Recently, A clinic in SouthEastern Wisconsin sent a variety of questions trying to understand PQRS. I am addressing these questions here so everyone can benefit.
Question: In PQRS, how many measures are required for each
patient? This is technically difficult to answer. I suppose the best answer is: As many as possible, up to nine” Medicare requires that providers complete nine measures (if available) on at least 50% of their fee for service patients. However, depending on how you report (e.g. claims or registry) you may not have 9 available measures. For psychologists reporting via claims, there are 7 available measures. However, not all of these measures will be appropriate for your practice or for each of your patients. For example, measure #317: Screening for high blood pressure and follow-up plan is a measure that few psychologists will choose to use, although it is available to us. Measure #181: elder maltreatment screen and follow-up plan is available, but not appropriate for patients who are younger than 64 years.
Question: If a patient is being screened for depression (#134),
a Geriatric Depression Scale is used and indicates depression, is G8431 the
only billing code required? You would report G8431 if you report via claims, you screened for clinical depression using a standardized tool, found depression and documented a follow-up plan. If you report via claims and did not find depression and thus follow-up plan not appropriate you would report code G8510. If you did not perform the measure because the patient was not appropriate (i.e. too medically ill to test) you would report G8433. Don’t forget to also include the procedure code (i.e. 90791) and diagnosis code. If you are reporting via registry, you don’t report any of the G-codes or CPTII codes.
b. Is this the only measure required for this patient? No, this is not the only measure required for this patient. You should complete as many measures as are available for each patient up to 9 measures. Available measures will vary depending on: how you report (claims vs registry), the age of the patient, the CPT code you are using and possibly the patient’s diagnosis. If reporting via claims, the average older adult being screened for depression at the time of initial evaluation (CPT 90791 or 96150), would also be eligible for measure #128 (BMI screening), Measure #130 (verification of meds), measure #131 (pain assessment), Measure #181 (elder maltreatment screen), measure #226 (tobacco screening), measure #317 (blood pressure screen). If you are reporting via registry, there are additional measures available.
Note that some measures can be used with all of the CPT codes psychologists use. Other measures are only available to be used with assessment CPT codes. The majority of measures are reporting once per reporting period (1 year), but some are required at every session (med review) and some are required to be completed every two years. You must read each measure to determine the qualifications for that measure.
c. Are there any specific instruments required to screen for
depression? Yes and no. CMS requires that you use a standardized tool that has been “appropriately normalized and validated for the population in which it is used.” Then they provide some examples such as Patient Health Questionnaire (PhQ9), Beck Depression Inventory (BDI or BDI-II) and Geriatric Depression Scale (GDS). They give other examples as well. Just use a scale that you know has been normed and validated for the particular population you work with and you will be fine.
2) Can you provide an example of “nine measures across three domains?” CMS has determined that measures cluster into national quality strategy domains (NQS). These are just types of measures that CMS believes are important such as “Effective clinical care,” “Patient safety,” “community/population health.” CMS wants providers to choose measures across domains and not just use measures from one domain. Psychologist’s don’t have to worry about this too much. In claims reporting, we only have 7 measures we can use and these measures represent at least 3 of the various domains. Use the measures available and you will automatically report measures over three domains.
What exactly does it mean and how does an individual provider comply?
2) 3) How often must measures be reported for each patient?
Every session? Once per month or year? An individual provider complies by reporting as many measures as available for that provider up to 9 measures. Reporting via claims, a psychologist has only 7 available measures. One of the measures pertains to blood pressure which most psychologists will not use, effectively there are 6 measures available. However, one of the 6 available measures is screening of elder abuse for patients 65 and older, so patients who are younger than 65 will only have 5 measures available.
The best way to do this is to prepare a cover sheet listing all available measures that you will use in your practice. Attach appropriate screening devices to your face sheet so you have everything you need to complete the measures.
Plan to complete the measures at each initial evaluation and you have met the requirement for most of the measures for the year for most of your patients. Some measures on your face sheet may not be applicable to your patient due to age, dx or other factor. Simply cross that measure off. You can only complete as many measures for that patient as are appropriate to that patient.
Some measures such as #130 (medication review) must be reported at every session and both assessment (90791, 90792, 96150) and psychotherapy codes (90832 etc.) are eligible. Some measures such as #131 (pain assessment) require reporting “at every session,” but the only CPT codes available are assessment codes and thus you never report pain assessment with a psychotherapy session.
Most of these measures, unless otherwise specified need to be reported only once a year so doing them during initial evaluation meets criteria for most of the measures and patients. Note that if you are seeing a patient over more than one year, you should repeat the measures sometime during the second and each subsequent year that you see that particular patient.
3) 4) For what length of time are measures required to be
reported for each patient? Measures are generally required to be reported once per year per patient. Each measure is different so you must read the requirements for each measure. As stated above, the medication review measure requires reporting at each session. Each eligible patient (only Medicare FFS, not Medicare Advantage, Medicaid or Commercial) should have measures repeated at least once per year (or more often if specified by the particular measure).
4) 5) For what percentage of all Medicare patients are
measures required? Is there a minimum of patients for which reporting is
required (what if I only see one or two Medicare patients)? You must report on at least 50% of your Medicare FFS patients. If you only have one Medicare FFS patient, you would report on only that one. While CMS presents reporting as mandatory, it is really only mandatory if you wish to avoid the 2% penalty to your Medicare reimbursements. Some providers may make the financial decision not to report because it is less costly to not report for a few Medicare patients, than to learn the PQRS system and do the work required. I can vouch that It is a very long and complex learning curve to figure out PQRS and do it correctly. There are other benefits to reporting that may have an impact later on. For example, the goal of the Affordable Care Act is to establish a score for each provider that is public (see physician compare website) and used to determine that providers quality as a provider. PQRS reporting is one way to positively contribute to your score.
5) 6) Are there any specific assessment instruments that are
required to be completed for any measure? CMS recommends that the instruments be normed and validated for the specific population you are working with and CMS gives some examples of appropriate instruments. It is up to you to select the instrument you feel is best for your population. You will have to read the requirements for each measure. They all vary.
6) 7) As independent practitioners, but part of a clinic, does
each psychologist have to sign up, or can we just start reporting? It depends on how you are reporting. Most clinicians are still reporting via claims. With claims reporting, each clinician reports independently via the normal billing claims. There is no requirement that all clinicians participate in a given clinic (unless you report via GPRO). With claims reporting, each provider is independent. You must report the pqrs measure at the time you place a claim to be paid for your service. If you are reporting via registry, you can collect the data all year and report at the end of the year (usually through February of the subsequent year). If you are reporting via GPRO (also through a registry), info is extracted from the medical record and the group gets credit for meeting criteria and it doesn’t matter so much what an individual provider did or didn’t complete.
Summary: PQRS is complex. One can report in a variety of ways. Requirements vary depending on reporting method, patient age, CPT code used and in some cases the patient’s diagnosis. Each measure has unique requirements, so a provider has to be familiar with the requirements of each measure that is used. Available measures and requirements are likely to change every year. PQRS (or some form of quality measurement) is here to stay. I recommend that providers learn the system now while everyone is going through the learning curve. Errors are tolerated now more than they might be in the future. Eventually, this data (and other data) will be used for establishing a “quality score” for each provider. This score can be used to determined your payment rate for not only Medicare, but for all insurances. Participating in PQRS will positively impact your score. The Affordable Care Act requires payments to be based upon quality of services and not just the service per se. Thus, we will all be paid somewhat differently for the same CPT code based upon our unique quality score.
Written by Dori Ann Bischmann, PhD
Wisconsin Psychological Association