2016 pqrs and vbm for anesthesia and pain management · by the merit-based incentive payment system...
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2016 PQRS and VBM for Anesthesia and Pain Management
Table of Contents
PQRS 1 Definitions 2 PQRSBasics 2 MAV 3 Claims-basedvs.Registry-based Reporting 32016PQRSChangesforAnesthesia 3AnesthesiaPQRSmeasuresfor2016 4CareTeamConsiderations 5Value-BasedPaymentModifier(VBM) 5PainManagementin2016 6
SUMMARY
AnesthesiaPQRSreportinghaschangedsignificantlyfor2016vs.2015.Thereareseveralnewmeasuresandonlyoneisavailableforclaims-basedfiling.
Like in2015, if2016PQRSisnotreported,ornotreportedaccurately (acommonproblem),anesthesiologistsingroupsof10ormoreproviderswillseea-6%adjustmenttoMedicarepaymentsin2018.Thoseinsmallergroupswillseea-4%adjustment.
ThereareseveralwaystoreportPQRSmeasuresbutaregistryistheonlypracticalsolutionformostanesthesiologists,sinceCMSisphasingoutclaims-basedreportingandEHRreportingusuallyisn’tpractical.Mostimportant,however,aregistryapproachcaneliminatetheriskofthe-4%to-6%penalty.
PQRSresultsalsoshowupon“PhysicianCompare”andproposedchangeswillmapPQRSperformanceintoa5starratingsystemforconsumersbycomparingresultsacrossproviders.
PQRS
Toavoidpenalties fornot reportingPQRSandVBM,anesthesiologistsandCRNAsmustmeet theBasic Reporting Requirements: -Individualsorgroupswhoreportindividualmeasuresmustcompleteninemeasuresforat
least50%of theeligibledenominator,andthosemeasuresmust include three National Quality Strategy Domains.
-Oneofthosemeasuresmustbe“cross-cutting,”asdefinedbyMedicare:apopulation-widemeasurerequiredforproviderswhoseeatleastonepatientina“face-to-face”encounter.
However,theserequirementsdonotmatchwellwithmostanesthesiologistssincecross-cuttingmeasures
AT A GLANCE:
-PQRS/VBMpenaltiesare-4%to-6%
-Registryreportingisstronglyrecommended
-Mostanesthesiagroupsmustreportviaregistrytoavoidpenalties
-Thereareseveralnewmeasuresin2016foreachofanesthesiaandpainmanagement
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mayormaynotapplyandtherearefewerthan9measuresapplicabletomanyanesthesiologists(seebelow).Asaresult,anesthesiologistsaresubjecttothe“MAV”audit,describedbelow.
PQRSissettoexpireafterthisyear(the2016reportingyearaffects2018payments)andbereplacedbytheMerit-BasedIncentivePaymentSystem(MIPS)in2017(whichwillaffect2019payments).MIPSismandatedbyMACRA(theMedicareAccessandCHIPReauthorizationActof2015).MACRAeliminatedtheannualSGRpaymentreductionsand,amongotheritems,replacesPQRS,MeaningfulUseandtheVBM(ValueBasedModifier)programs.
However,whilethenamePQRSwilleventuallydisappear,thequalityreportingcomponentofMIPSwillbeheavilybasedonPQRS,meaningthatworkdonetocomplywithPQRSwilltransitionintotheMIPS environment. Furthermore, non-reporting penalties increase with MIPS, adding additionalincentivetohavegoodqualityreportinginplace.
DEFINITIONS
Thefollowingabbreviationsareusedinthispaper,consistentwithCMSterminology:EP–EligibleprofessionalGP–GroupPracticeEHR–ElectronicHealthRecordQCDR–QualifiedClinicalDataRegistry
PQRSBASICS
-ThereisnoincentivepaymentforreportingPQRSmeasuresin2016.However,incentive/bonuspaymentsmaybeearnedviatheValueBasedModifierProgram.
-EPswhodonotsuccessfullyparticipatein2016willreceivea-2%PQRSpaymentadjustmentanda-4%VBMadjustmentontheir2018Medicarepayments.
-WhiletherearehundredsofPQRSmeasures,onlyasmallnumberapplytoanesthesia,asdescribedbelow.
-PQRScanbereportedviaclaims,registry,EHR,QCDRorGPRO(groupsonly).Thefirst4methodsaretypicallyusedforindividualEPs,evenwhenpartofagroup.However, claims-based reporting is being phased out by CMS so it is recommended to use one of the other methods.
-Foratleast50%ofMedicarepatients,CMSrequiresreportingon9measures,atleastoneofwhichisaso-called“cross-cuttingmeasure”.Butmanyanesthesiologistsdonothave9applicablemeasures,inwhichcasetheMAVapplies(seebelow).
Itisveryimportanttonotethatmeasuresaredefinedonameasure-by-measurebasis,not by specialty.Thatisbecausetwoprovidersinthesamespecialtymaynotperformthesameservices.
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MAV
For thosewhoreport fewer thanninemeasuresor fewer than threedomains, theMeasureApplicability Validation (MAV) Audit applies. Medicare compares your PQRS data to its measurespecifications to identifyothermeasureswhichcouldhavebeenreported,butwerenot.While themeasurestheyidentifymaynotseemrelevant,iftheymeetMedicare’sdefinition,theydirectlyaffectyourPQRScompliance.
CLAIMS-BASED VS. REGISTRY-BASED REPORTING
In this paper, we focus primarily on claims and registry-based reporting since many anesthesiagroupsdonothavetheabilitytouseanEHRforEHR-basedreporting(andmanyEHRsdonothavethenecessaryCEHRTcertificationtoreportthemeasures).QCDRisabroadertopicasthatreportingmethodforanesthesiatypicallyrequiresadditionalqualitymeasuresbeyondthoseinPQRS.
With PQRS penalties now significant (-4% to -6% when combined with the VBM penalty), registryreporting is becoming almost essential. This is because claims-based reporting doesn’t provideanyMAVinsight,untilitistoolate.Furthermore,theprocesstoreviewclaims-filedPQRSdataiscumbersome,atbest.In2015,countlesshourswerespenttryingtodeterminewhatdataCMSactuallyhad.Andevenwhenbaddatawasappealed,penaltieswerestillapplied.Registryreportingprovidesongoingfeedbackand,importantly,providesfeedbackonhowanEPorgroupwillfareinaMAVAudit.Inaddition,witharegistry,PQRSdatacanbeupdatedorevenreplaced,somethingthatisimpossiblewithclaims-basedfiling.Asaresult,usingaregistryeliminatesMAVandPQRSpenaltyrisks.
Formanyifnotmostanesthesiaproviders,claims-basedfilingisnotgoingtoworkin2016,asdescribedinthenextsection.
2016PQRSChangesforAnesthesia
Thebiggestchangein2016PQRSisthatmanyanesthesiologistsandCRNAswillnolongerbeabletouseclaims-basedPQRSreporting!ThisisbecauseCMSdeletedMeasure193(warming),andmovedMeasure44(betablocker)toregistryonly,leavingMeasure76(sterileCVC)astheonlyonereportableviaclaims.ButEPswhodon’tinsertcentrallinesorPAcathswillnotbeabletoreportMeasure76.ThismeansthatEPswhodon’tinsertcentrallinesorPAcathsmust report via registry or QCDR to avoid PQRS and VBM penalties![1]
Itisworthnotingthat,inagroup,ifoneproviderdoesinsertcentrallinesorPAcaths,theycanstillreportviaclaimsevenifotherproviderscannotandchoosetousearegistry.Inotherwords,alloftheprovidersinagrouparenotrequiredtousethesamereportingmethod.
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1VaughnandAssociates,“PQRSWarning:WhatifYouhaveNoMeasurestoReportviaClaims?”December18,2015.
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ThePQRSchangesin2016include: -“Changes to Existing Measure 76.Therequirementstocomplywiththesteriletechniquefor
CVChavechangedfor2016.Code6030Fnowrequiresdocumentationof“sterileultrasoundtechniques”whichisdefinedas“sterilegelandsterileprobecovers.”So,youwillneedtochangeyourMeasure76templatetocapturethefollowing:(1)cap(2)mask(3)sterilegown(4)sterilegloves(5)sterilefullybodydrape(6)handhygiene(7)skinpreparation,andifultrasoundisused(8)sterilegel,and(9)sterileprobecovers.
- Deleted Anesthesia Measure.Measure193(intraoperativetemperaturewarming)wasdeleted because there was 100% compliance. (Ironically, this same basic measure wasaddedtothelistofmeasurestoreportviaregistryasMeasure424.)
-Changed Method of Reporting.Measure44 (BetaBlocker)was removed from the listofavailablemeasurestoreportviaclaims,althoughitcanbereportedviaregistry.
-New Anesthesia Measures.Thereare5newanesthesiameasuresfor2016,butforregistryreportingonly.Theyare:SmokingAbstinence#404(reportableviaregistry),PerioperativeWarming#424,PACUTransferperFormalProtocol#426,ICUTransferperFormalProtocol#427,andPONVTherapyforInhalationGA#430.
-New Cross-Cutting Measures:Thereare3newcross-cuttingmeasuresfor2016.Theyare:UnhealthyAlcoholUse#431;BreastCancerScreening#112;FallsandRiskAssessment#154.
-New Chronic Pain Measures.Forgroupswithachronicpaincomponent,thereare3newopioid related measures, as follows: Opioid Therapy Follow-up Eval #408 (registry only);SignedOpioidTreatmentAgreement#412(registryonly);andInterviewforRiskofOpioidMisuse#414(registryonly).[2]
TheoptionsforrelevantPQRSmeasuresarequitelimitedforsomeanesthesiaproviderswhomayfind they need to report a measure with poor performance. While this may avoid the PQRS andValue-BasedPaymentModifier(VBPM)non-reportingpenalty,itdoesrisktriggeringaVBMpenalty(thoughtheVBMpenaltyis-2%to-4%vs.the-6%non-reportingpenalty.
AnesthesiaPQRSmeasuresfor2016
Asdescribedabove,mostanesthesiagroupswillbereportingviaregistryin2016.Ifso,thesearethepossiblemeasuresidentifiedtodate(eachEPandgroupneedstodeterminewhichapply): -44(BetaBlocker), -76(CVCsteriletechnique), -342(PainBroughtunderControlwithin48Hours;appliesto99231-99233), -404(Smokingabstinence), -424(Perioperativewarming), -426(TransfertoPACU), -427(TransfertoICU), -430(PONV), -1(Hemoglobin),and -47(Careplan).
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2VaughnandAssociates,“What’sNewinAnesthesiafor2016?”December21,2015.
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Thelast2arecross-cuttingmeasuresthatapplywhereveranEPhasaface-to-faceencounterwithapatient.Measure1[poorhemoglobin]and47[advancecareplan]arereportableifbillingpost-oppainroundsusing99231-99233;severalothermeasuresarereportable ifbillingoutpatientE&Mcodesusing99201-99205or99211-99215).
DetailsforeachmeasureareavailableintheCMSIndividualMeasuresGuide,availableasadownloadatthisCMS page.
CareTeamConsiderations
IncaseswherebothEPsintheCareTeambillMedicare,themeasureinformationforbothshouldbereported.Ifbillingisonlydoneforone,themeasureisonlyreportedforthatEP.IfbillingisdoneusingIndividualNPInumbers,themeasureinformationneedstobereportedusingeachIndividualNPI.Inotherwords,eachtimeabillingcodeissubmittedtoMedicareitisaneligibleinstance.SoifacodeisbeingbilledundertwoseparateNPIsthenbothNPIswouldbeableto(andneedto)reportfortheeligibleinstance.
Value-BasedPaymentModifier(VBM)
LikePQRS,theValue-BasedModifier(VBM)affectsMedicarepaymentswithaone-yeardelay.Hence,performancein2015hasalreadydeterminedPQRSandVBMpaymentadjustmentsfor2017.Andperformanceduringthisyear(2016)willdetermineadjustmentsfor2018payments.
For2015,CMSdescribedtheVBMasfollows:“Inordertobeeligibleforupward,downward,orneutralpaymentadjustmentsundertheValueModifierquality-tieringmethodologyandtoavoidanautomaticnegative twopercent (“-2.0%”) (forphysiciangroupswithbetween2 to9EPsandphysiciansolopractitioners) or negative four percent (“-4.0%”) (for physician groups with 10 or more EPs) ValueModifierpaymentadjustmentinCY2017,EPsingroupsandsolopractitionersMUSTparticipateinthePQRSandsatisfyreportingrequirementsasagrouporasindividualsinCY2015.Quality-tieringismandatoryforgroupsandsolopractitionerssubjecttotheValueModifierinCY2017.Groupswith10ormoreEPsaresubjecttoupward,neutral,ordownwardadjustmentunderquality-tiering,andgroupswithbetween2to9EPsandphysiciansolopractitionersaresubjecttoonlyupwardorneutraladjustmentunderquality-tieringin2017.”
Whilethepreciserulesfor2016arenotclearontheCMSwebsite,itappearsthatgroupsunder10providersarenowsubjecttoa-2%VBMpenalty,andcontinuetobeeligiblefora+2xincentive,basedontheirqualityandcostresults.ButthisassumesthatthegroupreportsitsPQRSmeasures.Anygroupunder10providersthatdoesnotreportPQRSsuccessfullywilldefinitelyseea-4%penalty.
Inaddition,for2016,non-physicianpractitioners(NPPs)areincludedintheVBM:PAs,NPs,CNSs,andCRNAs,etc.Asinpreviousyears,theseprovidersnewtotheprogramarenotsubjecttodownwardadjustments,butthatappliesonlytosoloNPPsorthose inagroupofonlyNPPs.Solophysiciansandgroupsoftwoormorephysiciansand/orNPPsaresubjecttopaymentadjustments(upordown)
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basedontheirratioofqualitytocostascomparedtootherprovidersintheMedicareprogram.
Tosummarize,theupwardordownwardpaymentadjustmentfactorsandpercentagesfor2016VBMareasfollows: -Forsolophysiciansandgroupsuptonineproviders:+2.0xand-2.0%. -Forgroupswith10ormoreproviders:+4.0xand-4.0%.
PainManagementin2016
Likeallotherspecialties,painmanagementmustreportatleast9measures,coveringatleast3oftheNQSdomainsANDreporteachmeasureforatleast50percentoftheEP’sMedicarepatients.SincepainmanagementproviderstypicallyseeMedicarepatientsinaface-to-faceencounter,theymust report on at least 1 cross-cutting measure. There are 3 new cross-cutting measures for2016:UnhealthyAlcoholUse#431 (reportableviaregistryandmeasuresgroups);BreastCancerScreening#112(reportableviaclaimsandregistry);andFalls:RiskAssessment#154(reportableviaclaimsandregistry).
Asnotedabove, thereare3newChronicPainopioid relatedmeasures:OpioidTherapyFollow-upEvaluation#408(registryonly);SignedOpioidTreatmentAgreement#412(registryonly);andInterviewforRiskofOpioidMisuse#414(registryonly).
PainmanagementgroupsusingQCDRreportinghavetheoptionof“measuresgroup”reporting. Itrequiresreportingfor20patients,themajorityofwhichareMedicare.The“PreventiveCareMeasuresGroup”istheonlymeasuresgroupthatappliestoPainManagementfor2016.Itcontains: -#39ScreeningforOsteoporosisforWomenAged65-85YearsofAge -#48UrinaryIncontinence:AssessmentofPresenceorAbsenceofUrinaryIncontinencein
WomenAged65YearsandOlder -#110PreventiveCareandScreening:InfluenzaImmunization -#111PneumoniaVaccinationStatusforOlderAdults -#112BreastCancerScreening -#113ColorectalCancerScreening -#128PreventiveCareandScreening:BodyMassIndex(BMI)ScreeningandFollow-UpPlan -#134PreventiveCareandScreening:ScreeningforClinicalDepressionandFollow-UpPlan -#226PreventiveCareandScreening:TobaccoUse:ScreeningandCessationIntervention -#431PreventiveCareandScreening:UnhealthyAlcoholUse:Screening&BriefCounseling
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