2014 pqrs reporting via the giquicqcdrgiquic.gi.org/docs/giquic_qcdr_webinar_12-03-14.pdfyou and the...

2014 PQRS Reporting

via the GIQuIC QCDR

2014 PQRS Reporting

via the GIQuIC QCDR

GI Quality Improvement Consortium Staff

Laurie Parker Eden Essex

�Review the requirements of PQRS reporting

via a qualified clinical data registry (QCDR)

�Review the measures available for PQRS

reporting via the GIQuIC QCDR

�Review how to select the reporting measures

for each of your individual providers

ObjectivesObjectives

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The Physician Quality Reporting System (PQRS)

is a quality reporting program that incentivizes

eligible professionals (EPs) to report quality

data.

Physician Quality Reporting SystemPhysician Quality Reporting System

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�Satisfactory participation

�May earn the 2014 PQRS incentive of 0.5% or

avoid the 2016 PQRS payment adjustment of

-2.0% (based on 2014 reporting)

�Successful PQRS participation tied to application

of the Value-based Modifier (2016 modifier

applied to group practices with 10+ EPs)

PQRS ParticipationPQRS Participation

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�Criteria to earn the 0.5% incentive

�Report at least 9 individual measures, with at least

1 outcome measure, covering at least 3 National

Quality Strategy (NQS) domains (all reporting

mechanisms)

�All data submission is based on calendar year 2014.


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�Criteria to avoid the -2.0% payment

adjustment

�Meet the criteria for the incentive payment or

�Report at least 3 individual measures covering at

least 1 NQS domain

�All data submission is based on calendar year 2014.


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�GIQuIC Qualified Clinical Data Registry (QCDR)

�The focus of today’s webinar

�Thank you for submitting a consent form on

behalf of yourself or providers in your unit

�Quintiles Qualified PQRS Registry

PQRS Reporting Mechanisms available

as a benefit to GIQuIC participants

PQRS Reporting Mechanisms available

as a benefit to GIQuIC participants

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�May 2014: GIQuIC deemed a qualified clinical

data registry (QCDR)

�A QCDR is an entity

�that collects medical or clinical data for the purposes of

patient and disease tracking to foster improvement in

the quality of care furnished to patients

�that has self-nominated, successfully completed a

qualification process, and been approved by CMS as a

PQRS reporting mechanism.

Qualified Clinical Data RegistryQualified Clinical Data Registry

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� The quality measures in a QCDR can be measures already

found in PQRS (i.e., PQRS measures) as well as a registry’s own

measures approved by CMS for PQRS reporting (i.e., NonPQRS

measures).

� The data submitted to CMS via a QCDR includes quality

measure data across all payers and is not limited to Medicare

beneficiaries.

� To satisfactorily participate in PQRS via QCDR individual EPs

must submit data that apply to each measure for at least 50

percent of the eligible professional’s applicable patients.

GIQuIC Qualified Clinical Data RegistryGIQuIC Qualified Clinical Data Registry

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�Important Considerations

�Length of time participating in GIQuIC

�Percentage of applicable patient cases in GIQuIC

�Do you practice at multiple sites?

�Quality of your data uploads

�Run your measure reports – at least 4X prior to end of

December 2014 – and if the data doesn’t look “right” to

you, look into it.

�Do you have a low-level performer?

�Should a default setting in your endowriter be reset?

�Do you have a technical question about how the registry

functions? Contact [email protected]. 10

GIQuIC Qualified Clinical Data RegistryGIQuIC Qualified Clinical Data Registry

�Criteria to earn the 0.5% incentive

�Report at least 9 individual measures, with at least

1 outcome measure, covering at least 3 National

Quality Strategy (NQS) domains for 50% or more

of applicable patients of each eligible provider

(12 months)

�Choose from 13 GIQuIC QCDR individual

measures, which include 4 outcome measures,

covering 4 NQS domains

GIQuIC QCDR: Meaningful MeasurementGIQuIC QCDR: Meaningful Measurement

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�Criteria to avoid the -2.0% payment

adjustment

�Meet the criteria for the incentive payment or

�Report at least 3 individual measures covering at

least 1 NQS domain for 50% or more of applicable

patients of each eligible provider

(12 months)

�Choose from 13 GIQuIC QCDR individual

measures, which include 4 outcome measures,

covering 4 NQS domains

PQRS Participation: What’s Your Goal?PQRS Participation: What’s Your Goal?

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Download the GIQuIC QCDR Measures ListDownload the GIQuIC QCDR Measures List

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Download the GIQuIC QCDR Measures ListDownload the GIQuIC QCDR Measures List

�GIQuIC QCDR Measure 1

Adenoma Detection Rate [Outcome]


Adequacy of Bowel Preparation [Process]


Photodocumentation of the cecum, which is also

known as cecal intubation rate – All Colonoscopies

[Process]

Effective Clinical CareEffective Clinical Care

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Photodocumentation of the cecum, which is also

known as cecal intubation rate – Screening

Colonoscopies [Process]


Documentation of history and physical rate –

Colonoscopy [Process]


Appropriate indication for colonoscopy [Process]

Effective Clinical CareEffective Clinical Care

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Incidence of Perforation [Outcome]

�Note: This is an inverse measure, meaning the target for

performance is 0%.

Patient SafetyPatient Safety

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Appropriate follow-up interval for normal

colonoscopy in average-risk patients [Process]


Colonoscopy interval for patients with a history of

adenomatous polyps – avoidance of inappropriate

use [Process]

Communication and Care CoordinationCommunication and Care Coordination

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Repeat colonoscopy recommended due to poor

bowel preparation [Outcome]

� Note: This is an inverse measure, meaning the target for

performance is 0%.


Age appropriate screening colonoscopy [Outcome]

� Note: This is an inverse measure, meaning the target for

performance is 0%.

Efficiency and Cost ReductionEfficiency and Cost Reduction

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Appropriate management of anticoagulation in the

peri-procedural period rate – EGD [Process]


Heliobacter pylori (H. pylori) status rate [Process]

Domain: Communication and Care Coordination

The EGD MeasuresThe EGD Measures

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�Information you will need:

�List of providers for whom a consent form

was submitted by October 31 along with

their NPI/TIN numbers for reporting

�This is information submitted for each provider on the

individual consent forms.

�GIQuIC Qualified Clinical Data Registry

Measures List

The “Mechanics” of Using GIQuIC as a QCDRThe “Mechanics” of Using GIQuIC as a QCDR

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Enter Each Provider’s TIN NumberEnter Each Provider’s TIN Number

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Select Each Provider’s Reporting MeasuresSelect Each Provider’s Reporting Measures

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Run a Provider Status Report for Each ProviderRun a Provider Status Report for Each Provider

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Provider Status ReportProvider Status Report

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Print the report for each provider

and retain a copy in your files

Provider Status ReportProvider Status Report

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� You and the provider(s) for whom you are reporting

are responsible for:

�Entering the correct TIN for each provider so that

the correct NPI/TIN combination is reported

�Ensuring data for at least 50% of the eligible

professional’s applicable patients are reported for

each measure selected

�Selecting the measures that will meet the desired

goal for each provider no later than January 15� To earn the incentive – 9 measures, including one outcome measure

covering at least three NQS domains

� To avoid an adjustment – 3 measures, covering at least one NQS domain

Important RemindersImportant Reminders

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�October 31, 2014: All provider consent forms were

received

� January 15, 2015: All data for 2014 reporting year is

collected from providers

�Provider Status Reports should be run by data managers

on or prior to this date.

� February 2015: GIQuIC performs validation checks

�March 2015: GIQuIC submits data to CMS

The GIQuIC Registry Team

301-263-9000

[email protected]

GIQuIC QCDR TimelineGIQuIC QCDR Timeline

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� GIQuICLaurie Parker

GIQuIC Executive Director

[email protected]

Eden Essex

ASGE Assistant Director of Quality and Health Policy

[email protected]

� The Quintiles Support Team1-888-526-6700

[email protected]

� QualityNet Help Desk

[email protected]

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Additional QuestionsAdditional Questions

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