Wednesday, July 25, 2012

Should doctors use the proposed "administrative claims" PQRS option to avoid the 2015 pay cut?


  • On July 6, 2012, the Centers for Medicare and Medicaid Services (CMS) issued its proposed rule to update the Physician Fee Schedule (PFS), effective January 1, 2013.  This proposed rule can be found here.  CMS is accepting public comments until September 4, 2012, and the final rule is anticipated to be published in November 2012.
  • Physicians who do not report PQRS in 2013 will have their pay cut by 1.5% in 2015. If  providers don't report PQRS during 2014, they will have a 2% penalty during 2016. 
  • CMS is  making easier for provides to report PQRS - for example, physicians reporting PQRS Group Measures (like Asthma, Diabetes, CAD, Preventive Care, etc) will only need to report 20 patients during 2013 instead of the required 30 in 2012.
  • In the fall of 2013, Medicare plans to produce and disseminate Physician Feedback reports at the TIN level to all groups of physicians with 25 or more eligible professionals and to individual physicians that satisfactorily reported measures through PQRS in 2012 using any of the PQRS reporting mechanisms. These reports will include a “first look” at the methodologies that CMS is proposing in this rule for a value-based payment modifier.
  • These are the multiple ways to report PQRS: 

  1. Claims. Reporting the individual Physician Quality Reporting System quality measures or Physician Quality Reporting System measures groups to CMS on the eligible professional's Medicare Part B claims for covered professional services furnished during the applicable reporting period. Please note that as usual,  claims may not be reprocessed or reopened for the sole purpose or reporting on individual Physician Quality Reporting System measures or measures groups. If a physician forgets to add the PQRS quality code to a claim, there is no way to go back and correct the problem like in a registry.
  2. Qualified registry. Reporting the individual Physician Quality Reporting System quality measures or Physician Quality Reporting System measures groups to a qualified registry. The selected registry will submit information to CMS on the eligible professional's behalf.
  3. Direct EHR product. Reporting the individual Physician Quality Reporting System quality measures to CMS by extracting clinical data from a direct EHR product. The providers themselves submit the extracted files from their EHR and submit them to CMS (using the providers account at the QualityNet CMS Portal. I believe last year only 14 providers submitted PQRS data using this option.
  4. EHR data submission vendor. This new 2012 process is similar to the Direct EHR process, except that the vendor (instead of the provider) is responsible to submit the data to the QualityNet CMS Portal.
  5. GPRO web-interface. For a group practices that are comprised of 25 or more eligible professionals, reporting individual PQRS quality measures to CMS using a CMS web-interface. These group practices will need to register with  CMS in the beginning of 2013 in order to use this process during 2013
  6. Administrative claims. Providers will need to register with CMS to participate in this option. CMS then will use Medicare part B claims data to calculate certain PQRS measures. Unlike traditional PQRS, providers don't submit quality data to Medicare. They will give permission to Medicare to analyze claims data to determine whether a clinical quality action related to a quality measure was performed. Medicare wants to encourage providers to report quality using  the options above but a provider that didn't report PQRS using options 1 to 5 during 2013, can still avoid the 2015 PQRS penalty by registering for the "Administrative claims" before the end of January 2015. One of the measures for example is Breast Cancer Screening for Women ≤ 69 (Percentage of eligible women 40-69 who receive a mammogram in during the measurement year or in the year prior to the measurement year.). Usually with the claims and registry process, providers report to PQRS who are the women that got the mammogram. Using the administrative claims method, CMS checks for all the mammogram paid claims and calculates the measure for the provider.

The new "administrative claims" option sounds like an easier option for providers to report PQRS but providers will have limited amount of quality measures available to report. That will mean that a dermatologist that elects to report PQRS using the administrative claims option could be judged by the number of mammograms done on her/his patients, the number of eye exams on diabetes patients or the use of statins.

These are the CMS Proposed Measures for Eligible Professionals and Group Practices who report using Administrative Claims to avoid the 2015 and 2016 PQRS Payment Cut:


  • Bacterial Pneumonia.The number of admissions for bacterial pneumonia per 100,000 population.
  • UTI. The number of discharges for urinary tract infection per 100,000 population. Age 18 Years and Older in a one year time period
  • Dehydration. The number of admissions for dehydration per 100,000 population.
  • Uncontrolled diabetes. The number of discharges for uncontrolled diabetes per 100,000 population. Age 18 Years and Older in a one year time period.
  • Short Term Diabetes complications.The number of discharges for diabetes short-term complications per 100,000. Age 18 Years and Older population in a one year period.
  • Long term diabetes complications. he number of discharges for long-term diabetes complications per 100,000 population. Age 18 Years and in a one year time period.
  •  Lower extremity amputation for diabetes. The number of discharges for lower-extremity amputation among patients with diabetes per 100,000 population Age 18 Years in a one year time period.
  • COPD. The number of admissions for chronic obstructive pulmonary disease (COPD) per 100,000 population.
  • Heart Failure. Percent of the population with admissions for CHF.
  • All Cause Readmission. The rate of provider visits within 30 days of discharge from an acute care hospital per 1,000 discharges among eligible beneficiaries assigned.
  • 30 Day Post Discharge Visit. The rate of provider visits within 30 days of discharge from an acute care hospital per 1,000 discharges among eligible beneficiaries assigned.
  • Follow-Up After Hospitalization for Mental Illness. Percentage of discharges for patients who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner
  • Annual Monitoring for Beneficiaries on Persistent Medications. Percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year.
  • Lack of Monthly INR Monitoring for Beneficiaries on Warfarin. Average percentage of 40-day intervals in which Part D beneficiaries with claims for warfarin do not receive an INR test during the measurement period.
  • Use of Spirometry Testing to Diagnose COPD. Percentage of patients at least 40 years old who have a new diagnosis or newly active chronic obstructive pulmonary disease (COPD) who received appropriate spirometry testing to confirm the diagnosis.
  • Pharmacotherapy Management of COPD Exacerbation. Percentage of chronic obstructive pulmonary disease (COPD) exacerbations for patients 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1–November 30 of the measurement year and were dispensed appropriate medications
  • Statin Therapy for Beneficiaries with Coronary Artery Disease. Medication Possession Ratio (MPR) for statin therapy for individuals over 18 years of age with coronary artery disease.
  • Lipid Profile for Beneficiaries Who Started Lipid-Lowering Medications. Percentage of patients age 18 or older starting lipid-lowering medication during the measurement year who had a lipid panel checked within 3 months after starting drug therapy
  • Osteoporosis Management in Women ≥ 67 Who Had a Fracture. Percentage of women 67 years and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the date of fracture.
  • Dilated Eye Exam for Beneficiaries ≤ 75 with Diabetes. Percentage of adult patients with diabetes aged 18-75 years who received a dilated eye exam by an ophthalmologist or optometrist during the measurement year, or had a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement year.
  • HbA1c Testing for Beneficiaries ≤ 75 with Diabetes. Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) per year.
  • Urine Protein Screening for Beneficiaries ≤ 75 with Diabetes. Percentage of adult diabetes patients aged 18-75 years with at least one test nephropathy screening test during the measurement year or who had evidence existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria).
  • Lipid Profile for Beneficiaries ≤ 75 with Diabetes. Percentage of adult patients with diabetes aged 18-75 who had an LDL-C test performed during the measurement year.
  • Lipid Profile for Beneficiaries with Ischemic Vascular Disease. Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to measurement year, who had a complete lipid profile during the measurement year.
  • Antidepressant Treatment for Depression. Percentage of discharges for patients who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner.
  • Breast Cancer Screening for Women ≤ 69. Percentage of eligible women 40-69 who receive a mammogram in during the measurement year or in the year prior to the measurement year

I think it would be better for providers to take a proactive approach in 2013 and choose to report PQRS measures connected with their specialty instead of waiting for 2015 and using "administrative claims" with measures that could be unrelated with their specialty.

1 comment:

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