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PQRS - Physician Quality

Reporting System 2016 Edition PrognoCIS v3b3

PQRS – Physician Quality Reporting System http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS

Applicable for Eligible Professionals Report on quality of care to Medicare

patients Avoid a negative payment adjustment

of 2% applied 2 years following the reporting period

Incentives ended with 2014 program year

No registration or sign-up required Claims-based reporting only

methodology supported in PrognoCIS PQRS is not the same as MU

Eligibility for Medical Professionals https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2016_PQRS_List_of_EPs.pdf

Differs from MU Eligibility criteria Medicare physicians, practitioners,

and therapists Must qualify for measure

denominators Billing methodologies apply

2015 Timeline http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015-17_CMS_PQRS_Timeline.pdf

Last day of 2015 reporting period for DOS 12/1 – 12/31.

2016 Timeline http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015-17_CMS_PQRS_Timeline.pdf

2015 claims must be billed to

Medicare

Claims-based Reporting Requirements http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015PQRS_Claims_Made_Simple.pdf

9 measures across 3 domains At least 50% of all Medicare

patients seen by the EP 1 cross-cutting measure Measures with 0% performance

are not applicable

1 – 8 measures, or 9+ measures for < 3 domains At least 50% of all Medicare

patients seen by the EP 1 cross-cutting measures Subject to MAV Measures with 0% performance

are not applicable

PQRS Measures http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html

CMS Web Tool for Measures https://pqrs.cms.gov/#/home

Cross-Cutting Measures https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/downloads/2016_PQRS-Crosscutting.pdf?agree=yes&next=Accept

Applies to Face-to-face encounters

At least 1 Cross-cutting Measure* applicable on at least 15 denominator-eligble claims

*Measures that are broadly applicable across multiple providers & specialties

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments /PQRS/AnalysisandPayment.html

MAV – Measure Applicability Validation

Many measures are broad across all specialties while some are specialty-specific

MAV applies for EP who cannot report successfully on 9 measures across 3 domains, or reports

between 1 and 8 measures across less than 3 domains

MAV is analytically complex & does not guarantee EP will avoid payment adjustment

Based on Measure Clusters, which groups individual measures relevant to your practice

MAV review is a 2-step process which validates claims against these clusters

MAV – Measure Applicability Validation (cont’d) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments /PQRS/Downloads/2016_PQRS_MAV_ProcessforClaimsBasedReporting_111715.pdf

MAV User Process Guide

w/Case Studies

http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_sampleCMS1500claim_12-19-2012.pdf

Claims-based Reporting (cont’d)

Reporting period covers entire calendar year Dates of Service Claims must be submitted to Medicare by end of February the following calendar year.

QDC must be reported on all applicable line-items w/only 1 ICD

All PQRS data is posted to the Assessment screen within EHR

Service provider (EP) is identified by his/her individual NPI/TIN

Automated cross-over to PM side within PrognoCIS

PQRS Report available for external PM/Billing Service users

Claims that are denied are not considered for PQRS credit (unless correctly rebilled/reprocessed)

Claims may not be resubmitted solely for the sake of reporting QDC that were originally missing

PQRS Measures Master – Measures Setup

Inactive measures will not be applied at encounter level.

Settings Configuration Codes/Drugs PQRS Measures

All current measures (by calendar year) for which PrognoCIS is certified with CMS

Only Active measures will be validated on each Medicare encounter per the Categories (PQRS

Domain) assigned to the Attending Provider’s user profile.

Category is the PQRS Domain which is assigned to the EP.

PQRS Measures Master – Measures Info The Info button displays the measure’s details (e.g.: Denominator, Numerator, Age, Gender, etc.)

Info button is also available at the encounter level.

Attending Provider User Profile Setup The PQRS Category defines the domains that the Attending Provider will be reporting, which will

pull applicable measures that are defined as Active within PQRS Measures master

Each provider may select different domains

Settings Configuration Medics Provider

User/Role Permissions Each provider should have appropriate security permissions for documenting PQRS

Patient Encounter PQRS allows you to document under the PQRS screen from encounter TOC

PQRS PQRS Measures allows you to assign measures as Active/Inactive under Configuration

Settings Configuration Admin Role

Only EMR Admin or EP requires these

rights.

EP & applicable clinical staff requires

these rights.

PQRS Encounters are identified by Insurance Type = Medicare under Patient Insurance

Note: This field is otherwise not used on the Patient Insurance screen.

Patient Insurance

Patient Register Patient Insurance ( )

Insurance Type

PQRS option will display on TOC for all encounters but will be disabled when not applicable*

All Active measures for the Attending Provider will display with status as of that encounter

PQRS Encounter

The option will be grayed-out when the Insurance Type is not Medicare.

Status reflects the Assessment screen

Info Button Same as we saw in the PQRS Measures master, the Info button displays the measure’s details (e.g.:

Denominator, Numerator, Age, Gender, etc.) at the encounter level

Assign ICD Button Displays all valid ICD codes as defined within the Denominator for the selected measure

Button only works when status = FAIL and the encounter is Missing ICD

Bi-directional with Assessment ICD tab

Click the ICD10 hyperlink and select appropriate

ICD

Assign CPT/HCPC Button Displays all valid CPT/HCPC codes as defined within the Denominator for the selected measure

Button only works when status = FAIL and the encounter is Missing CPT/HCPC

Bi-directional with Assessment CPT/HCPC tab

Note that the CPT/HCPC may be missing

even when there is an ICD present or

both may be missing for the same

measure

G-Code Icon ( )

Bi-directional with Assessment CPT/HCPC tab

Note: The physician will have to manually associate the applicable ICD code to the CPT/HCPC & QDC

combination in order for it to cross over to the billing side/report correctly.

If using PrognoCIS PM, it will populate on the CMS-1500 as a non-charge line item as required

The QDC along with an appropriate ICD & CPT/HCPC from the Denominator is what is required on the

claim in order to be considered successfully reported

Displays all valid QDC (Quality Data Code)* as defined within the Numerator for the selected measure

Button only works when status = PASS (Missing G-Code)

Note: An error will display if a CPT/HCPC has not yet been assigned; as the QDC must be associated to

a valid HCPC within the numerator. Note that the QDC is not always a “G” code

Workflow on the PQRS Screen Local preference decides if you prefer completing the Assessment first or use PQRS as a tool to do so

Select Encounter TOC PQRS Identify the measures applicable for

the current encounter Click to Assign ICD Click to Assign CPT/HCPC Each modified line will display in pale

yellow background until updated Click save to apply assignment of ICD

and CPT/HCPC Click and select QDC that is most

appropriate for the encounter Click OK Click save Status should = PASS Update Assessment screen (i.e.: map 1

valid ICD per each QDC code)

PQRS Data on the Assessment

Encounter TOC Assessment CPT/HCPC Source

Local preference decides if you prefer completing the Assessment first or use PQRS as a tool to do so

When data is chosen from PQRS screen the Source reflects that. Only 1 ICD

should be assigned to each QDC.

PQRS Report By provider, measures group, and date range

Share with external Billing Service when not using PrognoCIS PM/Billing module

Reports PQRS Report

Can specify individual or multiple providers for 1 or all

patients within period.

Charge Code = QDC (or G-Code)

Ensure all 9 measures you want to report are Active in PQRS Measures master Note: You must include at least 1 cost-cutting measure within these 9. MAV may apply for those who cannot report 9 measures/3 domains. Associate at least 3 PQRS Categories (Domains) to each eligible provider Remind Patient Registration to assign Ins Type = Medicare to patient insurance Document all clinical codes (ICD, CPT/HCPC, etc.) to the Assessment or assign them from the PQRS screen (they are bi-directional) Assign appropriate QDC (G-code) to each applicable measure Assign only 1 valid ICD to each QDC under Assessment CPT/HCPC tab Reporting period is the entire calendar year for Medicare B claims only Submit claims before Feb. 28 of the following year

Remember: Payment Adjustments will be applied 2 years

following the reporting period, i.e.: 2015 DOS will be adjusted in 2017 2016 DOS will be adjusted in 2018

24/7 technical support via Live Chat or (408) 873-3032 / (800) 552-3301

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