2016 PQRS Payment Adjustment and Informal Review Process
On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.
If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:
• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
• See the fact sheet and Analysis and Payment web page for more information
For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.
Showing posts with label PQRI. Show all posts
Showing posts with label PQRI. Show all posts
Nursing Home Five-Star Rating System review
CMS Announces Two Medicare Quality Improvement Initiatives
Administration redoubles its efforts to improve quality of post-acute care for Medicare beneficiaries
Today, the Centers for Medicare & Medicaid Services (CMS) announced two initiatives to improve the quality of post-acute care. First, the expansion and strengthening of the agency’s widely-used Five Star Quality Rating System for Nursing Homes will improve consumer information about individual nursing homes’ quality. Second, proposed new conditions of participation for home health agencies willmodernize Medicare’s Home Health Agency Conditions of Participation to ensure safe delivery of quality care to home health patients.
“We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries,” said Marilyn Tavenner, CMS administrator. “Whether it is the regulations that guide provider practices or the information we provide directly to consumers, our primary goal is improving outcomes.”
Nursing Home Five-Star Rating System
Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five Star Quality Rating System:
• Nationwide Focused Survey Inspections: Effective January 2015, CMS and states will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System. In Fiscal Year (FY 2014), CMS piloted special surveys of nursing homes that focused on investigating the coding of the
Minimum Data Set (MDS), which are based on resident assessments and are used in the quality measures.
• Payroll-Based Staffing Reporting: CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014.
• Additional Quality Measures: CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System. The first additional measure, starting January 2015, will be the extent to which antipsychotic medications are in use. Future additional measures will include claims-based data on re-hospitalization and community discharge rates.
• Timely and Complete Inspection Data: CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system.
• Improved Scoring Methodology: In 2015, CMS will revise the scoring methodology by which we calculate each facility’s quality measure rating, which is used to calculate the overall Five Star rating. We also note that sources independent of self-reporting by nursing homes already are weighted higher than self-reported components in the scoring methodology.
“Nursing homes are working to improve their quality, and we are improving how we measure that quality,” said Patrick Conway, M.D., deputy administrator for innovation and quality and CMS chief medical officer. “We believe the improvements we are making to the Five Star system will add confidence that the reported improvements are genuine, are sustained, and are benefiting residents.”
Home Health Conditions of Participation
The proposed Home Health Conditions of Participation would improve the quality of home health services for Medicare and Medicaid beneficiaries by strengthening patient rights and improving communication that focuses on patient wellbeing. Currently there are more than 5 million people with Medicare and Medicaid benefits that receive home health care services each year from approximately 12,500 Medicare-certified home health agencies.
The proposed regulation, to be displayed Monday, October 6, at the Federal Register, would modernize the home health regulations for the first time since 1989 with a focus on patient-centered, well-coordinated care. Elements in the regulation include expansion of patient rights requirements; refocusing of the patient assessment on physical, mental, emotional, and psychosocial conditions; improved communication systems and requirements for a data-driven quality assessment; and performance improvement (QAPI) program.
Administration redoubles its efforts to improve quality of post-acute care for Medicare beneficiaries
Today, the Centers for Medicare & Medicaid Services (CMS) announced two initiatives to improve the quality of post-acute care. First, the expansion and strengthening of the agency’s widely-used Five Star Quality Rating System for Nursing Homes will improve consumer information about individual nursing homes’ quality. Second, proposed new conditions of participation for home health agencies willmodernize Medicare’s Home Health Agency Conditions of Participation to ensure safe delivery of quality care to home health patients.
“We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries,” said Marilyn Tavenner, CMS administrator. “Whether it is the regulations that guide provider practices or the information we provide directly to consumers, our primary goal is improving outcomes.”
Nursing Home Five-Star Rating System
Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five Star Quality Rating System:
• Nationwide Focused Survey Inspections: Effective January 2015, CMS and states will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System. In Fiscal Year (FY 2014), CMS piloted special surveys of nursing homes that focused on investigating the coding of the
Minimum Data Set (MDS), which are based on resident assessments and are used in the quality measures.
• Payroll-Based Staffing Reporting: CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014.
• Additional Quality Measures: CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System. The first additional measure, starting January 2015, will be the extent to which antipsychotic medications are in use. Future additional measures will include claims-based data on re-hospitalization and community discharge rates.
• Timely and Complete Inspection Data: CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system.
• Improved Scoring Methodology: In 2015, CMS will revise the scoring methodology by which we calculate each facility’s quality measure rating, which is used to calculate the overall Five Star rating. We also note that sources independent of self-reporting by nursing homes already are weighted higher than self-reported components in the scoring methodology.
“Nursing homes are working to improve their quality, and we are improving how we measure that quality,” said Patrick Conway, M.D., deputy administrator for innovation and quality and CMS chief medical officer. “We believe the improvements we are making to the Five Star system will add confidence that the reported improvements are genuine, are sustained, and are benefiting residents.”
Home Health Conditions of Participation
The proposed Home Health Conditions of Participation would improve the quality of home health services for Medicare and Medicaid beneficiaries by strengthening patient rights and improving communication that focuses on patient wellbeing. Currently there are more than 5 million people with Medicare and Medicaid benefits that receive home health care services each year from approximately 12,500 Medicare-certified home health agencies.
The proposed regulation, to be displayed Monday, October 6, at the Federal Register, would modernize the home health regulations for the first time since 1989 with a focus on patient-centered, well-coordinated care. Elements in the regulation include expansion of patient rights requirements; refocusing of the patient assessment on physical, mental, emotional, and psychosocial conditions; improved communication systems and requirements for a data-driven quality assessment; and performance improvement (QAPI) program.
Medicare PQRS payment update
Medicare Physician Fee Schedule Update 2012:
In 2012, the Centers for Medicare & Medicaid Services (CMS) is implementing payment updates and policy changes to the Medicare Physician Fee Schedule, including:
• Policies and procedures to identify and provide accurate payment for misvalued services; and
• Changes to the factors used to adjust physician fee schedule payment for geographic differences in physicians’ practice costs.
Incentives and Payment Adjustments for Quality Reporting:
We are continuing our efforts to promote improvement in quality of care and patient outcomes through the Electronic Prescribing (eRx) Incentive Program and the Physician Quality Reporting System (PQRS). Eligible professionals or group practices that meet satisfactory reporting requirements under the PQRS in calendar year (CY) 2011 will be eligible for incentive payments equal to 1.0 percent of their total estimated allowed charges for the reporting period. This incentive payment will be made in CY 2012.
In addition, eligible professionals or group practices that meet satisfactory reporting requirements under the PQRS in CY 2012 will be eligible for incentive payments equal to 0.5 percent of their total estimated allowed charges for the reporting period.
Eligible professionals or group practices that meet the requirements of the eRx Incentive Program in CY 2011 will be eligible for incentive payments equal to 1.0 of their total estimated allowed charges for the reporting period. Similar to the PQRS, this incentive payment will be made in CY 2012. In addition, eligible professionals or group practices that meet the requirements of the eRx Incentive Program in CY 2012 will be eligible for incentive payments equal to 1.0 percent of their total estimated allowed charges for the reporting period.
Eligible professionals who did not become successful electronic prescribers by reporting on the electronic prescribing measure for at least 10 unique events from January 1, 2011, through June 30, 2011, or were not granted an exemption due to a significant hardship will be subject to a negative payment adjustment equal to 1.0 percent of their fee schedule amounts for covered professional services furnished during 2012. Feedback reports based on information reported by eligibleprofessionals to CMS during the 2012 eRx payment adjustment reporting period (i.e., January 1, 2011- June 30, 2011) are expected to be made available to eligible professionals in late-2011.
In addition, a negative payment adjustment equal to 1.5 percent of the physician fee schedule amounts for covered professional services furnished during 2013 will apply to eligible professionals unless:
(1) the eligible professional was a successful electronic prescriber for purposes of the 2011 eRx incentive;
(2) the eligible professional becomes a successful electronic prescriber by reporting on the electronic prescribing measure on at least 10 unique events (which need not be associated with the measure’s
denominator) from January 1, 2012, through June 30, 2012; or
(3) the eligible professional was granted an exemption due to a significant hardship.
In 2012, the Centers for Medicare & Medicaid Services (CMS) is implementing payment updates and policy changes to the Medicare Physician Fee Schedule, including:
• Policies and procedures to identify and provide accurate payment for misvalued services; and
• Changes to the factors used to adjust physician fee schedule payment for geographic differences in physicians’ practice costs.
Incentives and Payment Adjustments for Quality Reporting:
We are continuing our efforts to promote improvement in quality of care and patient outcomes through the Electronic Prescribing (eRx) Incentive Program and the Physician Quality Reporting System (PQRS). Eligible professionals or group practices that meet satisfactory reporting requirements under the PQRS in calendar year (CY) 2011 will be eligible for incentive payments equal to 1.0 percent of their total estimated allowed charges for the reporting period. This incentive payment will be made in CY 2012.
In addition, eligible professionals or group practices that meet satisfactory reporting requirements under the PQRS in CY 2012 will be eligible for incentive payments equal to 0.5 percent of their total estimated allowed charges for the reporting period.
Eligible professionals or group practices that meet the requirements of the eRx Incentive Program in CY 2011 will be eligible for incentive payments equal to 1.0 of their total estimated allowed charges for the reporting period. Similar to the PQRS, this incentive payment will be made in CY 2012. In addition, eligible professionals or group practices that meet the requirements of the eRx Incentive Program in CY 2012 will be eligible for incentive payments equal to 1.0 percent of their total estimated allowed charges for the reporting period.
Eligible professionals who did not become successful electronic prescribers by reporting on the electronic prescribing measure for at least 10 unique events from January 1, 2011, through June 30, 2011, or were not granted an exemption due to a significant hardship will be subject to a negative payment adjustment equal to 1.0 percent of their fee schedule amounts for covered professional services furnished during 2012. Feedback reports based on information reported by eligibleprofessionals to CMS during the 2012 eRx payment adjustment reporting period (i.e., January 1, 2011- June 30, 2011) are expected to be made available to eligible professionals in late-2011.
In addition, a negative payment adjustment equal to 1.5 percent of the physician fee schedule amounts for covered professional services furnished during 2013 will apply to eligible professionals unless:
(1) the eligible professional was a successful electronic prescriber for purposes of the 2011 eRx incentive;
(2) the eligible professional becomes a successful electronic prescriber by reporting on the electronic prescribing measure on at least 10 unique events (which need not be associated with the measure’s
denominator) from January 1, 2012, through June 30, 2012; or
(3) the eligible professional was granted an exemption due to a significant hardship.
Measures Available for EHR Reporting and PQRI 2011
Tables 55 & 56: Measures Available for EHR Reporting
The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.
Tables 57-69
The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Tables 55 & 56: Measures Available for EHR Reporting
The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.
Tables 57-69
The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Table 70: Proposed Measures for the Asthma Measures Group
The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:
• Asthma: Tobacco Use- Screening -Ambulatory Setting.
• Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
• Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.
The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.
Qualification Requirements for EHR Vendors and Products
CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.
The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.
CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.
Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).
Proposed Measures for the Asthma Measures Group
The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:
• Asthma: Tobacco Use- Screening -Ambulatory Setting.
• Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
• Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.
The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.
Qualification Requirements for EHR Vendors and Products
CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.
The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.
CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.
Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).
The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.
Tables 57-69
The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Tables 55 & 56: Measures Available for EHR Reporting
The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.
Tables 57-69
The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Table 70: Proposed Measures for the Asthma Measures Group
The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:
• Asthma: Tobacco Use- Screening -Ambulatory Setting.
• Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
• Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.
The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.
Qualification Requirements for EHR Vendors and Products
CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.
The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.
CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.
Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).
Proposed Measures for the Asthma Measures Group
The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:
• Asthma: Tobacco Use- Screening -Ambulatory Setting.
• Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
• Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
• Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.
The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.
Qualification Requirements for EHR Vendors and Products
CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.
The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.
CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.
Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).
Proposed 2011 PQRI Quality Measures and Measures Groups
Table 51- 2010 PQRI Measures Not Proposed for Inclusion in PQRI 2011
• The AMA supports the proposal to retire measures #114 and #115 and replace these retired measures with the new measure PCPI measure-Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.
• Measure # 135: Chronic Kidney Disease-Influenza Immunization. The AMA respectfully requests that CMS reconsider measure #135 for inclusion in PQRI 2011. The proposed rule states that this measure was considered for National Quality Forum (NQF) Endorsement, but ultimately not NQF-endorsed. This is incorrect. Measure #135 has not yet been reviewed by NQF, and therefore still meets the requirements for inclusion in the CMS PQRI program.
Tables 52 & 53- Proposed 2011 Measures Selected from the 2010 PQRI Program
• The AMA supports the continued inclusion of the measures listed in Table 52. However, CMS should be aware that the PCPI has received inquires from various stakeholders related to Measure #193 – Perioperative Temperature Management. Based on inquiries received, which questioned how the process component of the measure is defined, the PCPI work group that developed the measure reconvened in 2010 to review the evidence base. Upon reviewing updated guidelines and other changes to the evidence base, the work group convened a webinar inviting open presentations from interested stakeholders in measure #193. The work group considered the relevance of evidence and information presented during the webinar to the existing definitions in the process component of the measure (i.e., definition of active warming). Additionally, the work group directed PCPI staff to draft for its consideration a potentially more clinically-relevant version of the measure focused on the outcome component only (i.e., maintaining normal intraoperative temperature). The revision of the measure is ongoing, and will require the development of detailed specifications, an open public comment period, and PCPI approval upon work group review of comments and final consensus on the measure.
Table 54: Proposed New Individual Measures for PQRI 2011
• Care Transitions Measures: The AMA appreciates that CMS recognizes the importance of the four Care Transitions measures and for this reason has included them in the measures proposed for PQRI 2011. While the AMA looks forward to implementation of these measures in a national program, the Care Transitions measures were not designed for individual physician level measurement. These measures are specified at the facility (hospital) level, using the UB04 administrative data to identify the denominator population. Given that one of the PQRI program requirements is that the measures are for services covered by the Physician Fee Schedule, it does not seem feasible to include these in the PQRI program. The AMA will work with the Society for Hospital Medicine to determine whether these measures would be appropriate for a hospital-level quality reporting program. As a point of clarification, the National Committee for Quality Assurance is incorrectly included as a joint measure developer on these measures. The measures were developed by the PCPI in collaboration with the American Board of Internal Medicine Foundation, the American College of Physicians, and the Society for Hospital Medicine.
• Hypertension: Plan of Care- The AMA-PCPI, in collaboration with the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) recommends that this measure not be finalized for inclusion in PQRI 2011 individual measures (claims or registry) Hypertension-Plan of Care. When this measure was originally developed, it was developed as a “test measure” and was not designed for individual physician accountability, but rather internal quality improvement. The CAD/Hypertension measurement set is currently undergoing full maintenance and update by the PCPI/ACCF/AHA Measure Development work group. The expert work group has recommended that this measure be retired and will be replaced with another measure. The updated Hypertension measurement set is in its final stages of development, and the PCPI anticipates to have a new measure for consideration in PQRI 2012.
• Melanoma: Overutilization of Imaging Studies in Stage 0-IA Melanoma: this measure is proposed for either claims or registry reporting. The AMA would like to propose that the existing Melanoma measures #137 and #138 (currently registry only) also be proposed for either claims-based or registry-based reporting. This will provide consistency in reporting for dermatologists reporting on the Melanoma measures. In PQRI 2010, measures #137 and #138 are only available for registry-based reporting.
• Radiology: Reminder System for Mammograms; the AMA supports the inclusion of this new measure.
• Asthma: Assessment of Asthma Risk- Emergency Department (ED)/Inpatient Setting and Asthma: Discharge Plan- Emergency Department/Inpatient Setting. The AMA does not recommend these two measures be finalized for PQRI 2011 because they both are for the ED/Inpatient setting only and are not aligned in terms of care setting with the existing Asthma measures (#53, #64) in PQRI. CMS proposed an Asthma Measures Group for 2011 comprised of these two measures and the two existing Asthma measures in PQRI (#53, #64). However, as noted in comments for Table 70, these measures are not appropriate for inclusion in the Asthma Measures Group due to the varying settings of care. The AMA recommends that CMS consider adding the following Asthma measures for inclusion in PQRI 2011 for individual reporting (claims and registry) 1) Asthma: Tobacco Use: Screening- Ambulatory Care Setting; 2) Asthma: Tobacco Use: Intervention- Ambulatory Care Setting. The inclusion of these AMA proposed measures would enable CMS to proceed with creating an Asthma Measures Group unique to one setting of care.
• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention; the AMA supports the inclusion of this updated PCPI measure for tobacco use.
Understand public reporting PQRI data
Public Reporting of PQRI Data
The ACA requires the Secretary of HHS to develop a Physician Compare Internet Web site by January 1, 2011, on which information on physicians enrolled in the Medicare program and who participate in the PQRI program would be posted. CMS proposes for the 2011 PQRI to use the current Physician and Other Health Care Professional Directory as a foundation for the Physician Compare Web site. As with the 2010 PQRI, CMS will continue to make public the names of physicians and group practices that satisfactorily submit quality data for the 2011 PQRI. Specifically, CMS proposes to post the names of physicians who: (1) submit data on the 2011 PQRI quality measures through one of the reporting mechanisms available for the 2011 PQRI; (2) meet one of the proposed satisfactory reporting criteria of individual measures or measures groups for the 2011 PQRI as described above; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period, for purposes of satisfying the requirements on the Physician Compare Web site.
Similarly, for purposes of publicly reporting the names of group practices, on the Physician Compare Web site, for 2011, CMS proposes to post the names of group practices that: (1) submit data on the 2011 PQRI quality measures through one of the proposed group practice reporting options; (2) meet the proposed criteria for satisfactory reporting under the respective group practice reporting option; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period.
CMS also discusses that it is not proposing that performance information be made publicly available at either the group practice or individual level as a condition of participation in the 2011 PQRI. The AMA agrees with and supports CMS’ determination in this regard.
CMS discusses that section 10331 of the ACA, however, requires that not later than January 1, 2013, and with respect to reporting periods that begin no earlier than January 1, 2012, CMS must implement a plan for making publicly available through Physician Compare, information on physician performance, including measures collected under the PQRI. CMS will expand the information that is publicly posted on the Physician Compare Web site in future years and will be further described in future rulemaking.
The AMA looks forward to providing input into the design of the Physician Compare Web site. It is important to promote physician engagement in quality improvement though such factors as accurate benchmarking and other beneficial functions. We also suggest a process by which a physician or group can review and update their demographic information. The AMA understands this was a major challenge when the CMS Hospital Compare Web site was initiated.
Further, public reporting of performance information, if not approached thoughtfully, can have unintentional adverse consequences for patients. For example, patient de-selection can occur for individuals at higher-risk for illness due to age, diagnosis, severity of illness, multiple co-morbidities, or economic and cultural characteristics that make them less adherent with established protocols. Further, health literacy may not be adequate to comprehend basic medical information. Programs must be designed so that appropriate and accurate information is available to patients to enable them to make educated decisions about their health care needs.
If done correctly, public reporting has the potential to help provide such appropriate and accurate information to patients. There remain, however, several critical issues that must be resolved before public reporting provisions can be implemented. There must be a method for ensuring that any publicly reported information is: (i) correctly attributed to those involved in the care; (ii) appropriately risk-adjusted; and, (iii) accurate, user-friendly, relevant and helpful to the consumer/patient. Moreover, as CMS has acknowledged, an important aspect of a quality reporting program is that physicians have the opportunity to review their data on reporting rates on PQRI quality measures. Physicians and other providers involved in the treatment of a patient must have the opportunity for prior review and comment and the right to appeal with regard to any data that is part of the public review process. Any such comments should also be included with any publicly reported data. This is necessary to give an accurate and complete picture of what is otherwise only a snapshot, and possibly skewed, view of the patient care provided by physicians and other professionals or providers involved in the patient’s care.
Other factors that must be considered as part of any initiative to make performance data available to the public are as follows:
• To date, there has been no formal, rigorous evaluation of the PQRI to determine such factors as: its impact on quality of care, whether it allows for fair and meaningful comparison of performance among physicians, and whether the data on physician participation is valid and can be verified.
• A detailed educational program for the public should be undertaken to explain the PQRI and openly address its limitations, including barriers to physician participation and the fact that quality measures used in the program take into account only a small fraction of all dimensions that explain overall physician performance.
• CMS should provide physicians an opportunity to explain why they did not participate in the voluntary PQRI and detail any quality improvement initiatives in which the physician is participating. This information should be provided to the public by CMS. Many physicians are participating in health care quality improvement projects conducted by Medicare’s Quality Improvement Organizations, CMS’ Coverage with Evidence Development mandates, health plans and various other quality initiatives. Physicians should have an opportunity to highlight these quality improvement efforts.
The ACA requires the Secretary of HHS to develop a Physician Compare Internet Web site by January 1, 2011, on which information on physicians enrolled in the Medicare program and who participate in the PQRI program would be posted. CMS proposes for the 2011 PQRI to use the current Physician and Other Health Care Professional Directory as a foundation for the Physician Compare Web site. As with the 2010 PQRI, CMS will continue to make public the names of physicians and group practices that satisfactorily submit quality data for the 2011 PQRI. Specifically, CMS proposes to post the names of physicians who: (1) submit data on the 2011 PQRI quality measures through one of the reporting mechanisms available for the 2011 PQRI; (2) meet one of the proposed satisfactory reporting criteria of individual measures or measures groups for the 2011 PQRI as described above; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period, for purposes of satisfying the requirements on the Physician Compare Web site.
Similarly, for purposes of publicly reporting the names of group practices, on the Physician Compare Web site, for 2011, CMS proposes to post the names of group practices that: (1) submit data on the 2011 PQRI quality measures through one of the proposed group practice reporting options; (2) meet the proposed criteria for satisfactory reporting under the respective group practice reporting option; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period.
CMS also discusses that it is not proposing that performance information be made publicly available at either the group practice or individual level as a condition of participation in the 2011 PQRI. The AMA agrees with and supports CMS’ determination in this regard.
CMS discusses that section 10331 of the ACA, however, requires that not later than January 1, 2013, and with respect to reporting periods that begin no earlier than January 1, 2012, CMS must implement a plan for making publicly available through Physician Compare, information on physician performance, including measures collected under the PQRI. CMS will expand the information that is publicly posted on the Physician Compare Web site in future years and will be further described in future rulemaking.
The AMA looks forward to providing input into the design of the Physician Compare Web site. It is important to promote physician engagement in quality improvement though such factors as accurate benchmarking and other beneficial functions. We also suggest a process by which a physician or group can review and update their demographic information. The AMA understands this was a major challenge when the CMS Hospital Compare Web site was initiated.
Further, public reporting of performance information, if not approached thoughtfully, can have unintentional adverse consequences for patients. For example, patient de-selection can occur for individuals at higher-risk for illness due to age, diagnosis, severity of illness, multiple co-morbidities, or economic and cultural characteristics that make them less adherent with established protocols. Further, health literacy may not be adequate to comprehend basic medical information. Programs must be designed so that appropriate and accurate information is available to patients to enable them to make educated decisions about their health care needs.
If done correctly, public reporting has the potential to help provide such appropriate and accurate information to patients. There remain, however, several critical issues that must be resolved before public reporting provisions can be implemented. There must be a method for ensuring that any publicly reported information is: (i) correctly attributed to those involved in the care; (ii) appropriately risk-adjusted; and, (iii) accurate, user-friendly, relevant and helpful to the consumer/patient. Moreover, as CMS has acknowledged, an important aspect of a quality reporting program is that physicians have the opportunity to review their data on reporting rates on PQRI quality measures. Physicians and other providers involved in the treatment of a patient must have the opportunity for prior review and comment and the right to appeal with regard to any data that is part of the public review process. Any such comments should also be included with any publicly reported data. This is necessary to give an accurate and complete picture of what is otherwise only a snapshot, and possibly skewed, view of the patient care provided by physicians and other professionals or providers involved in the patient’s care.
Other factors that must be considered as part of any initiative to make performance data available to the public are as follows:
• To date, there has been no formal, rigorous evaluation of the PQRI to determine such factors as: its impact on quality of care, whether it allows for fair and meaningful comparison of performance among physicians, and whether the data on physician participation is valid and can be verified.
• A detailed educational program for the public should be undertaken to explain the PQRI and openly address its limitations, including barriers to physician participation and the fact that quality measures used in the program take into account only a small fraction of all dimensions that explain overall physician performance.
• CMS should provide physicians an opportunity to explain why they did not participate in the voluntary PQRI and detail any quality improvement initiatives in which the physician is participating. This information should be provided to the public by CMS. Many physicians are participating in health care quality improvement projects conducted by Medicare’s Quality Improvement Organizations, CMS’ Coverage with Evidence Development mandates, health plans and various other quality initiatives. Physicians should have an opportunity to highlight these quality improvement efforts.
Electronic Prescribing Incentive Program Requirements and penalty program
Electronic Prescribing
2011 Electronic Prescribing Incentive Program Requirements and 2012 and 2013 Electronic Prescribing Penalty Programs
In summary, CMS proposes to continue with the 2010 e-prescribing reporting requirement in 2011, which is to require eligible physicians to report on 25 services in 2011 involving electronic prescriptions in order to qualify for incentives. CMS also plans to publicly report the names of 2011 successful e-prescribers on CMS’ website.
In addition, CMS has provided and seeks input on the 2012 and 2013 penalty phases of the e-prescribing program. CMS’ proposal is to levy financial penalties in 2012 and 2013 against physicians who fail to report the e-prescribing measure during the first six months in 2011.
We strongly support CMS’ proposed requirements for the 2011 e-prescribing incentive payment program, which is to reduce the reporting burden from 50 percent of all applicable services, which was the requirement in 2009, to reporting only 25 services involving electronic prescriptions. We do however, strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013. We also strongly recommend that CMS add more exception categories so that physicians who face hardship are exempt from penalties in 2012 and 2013. Finally, we recommend feedback reports from CMS to assess the incentive program, the establishment of an appeals process, and that CMS ensure that the posting of the names of successful e-prescribers is done correctly.
2011 Electronic Prescribing Incentive Program Requirements and 2012 and 2013 Electronic Prescribing Penalty Programs
In summary, CMS proposes to continue with the 2010 e-prescribing reporting requirement in 2011, which is to require eligible physicians to report on 25 services in 2011 involving electronic prescriptions in order to qualify for incentives. CMS also plans to publicly report the names of 2011 successful e-prescribers on CMS’ website.
In addition, CMS has provided and seeks input on the 2012 and 2013 penalty phases of the e-prescribing program. CMS’ proposal is to levy financial penalties in 2012 and 2013 against physicians who fail to report the e-prescribing measure during the first six months in 2011.
We strongly support CMS’ proposed requirements for the 2011 e-prescribing incentive payment program, which is to reduce the reporting burden from 50 percent of all applicable services, which was the requirement in 2009, to reporting only 25 services involving electronic prescriptions. We do however, strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013. We also strongly recommend that CMS add more exception categories so that physicians who face hardship are exempt from penalties in 2012 and 2013. Finally, we recommend feedback reports from CMS to assess the incentive program, the establishment of an appeals process, and that CMS ensure that the posting of the names of successful e-prescribers is done correctly.
Group Practice Reporting Options in PQRI program
Group Practice Reporting Options (GPRO)
CMS proposes for the 2011 PQRI to change the definition of “group practice” to allow a minimum group size of 2 (in contrast to the 2010 minimum group size of 200) to enable more group practices to participate in the PQRI GPRO. The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the GPRO for 2011.
We are also pleased that CMS has called for deeming eligible group practices participating in the Physician Group Practice (PGP), Medicare Care Management Performance and Electronic Health Record demonstrations to be participating in PQRI. As such, all eligible professionals participating in these demonstrations automatically receive PQRI bonus payments. Adopting this proposal will help reduce the reporting burden for physicians.
CMS proposes for the 2011 PQRI GPRO I (large group practices) that it will validate that the group practice consists of a minimum of 200 NPIs and will supply group practices with this list. This is a change from 2010, and the AMA seeks clarification on how it will validate NPIs.
The AMA supports CMS’ decision to allow those group practices selected to participate in the 2010 GPRO to automatically participate in the 2011 PQRI GPRO, without being required to complete the 2011 GPRO I self-nomination process.
CMS invites comments regarding its proposal to publicly report GPRO II information with respect to satisfactory PQRI participation. The AMA seeks clarification on what the agency means by “information.” “Performance” information would be problematic, considering 2011 would be the first year for the GPRO II. GPRO II information for public reporting must not include performance information.
CMS proposes for the 2011 PQRI to change the definition of “group practice” to allow a minimum group size of 2 (in contrast to the 2010 minimum group size of 200) to enable more group practices to participate in the PQRI GPRO. The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the GPRO for 2011.
We are also pleased that CMS has called for deeming eligible group practices participating in the Physician Group Practice (PGP), Medicare Care Management Performance and Electronic Health Record demonstrations to be participating in PQRI. As such, all eligible professionals participating in these demonstrations automatically receive PQRI bonus payments. Adopting this proposal will help reduce the reporting burden for physicians.
CMS proposes for the 2011 PQRI GPRO I (large group practices) that it will validate that the group practice consists of a minimum of 200 NPIs and will supply group practices with this list. This is a change from 2010, and the AMA seeks clarification on how it will validate NPIs.
The AMA supports CMS’ decision to allow those group practices selected to participate in the 2010 GPRO to automatically participate in the 2011 PQRI GPRO, without being required to complete the 2011 GPRO I self-nomination process.
CMS invites comments regarding its proposal to publicly report GPRO II information with respect to satisfactory PQRI participation. The AMA seeks clarification on what the agency means by “information.” “Performance” information would be problematic, considering 2011 would be the first year for the GPRO II. GPRO II information for public reporting must not include performance information.
Maintenance of Certification Reporting Option in PQRI program
Maintenance of Certification Reporting Option
Section 3002(c) of the ACA requires a mechanism under which a physician may provide data on quality measures through a Maintenance of Certification Program (MOCP) operated by a specialty body of the American Board of Medical Specialties (ABMS), with an additional 0.5 percent incentive payment for years 2011 through 2014 if certain requirements are met. These requirements include that the physician must satisfactorily submit data on quality measures under the PQRI for a year and have such data submitted on their behalf through the MOCP. Physicians must also more frequently than is required to qualify for or maintain Board certification status, participate in an MOCP for a year, and successfully complete a qualified MOCP for a year.
CMS must provide further clarification on the requisite interconnected steps and processes for participating in the PQRI and MOCP to qualify for the additional 0.5 percent incentive. Without clearer articulation, physicians will not be able to understand the necessary processes to qualify under what is already a detailed and at times overwhelming incentive program. Further, requiring physicians to interact with both CMS carriers and the Medical Boards on an added PQRI reporting option allows for confusion and duplication of effort. If this additional reporting option is to succeed, CMS and the Boards must work together prior to January 1, 2011, to clarify the parameters and processes of this added reporting option, and communicate PQRI MOCP reporting option requirements clearly and often to physicians.
Further, to engage in an MOCP “more frequently” in the current health care environment, comprised of new requirements and programs, e.g., RUR meaningful use, will severely deter or even prevent many physicians from electing the MOCP option in 2011. The AMA understands that most Boards do not have a fully developed and tested Part IV MOCP, which is referred to as “practice assessment.” Therefore, if most Boards do not have operational and tested “practice assessment” capability, it is not possible for physicians participate in the program at all, much less “more frequently.” We look forward to working with CMS and the Boards to improve the availability of operational and tested practice assessment programs, such as condition-specific Practice Improvement Modules (PIMs). These modules incorporate quality measures that permit physicians to complete the module using their own patient population to produce a quality improvement score.
Physicians will further have difficulty meeting the “more frequent” standard because, as we understand, some practice assessment activity must be competed every one to four years. “More frequent” compliance could occur every two years, for example, and therefore, would not align with current PQRI reporting periods. In addition, meeting the “more frequent” standard in these instances may not yield meaningful learning from the collection and reporting of quality measures because evidence-based medicine, although a dynamic process, may not have substantially changed.
Even if a physician has the ability to participate in a practice assessment on a “more frequent” basis, issues of accurate data capture and transmission to CMS remain questionable. If practice assessment data for a physician were submitted through an MOCP that meets the criteria for a registry under the PQRI, the only PQRI qualified Board registry currently available, according to the 2010 PQRI Qualified Registries, would be the American Board of Family Medicine. Since no other Board registries exist under the PQRI, it is questionable whether they would have the capability to submit data for the 2011 PQRI (and beyond). While more Boards may request to qualify as a registry in 2011 or satisfy the rule by “meeting the criteria for a registry,” as noted in the proposal, most Boards will not be able to do so, preventing most physician specialties from electing to participate in the PQRI MOCP reporting option.
Additionally, the AMA believes there is inadequate time to test whether MOCPs have the capabilities to collect and transmit quality data to CMS accurately and consistently. Testing must occur first. If MOCP or CMS systems are faulty, CMS must provide a formal opportunity for physicians to file a complaint.
To qualify for the additional incentive payment, the MOCP should submit to CMS in a form or manner specified by the Secretary, that the physician has successfully completed a qualified MOCP practice assessment for such year, as well as the methods, measures, and data used under the MOCP and qualified MOCP practice assessment. Only “if requested by the Secretary,” does information on the survey of patient experience need to be provided. The AMA urges patient experience information not be submitted, as the collection methods and data accuracy associated with patient experience lack uniformity and validity.
Under the ACA, the Secretary has the discretion to incorporate participation in an MOCP and successful completion of a qualified MOCP practice assessment into quality composite measures for purposes of the physician fee schedule payment modifier under section 3007 of the ACA. Considering incorporation of MOCP as part of the physician fee schedule payment modifier is premature. The Secretary should not adopt this approach until there is ample time to understand and act upon lessons learned with the PQRI MOC reporting option.
In addition to requiring Boards to either operate a qualified PQRI registry or to self-nominate to submit MOCP data to CMS on behalf of their members, CMS is also considering requiring the various Boards to submit data to ABMS and ABMS would then channel this information from the Boards to CMS. The AMA understands that the medical Boards and their representative organizations do not have the tools or resources to facilitate this type of data transfer. While this may be a temporary option for handling the data transfer from smaller Boards, it is an inefficient, piecemeal approach which places unnecessary data transfer burden and additional costs on the larger Boards that have not yet proven they can manage submission directly to CMS. The AMA remains concerned about the integrity of physician quality data, and it is critical that CMS not focus on data transfer for the sake of data transfer, but on adopting structured and understandable objectives for transferring and interpreting health care quality data.
Section 3002(c) of the ACA requires a mechanism under which a physician may provide data on quality measures through a Maintenance of Certification Program (MOCP) operated by a specialty body of the American Board of Medical Specialties (ABMS), with an additional 0.5 percent incentive payment for years 2011 through 2014 if certain requirements are met. These requirements include that the physician must satisfactorily submit data on quality measures under the PQRI for a year and have such data submitted on their behalf through the MOCP. Physicians must also more frequently than is required to qualify for or maintain Board certification status, participate in an MOCP for a year, and successfully complete a qualified MOCP for a year.
CMS must provide further clarification on the requisite interconnected steps and processes for participating in the PQRI and MOCP to qualify for the additional 0.5 percent incentive. Without clearer articulation, physicians will not be able to understand the necessary processes to qualify under what is already a detailed and at times overwhelming incentive program. Further, requiring physicians to interact with both CMS carriers and the Medical Boards on an added PQRI reporting option allows for confusion and duplication of effort. If this additional reporting option is to succeed, CMS and the Boards must work together prior to January 1, 2011, to clarify the parameters and processes of this added reporting option, and communicate PQRI MOCP reporting option requirements clearly and often to physicians.
Further, to engage in an MOCP “more frequently” in the current health care environment, comprised of new requirements and programs, e.g., RUR meaningful use, will severely deter or even prevent many physicians from electing the MOCP option in 2011. The AMA understands that most Boards do not have a fully developed and tested Part IV MOCP, which is referred to as “practice assessment.” Therefore, if most Boards do not have operational and tested “practice assessment” capability, it is not possible for physicians participate in the program at all, much less “more frequently.” We look forward to working with CMS and the Boards to improve the availability of operational and tested practice assessment programs, such as condition-specific Practice Improvement Modules (PIMs). These modules incorporate quality measures that permit physicians to complete the module using their own patient population to produce a quality improvement score.
Physicians will further have difficulty meeting the “more frequent” standard because, as we understand, some practice assessment activity must be competed every one to four years. “More frequent” compliance could occur every two years, for example, and therefore, would not align with current PQRI reporting periods. In addition, meeting the “more frequent” standard in these instances may not yield meaningful learning from the collection and reporting of quality measures because evidence-based medicine, although a dynamic process, may not have substantially changed.
Even if a physician has the ability to participate in a practice assessment on a “more frequent” basis, issues of accurate data capture and transmission to CMS remain questionable. If practice assessment data for a physician were submitted through an MOCP that meets the criteria for a registry under the PQRI, the only PQRI qualified Board registry currently available, according to the 2010 PQRI Qualified Registries, would be the American Board of Family Medicine. Since no other Board registries exist under the PQRI, it is questionable whether they would have the capability to submit data for the 2011 PQRI (and beyond). While more Boards may request to qualify as a registry in 2011 or satisfy the rule by “meeting the criteria for a registry,” as noted in the proposal, most Boards will not be able to do so, preventing most physician specialties from electing to participate in the PQRI MOCP reporting option.
Additionally, the AMA believes there is inadequate time to test whether MOCPs have the capabilities to collect and transmit quality data to CMS accurately and consistently. Testing must occur first. If MOCP or CMS systems are faulty, CMS must provide a formal opportunity for physicians to file a complaint.
To qualify for the additional incentive payment, the MOCP should submit to CMS in a form or manner specified by the Secretary, that the physician has successfully completed a qualified MOCP practice assessment for such year, as well as the methods, measures, and data used under the MOCP and qualified MOCP practice assessment. Only “if requested by the Secretary,” does information on the survey of patient experience need to be provided. The AMA urges patient experience information not be submitted, as the collection methods and data accuracy associated with patient experience lack uniformity and validity.
Under the ACA, the Secretary has the discretion to incorporate participation in an MOCP and successful completion of a qualified MOCP practice assessment into quality composite measures for purposes of the physician fee schedule payment modifier under section 3007 of the ACA. Considering incorporation of MOCP as part of the physician fee schedule payment modifier is premature. The Secretary should not adopt this approach until there is ample time to understand and act upon lessons learned with the PQRI MOC reporting option.
In addition to requiring Boards to either operate a qualified PQRI registry or to self-nominate to submit MOCP data to CMS on behalf of their members, CMS is also considering requiring the various Boards to submit data to ABMS and ABMS would then channel this information from the Boards to CMS. The AMA understands that the medical Boards and their representative organizations do not have the tools or resources to facilitate this type of data transfer. While this may be a temporary option for handling the data transfer from smaller Boards, it is an inefficient, piecemeal approach which places unnecessary data transfer burden and additional costs on the larger Boards that have not yet proven they can manage submission directly to CMS. The AMA remains concerned about the integrity of physician quality data, and it is critical that CMS not focus on data transfer for the sake of data transfer, but on adopting structured and understandable objectives for transferring and interpreting health care quality data.
Integration of PQRI and EHR reporting
Integration of PQRI and EHR reporting
Section 3002(d) of the ACA requires CMS to move toward integration of EHR measures with respect to the PQRI program. The AMA strongly supports efforts to streamline the clinical quality measures used in both the PQRI and EHR reporting programs. We encourage CMS to work with the PCPI to improve the development, and accelerate the testing, of clinically relevant measures for all Medicare physician specialties.
In order to align the two programs, clear program objectives must first be established. Currently, PQRI is a pay-for-reporting program and the CMS EHR Incentive Program is to demonstrate meaningful use of a certified EHR system. After the program objectives have been established and aligned, the measures and format for reporting the measures must then be aligned. The steps that the AMA recommends to achieve alignment of the PQRI and EHR Incentive program include:
• Establish common program objectives;
• Align the measures and establish a common format for reporting;
• Once the "measures" and "reporting format" have been finalized and are aligned, the measures should be tested to see if they can be implemented in an EHR system; and
• Upon completion of system testing, the measures should be piloted in an actual clinical environment. Pilots are very common in information technology. In fact, any technology implementation or rollout typically has a pilot test completed. Pilot testing provides real world results and feedback in a selected and controlled environment. Upon completion of pilot testing, an evaluation will need to be performed to determine that the results meet the original program objectives.
Section 3002(d) of the ACA requires CMS to move toward integration of EHR measures with respect to the PQRI program. The AMA strongly supports efforts to streamline the clinical quality measures used in both the PQRI and EHR reporting programs. We encourage CMS to work with the PCPI to improve the development, and accelerate the testing, of clinically relevant measures for all Medicare physician specialties.
In order to align the two programs, clear program objectives must first be established. Currently, PQRI is a pay-for-reporting program and the CMS EHR Incentive Program is to demonstrate meaningful use of a certified EHR system. After the program objectives have been established and aligned, the measures and format for reporting the measures must then be aligned. The steps that the AMA recommends to achieve alignment of the PQRI and EHR Incentive program include:
• Establish common program objectives;
• Align the measures and establish a common format for reporting;
• Once the "measures" and "reporting format" have been finalized and are aligned, the measures should be tested to see if they can be implemented in an EHR system; and
• Upon completion of system testing, the measures should be piloted in an actual clinical environment. Pilots are very common in information technology. In fact, any technology implementation or rollout typically has a pilot test completed. Pilot testing provides real world results and feedback in a selected and controlled environment. Upon completion of pilot testing, an evaluation will need to be performed to determine that the results meet the original program objectives.
PQRI - Qualified registries
Qualified Registries
CMS proposes to post on the PQRI section of the CMS Web site a list of qualified registries for the 2011 PQRI, including the registry name, contact information, and the 2011 measure(s) and/or measures group(s) and e-prescribing reporting (if qualified) for which the registry is qualified and intends to report. At the February 2, 2010, PQRI Listening Session, the AMA and other attendees recommended that CMS post additional registry information including cost to participate; number of past or current participants; frequency of registry feedback reports; and success rate of participants. CMS did not reflect these comments in the proposed rule, and the AMA urges CMS to seriously consider these recommendations and include these additional topics of information to better assist physicians in selecting a registry most appropriate for their practice. In addition, the AMA recommends that PQRI participants have an opportunity to file complaints directly with CMS regarding particular registries.
As discussed in the proposed rule, CMS continues to be concerned that an individual physician or a small practice does not have either the resources or the capabilities to successfully submit quality measures results and numerator and denominator data on PQRI individual measures or measures groups through the registry data submission process. The AMA shares this concern, which is why we continue to have reservations about the requirement that physicians must meet all 15 core measures (including clinical quality measure reporting) and five additional measures from a defined menu in order to qualify for meaningful use (MU) program incentives.
The PCPI seeks to test its measures across a variety of Medicare incentive programs using different data sources, and has a long-established protocol to conduct such testing. Our difficulty has been identifying practice sites that participated in PQRI claims reporting for a complete year on specific measurement sets, and who have the capacity to participate in a testing project. It appears the qualified registries may have such information readily available and be in a position to collaborate with the PCPI on testing quality measures. The AMA welcomes an opportunity to discuss quality measures testing with CMS and the qualified registries.
CMS proposes to post on the PQRI section of the CMS Web site a list of qualified registries for the 2011 PQRI, including the registry name, contact information, and the 2011 measure(s) and/or measures group(s) and e-prescribing reporting (if qualified) for which the registry is qualified and intends to report. At the February 2, 2010, PQRI Listening Session, the AMA and other attendees recommended that CMS post additional registry information including cost to participate; number of past or current participants; frequency of registry feedback reports; and success rate of participants. CMS did not reflect these comments in the proposed rule, and the AMA urges CMS to seriously consider these recommendations and include these additional topics of information to better assist physicians in selecting a registry most appropriate for their practice. In addition, the AMA recommends that PQRI participants have an opportunity to file complaints directly with CMS regarding particular registries.
As discussed in the proposed rule, CMS continues to be concerned that an individual physician or a small practice does not have either the resources or the capabilities to successfully submit quality measures results and numerator and denominator data on PQRI individual measures or measures groups through the registry data submission process. The AMA shares this concern, which is why we continue to have reservations about the requirement that physicians must meet all 15 core measures (including clinical quality measure reporting) and five additional measures from a defined menu in order to qualify for meaningful use (MU) program incentives.
The PCPI seeks to test its measures across a variety of Medicare incentive programs using different data sources, and has a long-established protocol to conduct such testing. Our difficulty has been identifying practice sites that participated in PQRI claims reporting for a complete year on specific measurement sets, and who have the capacity to participate in a testing project. It appears the qualified registries may have such information readily available and be in a position to collaborate with the PCPI on testing quality measures. The AMA welcomes an opportunity to discuss quality measures testing with CMS and the qualified registries.
Appeal process on PQRI - review of determination
Appeals Process
Sec. 3002 (f)(2) of ACA requires the Secretary to establish by not later than January 1, 2011, an informal appeals process so that physicians can seek review of the determination that the physician did not satisfactorily submit data on quality measures under the PQRI. CMS proposes to base the informal process on its current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and e-prescribing incentive program information, information on PQRI feedback report availability and access, and/or information on PQRI Portal password issues.
The AMA supports a PQRI appeals process, which is critical for re-evaluating the participation status of a physician who may have been incorrectly deemed not successful. We have strong concerns, however, with use of the current structure of the Quality Net Help Desk. Physicians have had many difficulties in accessing and obtaining reliable information from the Quality Net Help Desk. At times, they could not get through, or worse, the Help Desk representative was ill-equipped to answer their specific questions, which has led to frustration among physicians who are attempting to successfully participate in the PQRI. Therefore, the AMA urges that CMS significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff. If the Quality Help Desk is not adequately resourced to handle the additional processes related to an informal PQRI appeals process, CMS’ efforts will not be viewed as sincere in trying to add a successful informal PQRI appeals process. We also urge that CMS post on its Web site the names of physicians who have been determined to be a successful participant upon appeal.
Sec. 3002 (f)(2) of ACA requires the Secretary to establish by not later than January 1, 2011, an informal appeals process so that physicians can seek review of the determination that the physician did not satisfactorily submit data on quality measures under the PQRI. CMS proposes to base the informal process on its current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and e-prescribing incentive program information, information on PQRI feedback report availability and access, and/or information on PQRI Portal password issues.
The AMA supports a PQRI appeals process, which is critical for re-evaluating the participation status of a physician who may have been incorrectly deemed not successful. We have strong concerns, however, with use of the current structure of the Quality Net Help Desk. Physicians have had many difficulties in accessing and obtaining reliable information from the Quality Net Help Desk. At times, they could not get through, or worse, the Help Desk representative was ill-equipped to answer their specific questions, which has led to frustration among physicians who are attempting to successfully participate in the PQRI. Therefore, the AMA urges that CMS significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff. If the Quality Help Desk is not adequately resourced to handle the additional processes related to an informal PQRI appeals process, CMS’ efforts will not be viewed as sincere in trying to add a successful informal PQRI appeals process. We also urge that CMS post on its Web site the names of physicians who have been determined to be a successful participant upon appeal.
PQRI reporting periods for FY 2011
Reporting Periods
AMA supports the agency’s proposal to retain 2010 PQRI reporting periods for FY 2011. CMS proposes to retain the claims-based reporting mechanism for 2011, but notes that the agency continues to consider significantly limiting the claims-based mechanism of reporting clinical quality measures in future program years. This limitation continues to be contingent upon there being an adequate number and variety of registries available and/or the continuation/expansion of the electronic health record (EHR) reporting option. Potentially, CMS would continue to retain claims-based reporting in years after 2011 principally for the reporting of structural measures and in circumstances where claims-based reporting is the only available mechanism for certain categories of physicians to report PQRI quality measures. The AMA encourages CMS to be cautious in how it determines to phase-out the claims-based reporting option until it is abundantly clear that all physicians understand and are able to consistently and accurately capture quality measures using EHRs or registries.
CMS must also consider whether the eventual elimination of claims-based reporting would unnecessarily penalize physicians who do not own an EHR or participate in a registry because of extenuating circumstances, e.g., small, rural providers lacking digital connection. The availability of a claims-based reporting option enables most physicians to participate in the PQRI without incurring significant technology. Transitioning away from claims-based reporting too quickly, without consideration of the small or rural provider, could inappropriately burden physicians who are making a good faith effort to report measures for quality improvement.
Regardless of the reporting mechanism, CMS should provide developers of measures utilized in the PQRI with support to carry out validity and reliability testing of measures. The AMA Physician Consortium for Performance Improvement (PCPI) has significant experience in testing quality measures in various platforms and would be a valuable resource as CMS continues to evaluate all reporting options for the PQRI.
AMA supports the agency’s proposal to retain 2010 PQRI reporting periods for FY 2011. CMS proposes to retain the claims-based reporting mechanism for 2011, but notes that the agency continues to consider significantly limiting the claims-based mechanism of reporting clinical quality measures in future program years. This limitation continues to be contingent upon there being an adequate number and variety of registries available and/or the continuation/expansion of the electronic health record (EHR) reporting option. Potentially, CMS would continue to retain claims-based reporting in years after 2011 principally for the reporting of structural measures and in circumstances where claims-based reporting is the only available mechanism for certain categories of physicians to report PQRI quality measures. The AMA encourages CMS to be cautious in how it determines to phase-out the claims-based reporting option until it is abundantly clear that all physicians understand and are able to consistently and accurately capture quality measures using EHRs or registries.
CMS must also consider whether the eventual elimination of claims-based reporting would unnecessarily penalize physicians who do not own an EHR or participate in a registry because of extenuating circumstances, e.g., small, rural providers lacking digital connection. The availability of a claims-based reporting option enables most physicians to participate in the PQRI without incurring significant technology. Transitioning away from claims-based reporting too quickly, without consideration of the small or rural provider, could inappropriately burden physicians who are making a good faith effort to report measures for quality improvement.
Regardless of the reporting mechanism, CMS should provide developers of measures utilized in the PQRI with support to carry out validity and reliability testing of measures. The AMA Physician Consortium for Performance Improvement (PCPI) has significant experience in testing quality measures in various platforms and would be a valuable resource as CMS continues to evaluate all reporting options for the PQRI.
How to report PQRI
PQRI reporting in 2010 - (Physician Quality Reporting Initiative )
What is the “frequency?”
The frequency refers to how often the measure should be reported. Measure #20 should be reported each time an applicable procedure is performed during the reporting period (full or half-year).
What is the performance time frame?
The performance time frame for measure #20 is indicated as within one hour (two hours if fluoroquinolone or vancomycin) prior to surgical incision, or start of procedure when no incision is required.
How do I report measure #20 via claims?
The measure specifications for measure #20 indicate that it is a claims and registry measure, meaning it can be reported using either the claims-based or the registry-based method. This article looks at the claims-based method only. The Current Procedural Terminology (CPT) codes and patient demographics identify the patients who are included in measure #20, otherwise known as the denominator. The Measure Specifications Manual, there is a listing of all surgical procedures and CPT codes that qualify patients as eligible to meet this measure’s inclusion requirements. It is important to review the CPT codes associated with each measure reported. Also, please note that the included procedure codes may change from year to year, so review the 2010 measure specifications before beginning to report for this year.
What are the steps to be taken after identifying a patient in the denominator for Measure #20?
CPT II codes, or quality data codes (QDCs), are used to report the clinical action required by the measure on the claims form. For measure #20, there are four choices: 4047F, 4048F, 4047F with 1P and 4047F with SB 4047F indicates the order for prophylactic parenteral antibiotics was given; 4048F indicates prophylactic parenteral antibiotic has been given; 4047F with 1P modifier indicates the order for prophylactic parenteral antibiotic was not given due to medical reasons; and 4047F with SP modifier indicates prophylactic pare nteral antibiotic was not given and the reason was not specified. Please note that both the CPT code and the appropriate CPT II code should be submitted on the same claim form.
It is important to note that for measure #20, Table 2 (this page) is included in the measure specifications and lists the antimicrobial drugs considered prophylactic parenteral antibiotics for the purposes of this measure. Code 4047F-8P should be reported when antibiotics from this table were not ordered.
What is the “frequency?”
The frequency refers to how often the measure should be reported. Measure #20 should be reported each time an applicable procedure is performed during the reporting period (full or half-year).
What is the performance time frame?
The performance time frame for measure #20 is indicated as within one hour (two hours if fluoroquinolone or vancomycin) prior to surgical incision, or start of procedure when no incision is required.
How do I report measure #20 via claims?
The measure specifications for measure #20 indicate that it is a claims and registry measure, meaning it can be reported using either the claims-based or the registry-based method. This article looks at the claims-based method only. The Current Procedural Terminology (CPT) codes and patient demographics identify the patients who are included in measure #20, otherwise known as the denominator. The Measure Specifications Manual, there is a listing of all surgical procedures and CPT codes that qualify patients as eligible to meet this measure’s inclusion requirements. It is important to review the CPT codes associated with each measure reported. Also, please note that the included procedure codes may change from year to year, so review the 2010 measure specifications before beginning to report for this year.
What are the steps to be taken after identifying a patient in the denominator for Measure #20?
CPT II codes, or quality data codes (QDCs), are used to report the clinical action required by the measure on the claims form. For measure #20, there are four choices: 4047F, 4048F, 4047F with 1P and 4047F with SB 4047F indicates the order for prophylactic parenteral antibiotics was given; 4048F indicates prophylactic parenteral antibiotic has been given; 4047F with 1P modifier indicates the order for prophylactic parenteral antibiotic was not given due to medical reasons; and 4047F with SP modifier indicates prophylactic pare nteral antibiotic was not given and the reason was not specified. Please note that both the CPT code and the appropriate CPT II code should be submitted on the same claim form.
It is important to note that for measure #20, Table 2 (this page) is included in the measure specifications and lists the antimicrobial drugs considered prophylactic parenteral antibiotics for the purposes of this measure. Code 4047F-8P should be reported when antibiotics from this table were not ordered.
What is Physician Quality Reporting Initiative (PQRI)
PQRI reporting in 2010 - (Physician Quality Reporting Initiative )
The Centers for Medicare & Medicaid Services (CMS) has continued the Physician Quality Reporting Initiative (PQRI) into 2010 as required under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). PQRI is the first CMS-crafted national program to link the reporting of quality data to physician payment. The incentive payment for those eligible professionals who successfully participate in the program is 2 percent of the total allowed charges for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period.
How does one use the measure specifications manual?
The first step for implementing PQRI in your office is to use the 2010 PQRI Measure Specifications Manual to identify measures applicable for professional services for which a physician’s practice routinely provides. The next step is to select those measures that make sense based upon prevalence and volume in the physician’s practice, as well as their individual or practice performance analysis and improvement priorities.
What is the description of the measure?
The measure specifications describe measure #20 as “Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior the surgical incision (or start of procedure when no incision is required).” This narrative gives a high-level description of measure #20.
What are the instructions?
The instructions explain when the measure should be reported and who should report it. According to the instructions, measure #20 should be reported every time the procedure is performed on patients 18 years and older, with the indications for prophylactic parenteral antibiotics. The instructions further state that “Clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure,” clearly indicating who should report the measure. In addition, the instructions indicate that there is no diagnosis associated with this measure.
The Centers for Medicare & Medicaid Services (CMS) has continued the Physician Quality Reporting Initiative (PQRI) into 2010 as required under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). PQRI is the first CMS-crafted national program to link the reporting of quality data to physician payment. The incentive payment for those eligible professionals who successfully participate in the program is 2 percent of the total allowed charges for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period.
How does one use the measure specifications manual?
The first step for implementing PQRI in your office is to use the 2010 PQRI Measure Specifications Manual to identify measures applicable for professional services for which a physician’s practice routinely provides. The next step is to select those measures that make sense based upon prevalence and volume in the physician’s practice, as well as their individual or practice performance analysis and improvement priorities.
What is the description of the measure?
The measure specifications describe measure #20 as “Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior the surgical incision (or start of procedure when no incision is required).” This narrative gives a high-level description of measure #20.
What are the instructions?
The instructions explain when the measure should be reported and who should report it. According to the instructions, measure #20 should be reported every time the procedure is performed on patients 18 years and older, with the indications for prophylactic parenteral antibiotics. The instructions further state that “Clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure,” clearly indicating who should report the measure. In addition, the instructions indicate that there is no diagnosis associated with this measure.
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