting Participation: Individual vs GPRO
Individual GPRO
Registration required
No Yes
Data analysis Analyzed at the individual (NPI) level; looks are the reporting rate of each professional on the selected measures
Analyzed at the group (TIN) level; looks are the cumulative reporting rate of the group on the selected measures
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Getting Started: Staff Education
• Educate staff about the measure specifications and billing procedures– Create processes that support PQRS
implementation• Flow charts or algorithms for clinicians
– AMA tool for 2013 updates typically posted by February http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system-2012.page
• Checklists for billing staff
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Getting Started: Auditing Your Success
• Plan an auditing process to evaluate your success– Billing audit for claims submission
• Use billing data and N365 remittance advice code on EOB– Quality Net quarterly dashboard reports– Registry feedback reports – Chart review for content
• Documentation must support the clinical quality action as indicated by the chosen QDC
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PQRS REPORTING: CASE EXAMPLES
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PQRS Process
Source: CMS Open Door Forum 3/22/201113
PQRS Audit
Interim Quarterly Dashboard Reports
Final 2013 Feedback Report- Fall 2014
Case Example: Individual Measures
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Mrs. S is a new
patient she presents for her initial
evaluation on with
adhesive capsulitis
of the shoulder
The therapist performs the initial evaluation and completes the measures:• Ensure
patient is eligible for the measure
• Select the corresponding G-Code or CPT II modifier
• Document to support the quality activities
The administrative staff submits the bill for processing• Ensure
the claim is accepted and check the EOB for the N365 remittance advice code
Case Example: Measure #130Percentage of patients aged 18 years and older with a list of current medications
(includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) documented by the provider, including drug name, dosage, frequency
and route
Current Medications with Name, Dosages,
Frequency and Route Documented
G8427: List of current
medications (includes
prescription, over-the-counter,
herbals, vitamin/mineral/diet
ary [nutritional] supplements)
documented by the provider, including
drug name, dosage, frequency
and route
Current Medications with Dosages not
Documented, Patient not Eligible
G8430: Provider documentation that
patient is not eligible for medication assessment
Current Medications with Name, Dosages,
Frequency, Route not Documented, Reason
not Specified
G8428: Current medications
(includes prescription, over-
the-counter, herbals,
vitamin/mineral/dietary [nutritional]
supplements) with drug name,
dosage, frequency and route not
documented by the provider, reason
not specified
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Case Example: Measure #131Percentage of patients aged 18 years and older with documentation of a pain
assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
Pain Assessment Documented as Positive
G8730: Pain assessment
documented as positive utilizing a standardized tool AND a follow-up
plan is documented
G8509: Documentation of
positive pain assessment; no
documentation of a follow-up plan,
reason not specified
Pain Assessment Documented as
Negative, No Follow-Up Plan RequiredG8731: Pain assessment
documented as negative, no follow-
up plan required
Patient not Eligible for Pain Assessment for
Documented ReasonsG8442:
Documentation that patient is not
eligible for a pain assessment
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Case Example: Measure #154
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
Risk Assessment for
Falls Completed
3288F: Falls risk
assessment documente
dAND
1100F: Patient
screened for future fall risk;
documentation of two or more falls in
the past year or any
fall with injury in the past year
Risk Assessment for
Falls not Completed for
Medical Reasons
3288F with 1P:
Documentation of
medical reason(s)
for not completing
a risk assessment for falls (i.e.,
reduced mobility,
bed ridden, immobile,
confined to chair, etc)
AND1100F: Patient
screened for future fall risk
If patient is not eligible for this
measure because patient
has documentation
of no falls or only one fall without injury the past year, report: Patient not at Risk for
Falls
1101F: Patient
screened for future fall risk;
documentation of no
falls in the past year or only one fall
without injury in the past year
If patient is not eligible for this
measure because falls status is not documented, report: Falls Status not
Documented1101F with 8P: No
documentation of falls
status
Risk Assessment for
Falls not Completed, Reason not Specified
3288F with 8P: Falls
risk assessment
not completed, reason not otherwise specified
AND1100F: Patient
screened for future fall risk
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Case Example: Measure #155
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months
Plan of Care Documented
0518F: Falls plan of care
documented
Plan of Care not Documented for Medical
Reasons
0518F with 1P: Documentation of medical reason(s) for no plan of care
for falls
Plan of Care not Documented, Reason
not Specified
0518F with 8P: Plan of care not
documented, reason not
otherwise specified
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Case Example: Individual Measures
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Additional Resources
• APTA:– Case studies– Podcasts on specific measures– Successful reporting requirements
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