Our hero’s name is Dr. Amy Rosett, a California psychologist who challenged CMS and won!
This is her story: In 2014, Amy participated in PQRS, reporting measures via claims. While CMS required providers to report 9 measures to receive a bonus, Amy was only able to report 8 measures because there were a limited number of measures pertinent to psychology and her geropsychology practice that can be reported via claims. Her reporting rate was 100% for each of the 8 measures she reported. She went through the MAV (Measure applicability process: CMS computerized process which attempts to fairly evaluate providers who do not have 9 available measures to report) . The MAV indicated that Amy did not meet 2014 PQRS bonus requirements because she should have used measure # 46 and #317. Measure #46 (Medication reconciliation post-discharge) requires the provider to review a recent inpatient medication list and correct any discrepancies between the inpatient and outpatient medication list (To fully reconcile errors, the provider must have the capacity to prescribe, adjust dosages or discontinue a medication). Measure #317 (screening for high blood pressure) requires providers to measure blood pressure during a session and counsel patients about abnormal blood pressure readings. While our initial assessment and psychotherapy CPT codes are connected to these measures, most psychologists agree (informal survey, Bischmann 2016) that the quality actions (taking a blood pressure and reconciling medications) required by these measures are not within most psychologist’s scope of practice.
Amy reached out to Diane Pedulla, JD, APAPO (APA provider organization) who specializes in Medicare. Amy wondered if other psychologists were denied by the MAV review because they hadn’t used the blood pressure and medication reconciliation measure. There was little information regarding the experiences psychologists were having with PQRS and the MAV. Mostly, we heard that many psychologists were frustrated with PQRS and had given up on it. Diane helped Amy write an “informal review and submit it to the quality net help desk (firstname.lastname@example.org).
Per CMS protocol, the “informal review” is a formal way to appeal the MAV results. In her review, Amy aptly pointed out that most psychologists are not trained to measure blood pressure and this is outside our scope of practice. She also pointed out that the medication reconciliation measure states the measure is to be performed by “physician, prescribing practitioner, registered nurse, or clinical pharmacist.” Psychologists are not included in the list nor do we have the prescribing capacity to correct a medication list.
Unfortunately, Amy’s informal review supported the original MAV results: CMS expected Amy to have performed the blood pressure and medication reconciliation measure. Amy wasn’t willing to accept this. With Diane Pedulla’s assistance, a request was made via APA for CMS to review the outcome of Amy’s informal review. CMS reviewed the outcome and agreed that Amy’s informal review came to the wrong conclusion. Amy won!
CMS is a large governmental organization. Various departments administer different portions of the PQRS, MAV and provider feedback process. Amy’s initial denial via the MAV was an unintended consequence. The issue is that providers such as nurses and others use the CPT codes psychologist’s use. While it is appropriate for psychiatric nurse practitioners to measure blood pressure and complete a medication reconciliation, it is not typical for psychologists to perform these actions. Through Amy’s determination, CMS recognized a flaw in the MAV system and they are working on correcting it.
CMS is asking that psychologists send examples (e.g. screen shots, copies etc) of reports they get via MAV so that CMS can continue to correct any errors and make PQRS work as it was intended. You might wonder why CMS cannot review information internally to identify errors. Apparently, the people who approve the measures and set up the formula’s for the MAV do not have access to the reports that providers receive.
APA asks that you send examples to email@example.com. You can also send things to me and I will make sure it gets to APA.
Written by: Dori Ann Bischmann, PhD
WPA liaison to Medicare
AMA (2015). Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge-National Quality Strategy Domain: Communication and Care Coordination.
AMA (2015). Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented-National Quality Strategy Domain: Community/Population Health.
APAPO (winter 2016). Participating Successfully in the Medicare PQRS Program: What to know and do for the 2015 and 2016 reporting years. Good Practice: Tools and information for Professional Psychologists, 12-15.
Rosett, A. (2015/2016) personal communications regarding PQRS. California. http://www.dramyrosett.com.
QualityNet Help Desk (1-866-288-8912, firstname.lastname@example.org).