Low-volume Threshold: MIPS 2018

The Centers for Medicare and Medicaid Services (CMS) are beginning to recognize that solo and small practices are having difficulty meeting the requirements of the Merit-Based Incentive Payment System (MIPS).  As a result, they have expanded the low-volume threshold in 2018 (APAPO, 2017).  This is good news for psychologists because many of us will fall under the low volume threshold and not be required to report under MIPS.

In 2018, a psychologist will not have to report under MIPS if he/she treats 200 or fewer Medicare Part B beneficiaries or bills Medicare Part B for $90,000 or less in allowable charges.   This is 200 or fewer unique patients, not sessions.  Revenue from Medigap policies (secondary payers) or Medicare Advantage plans is not included in the $90,000 figure.  Thus, only revenue directly from Medicare Part B reimbursement is counted.  Also, patient’s that have Medicare Advantage plans are not included in the patient count. This means that if you saw 201 or more patients, but received less than $90,000, you still would not have to report.  Likewise, if revenue was over $90,000, but you saw 200 or fewer unique Medicare Part B patients, you would not have to report.

If you are in solo practice, it is very straight forward: you simply count your Medicare Part B patients and tally your Medicare Part B revenue.  If you are in a group practice, you may or may not have to report MIPS depending on how you are categorized (billed).

If you are categorized as being in a group practice it is not so clear.  If billing is done using your own NPI number but the group’s Tax ID number, then the cumulative Medicare Part B reimbursement of all members of the group practice might count toward the low volume threshold.  In this case, if revenue was over $90,000 (and 201 or more unique individual patients were seen) all members would be required to report under MIPS.

For further clarification and with the help of Diane Pedulla we asked CMS how an individual psychologist would be categorized (i.e., as an individual provider within a group or as part of a group) when using a billing service that uses the same Tax ID number for all the providers that are billed through that service.  We have not yet received a response but will update you as this information becomes available.

So,  currently it isn’t entirely clear how CMS tracks whether you are part of a group or an individual within a group, especially if you are an independent contractor (personal communication with Diane Pedulla, 2018).   You may very well be able to determine for yourself how you want to categorize yourself.  The obvious benefit of falling under the low volume threshold is that you don’t have to worry about MIPS and you will not receive a payment penalty.  However, you will also not be eligible for a payment bonus.  The penalty/bonus is expected to reach +/-9% in 2022.

Many psychologists will elect to participate in MIPS to benefit from a payment bonus, even if they fall under the low volume threshold.   Psychologists have been exempt from MIPS in the first two years of the program.  In 2019, we will be required to participate in MIPS if we don’t fall under the low volume threshold. Participation in 2019 will make us eligible for a payment penalty or bonus in 2021.

Always keep in mind that CMS may change the low volume threshold and/or any other aspect of the MIPS program on a yearly basis.

In the next blog, I will begin to address the various aspects of MIPS reporting.

 

Dori Ann Bischmann, PhD

Clinical psychologist

Federal Advocacy Coordinator for APA

 

APAPO (11/30/2017).  Low-volume threshold expanded in 2018 Quality Payment Program Rule. http://www.apapracticecentral.org/update/2017/11-30/low-volume-threshold.aspx.

Pedulla, D. (2018).  APAPO Government relations staff. Personal communication regarding MIPS.

 

 

Advertisements

Moving from Fee for Service to Pay for Quality

With the Affordable Care Act (ACA or PPACA, 2010) and Medicare Access and CHIP Reauthorization Act (MACRA, 2015), the Centers for Medicare & Medicaid services (CMS) have moved further away from fee-for-service payment and toward pay for quality. Under fee-for-service payment, a provider is paid for the volume of services that are completed. Quality, efficacy and cost efficiency are not factors of payment (CMS, 2018).

Pay for quality, at least in theory, is meant to improve the quality and outcome of services while simultaneously decreasing cost. If a smaller number of high quality, pertinent services are provided to a patient, the patient should experience a more positive result (better medical outcome, higher satisfaction, prevention of other medical illnesses, etc.) and the cost would be less. Additionally, if we address prevention, compliance, and engagement we can affect changes at the population level; we can improve the health of the population as a whole and reduce the cost of medical services in the United States.

CMS offers providers two pay for quality tracks, Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (CMS, 2018).

An APM is a payment approach that provides incentives to clinicians who provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population (CMS, 2018). You might have heard of these programs via various names such as Accountable Care Organizations (ACO), shared saving programs, or care models. This type of payment model is most often initiated by a larger hospital or physician system. The system is paid upfront on a monthly basis for care to a given population. Quality measures and other assessments are part of the system. If the clinicians provide high-quality and cost-efficient care, they are eligible for bonuses. If the various measures applied do not meet expected criteria, money has to be returned to CMS.  Therefore, the hospital or physician group that adopts an APM takes on a high level of risk. As a psychologist, you are most likely to be in this type of payment model if you are an employee of a large medical organization. Psychologists can play an important role via decreasing overall cost by attending to the mental health needs of the patients via improving compliance, changing behavioral factors that lead to illness, and in many other ways.

Most psychologists will participate in CMS’s second track called the Merit-Based Incentive Payment System (MIPS). In MIPS, the clinician reports quality measures and other activities that are intended to improve the quality of services provided. It is also hoped that implementation of MIPS will improve clinical outcomes and cost efficiency. Eligible providers began reporting under MIPS in 2017. Psychologists are exempt from reporting MIPS until 2019. Successful participation in MIPS could lead to a payment bonus, but non participation will, likewise, lead to a payment penalty. The potential bonuses and penalties will increase as we approach 2020 and beyond (APA, 2016).

The MIPS system is complex and many aspects of it may not be easy for psychologists to complete, especially those in solo or small practices. CMS established a low volume threshold which many psychologists in smaller practices will fall under.  These psychologists may not have to report MIPS at all. However, keep in mind that any low volume threshold established by CMS is subject to change. The eventual goal of CMS is to have all providers participating in quality reporting.

Because these issues are complex, I will address various MIPS  topics in separate blog posts. The next blog will be about the low volume threshold.

Dori Ann Bischmann, PhD
Clinical Psychologist
APA and WPA Federal Advocacy Coordinator

References:

APA (2016). CMS proposes new Medicare incentive payment system. PracticUpdate Newsletter.
CMS (2018). Quality Payment Program. MACRA-Quality-Payment -Program-, https://www.cms.gov
The patient protection and affordable care act (PPACA), (2010, Mar 23) pub.L.No. 111-148, 124 stat. 119.
The Medicare access and CHIP Reauthorization act (MACRA), (2015)(H.R. 2, Pub. L. 114-10.

The Structure of Advocacy in the Practice of Psychology

Advocacy is an important function in today’s society.  Those that speak the loudest and/or make the largest donations are able to affect important governmental changes.  Psychologists play an important role in advocacy because we not only advocate for our profession, but we advocate for the mental health needs of our patients and improvements in society at large. We are fortunate to have an advocacy structure set up for us.

APA has the Practice Organization (known as APAPO) which advocates for psychologists and the people we provide services to.  Among the many issues that APAPO might advocate is:  improved mental health care, increased funding for mental health care, improvements to insurance that facilitate access to mental health care, advocating the inclusion of psychologists (and good mental health care) into healthcare initiatives (Affordable care act), parity, changing Medicare law to facilitate psychological services/access and much more.

In order for advocacy to be effective, it is imperative that many psychologists, at the grass-roots level, be involved in sending messages to legislators.  APA has a system  in place that makes it easy for every psychologist to advocate.

Every state, territory and district of the United States has a psychologist designated as the Federal Advocacy Coordinator (FAC).  I am the Wisconsin FAC.  In the FAC role, I represent both APA and WPA and have a variety of responsibilities.  First, through a data base provided by APA, I send out action and information alerts to Wisconsin psychologists.  The alerts are written by APA and then sent out to the FACs for distribution.  You are in the data base if you are a member of APAPO or have previously used the APA (Capwiz) political action portal.

I encourage you to write to your legislators, at the very minimum, when you receive an action alert.  This is the cornerstone of grass-roots advocacy and it really does make a difference.  When a message avalanche hits the hill, legislators and their offices take notice. APA makes it easy by putting a clickable button in the action alert that will take you directly to the advocacy portal.  Enter your zip code to identify your specific federal legislators and then send emails.  APA provides a sample letter for you to use; you can edit the letter any way you wish or send it as written.  Even if you disagree with the APA stance on an issue, I encourage you to make your voice heard and write what you think the legislator should do to address the issue.

A second FAC responsibility is to attend the annual Practice Leadership Conference in March.  The conference provides several days of workshops on cutting edge issues related to the practice of psychology and health care in general. We also receive advocacy training.  On the last day of the conference, we go to Capitol hill in Washington D.C.  We meet with as many Wisconsin legislators as possible while the  other FAC’s meet with their respective legislators.  We essentially blanket the hill advocating the specific agenda delineated by APA.

This year we advocated to include psychologists in the “physician definition” under Medicare law.  We are the only doctoral level providers, licensed to work independently in our states, that are not included under this definition.  Chiropractors, dentists, podiatrists and optometrists are included under the physician definition.  This is important because many Medicare initiatives have been tied to providers that fall under “physician” such as funding to develop electronic health records, use of E & M codes and the ability to be independent in all places of service under all insurances.  Currently, it is required that psychologists have an MD sign off in some places of service for our work with Medicare fee for service beneficiaries. In contrast, MD sign off is not required when the patient has commercial insurance, Medicaid or Medicare advantage plans.  We also advocated to keep mental health services included in Medicaid and other health plans as congress continues to address the affordable care act and Medicaid.

A third responsibility for FAC’s is to meet with, write to or in other ways be active with legislators when they come to their Wisconsin districts.  I go to town hall meetings, listen to Facebook town hall meetings and write to the legislators and their aides.

Finally, the FAC brings this information back to you via education at annual conference, newsletter articles and this blog.  I also communicate with Wisconsin psychologists who have questions about action alerts.

At times, this is a huge responsibility (i.e. when major changes in health care bills are being voted on), but it is rewarding and important work.  I am proud of the role I play in affecting change at the governmental level.   Perseverance and patience are required because change does not occur quickly.  For many years in a row we go to the hill with virtually the same agenda items. Over time, you witness a slow, but important change occurring and then suddenly, or so it seems, the advocated change occurs!

If you have any questions or suggestions, please do not hesitate to contact me.  Thank you for all the help you have given me over the years by contacting your legislators!  Keep it up, we are making progress.

Dori Ann Bischmann, PhD

Federal Advocacy Coordinator

APA and WPA

Capwiz: an online advocacy program developed by Capitol Advantage that allows users to send advocacy messages and alerts to members.  APAPO is a member of Capwiz and utilizes this system to send alerts to psychologists.

IMG_1466

 

 

 

 

Workshop coming your way!  For psychologists and billing professionals.

 

Go to http://www.wipsychology.org for online registration

Or submit registration form below

This workshop is for mental health providers and billers who wish to be successful at capturing the complexity of mental health interventions and reporting/billing services in a way that maximizes reimbursement while complying with Medicare’s ever-changing requirements. More than ever before, Medicare policy dictates requirements and implementation of all insurances. So, even if you are not primarily a Medicare provider/biller, the workshop will prepare you for upcoming changes in reimbursement. As we move away from fee-for-service payment to a tiered payment system, providers will need to demonstrate that their services meet certain quality, value and effectiveness criteria. Billers will play a major role in coding and reporting these criteria. The workshop will first review the basic Medicare requirements for mental health assessment, intervention and documentation. We will also review basic Medicare billing strategies. We will then explore the more complex aspects of Medicare including PQRS, secondary insurances, codes for special circumstances, and a variety of helpful strategies that have been learned via trial and error. Finally, we will introduce attendees to MIPS and the upcoming requirements proposed by Medicare. Plenty of time will be available for questions and exploration of your unique experiences with coding and billing mental health services. By the end of this workshop, you will be ready for the changes coming in 2017 and 2018.

 

OUTLINE

Review of Medicare requirements for mental health services

Medical necessity, documentation, physician definition, FFS vs Advantage plans, 

H&B codes/complexity & add-on codes

Detailed examination of PQRS

Available measures, reporting options, billing codes, MAV, Quality Net help desk

MIPS & other new Medicare requirements

Quality measurement, psychologist reporting requirements for next 2 years

Exploration of billing strategies

What both psychologists & billers need to know, strategies for special populations/place of service (acute care, LTACH, Rehab, SNF, hospice), unique billing differences among various insurers, appealing denials

Panel discussion with Q&A

Ask questions, explore coding & billing challenges, learn from other attendees, network

 
 

Learning Objectives

 At the conclusion of this workshop, participants will be able to:

 

Ø Recognize & define key Medicare requirements for mental health services

Ø Identify available measures and billing codes for PQRS along with appropriate reporting options, and help resources

Ø Describe MIPS and other new Medicare requirements

Ø Outline billing strategies both psychologists & billers should know for special populations/places of service and unique insurance requirements

Ø Give examples of coding and billing challenges

Presenters

 

Dori Bischmann, PhD

Dori Bischmann is a clinical psychologist with 25 years of Medicare experience both as an employee and in private practice. She has worked in a variety of settings including medical and psychiatric hospitals, long-term care and outpatient sites. Currently, she is employed half-time as a rehabilitation psychologist in a system with electronic health records (EHR) and introduced PQRS to that system. In her private practice, she has participated in the PQRS system since its inception. Dori is involved in many professional activities regarding PQRS. As the WPA liaison to Medicare, she is involved in trying to improve the Medicare system and educating Wisconsin psychologists about Medicare and PQRS. As the APA Federal Advocacy Coordinator (FAC) for Wisconsin, she advocates for Medicare issues at the national level along with FACs from every state and territory. She is the APA representative to the Physician’s Consortium of Provider Improvement, an AMA group that oversees the development of PQRS measures.

Diane Pedulla, JD

Diane Pedulla is the Director of Regulatory Affairs for the Practice Directorate of the American Psychological Association. She is responsible for monitoring federal policies that affect the independent practice of psychology, including coverage and reimbursement issues. Currently, her work focuses on performance measurement and quality reporting, including the development and marketing of the APAPO PQRSPRO registry for PQRS reporting in Medicare, the first registry designed specifically for psychologists and other mental health professionals. Diane holds a JD degree from the University of Wisconsin Law School, an MS in Higher Education from Syracuse University, and a BA in Psychology from the University of Massachusetts at Amherst. Prior to joining APA in 1999, she served as an attorney for the US Department of Labor in Washington, DC, and San Francisco, CA.

 

Heather Hutchison, MHA

Heather Hutchison is Office Manager at Behavioral Solutions in Milwaukee. She holds a Masters degree in Health Care Administration from the University of St Francis – Joliet and a Bachelors in Health Care Administration/Business from UW Milwaukee. With 10 years of billing experience, Heather currently runs the life cycle of a claim from start to finish including insurance verification, billing, collections and appeals with mental health services in various place of services. She has extensive experience in billing Medicare for psychiatrists, psychiatric nurse practitioners and psychologists who provide services to SNF, LTACH, assistive living, rehabilitation, home and various outpatient locations. She is knowledgeable in PQRS and coding   

Location / Reservations 

The Hilton Garden Inn is located just off I-94 near Oconomowoc. There is no room block reserved for this workshop, but rates at this facility are very reasonable. Call 262-200-2222 or go online for reservations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychology has a Hero!

Pro Photo of Amy Rosett (2)      

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 (qnetsupport@hcqis.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 pracgovt@apa.org.  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

Advocacy Cabinet

References:

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, qnetsupport@hcqis.org).

 

 

Pqrs Inquiry

I need your help.   I am trying to gather information regarding psychologist’s experiences with PQRS to share with APA.  I would appreciate any info you can provide about your own experiences and/or what you have heard from peers.

 

Here are some questions to guide you to the types of information I need.

 

  1.  Do you participate in PQRS?   If not, what factors contribute to your decision not to participate?

The following questions are for those who participate in PQRS:

  1. How do you report?   Claims, registry, EHR, GPRO?
  2. For 2014 data, how many measures did you report?
  3. Did you go through the MAV?
  4. Did you pass the MAV?
  5. Did you submit an informal review to CMS?
  6. If you submitted an informal review, what were the results?

7.  Are you aware that there are measures that include 90791 and the psychotherapy codes that require: taking a blood pressure and doing a “medication reconciliation?”

8.  Do you think that it is the scope of practice of most psychologists to measure blood pressure or do medication conciliation? Are these activities that you would feel appropriate doing in your practice?

9. Any other comments you would like to make are very welcome.

 

Thank you in advance for your help.  I will not be including any names in the summary information I provide to APA.  Although I haven’t written on this blog for a long time.  I continue to work on PQRS with others around the nation who work on PQRS issues for and on behalf of psychologists.  We are working to improve the process for psychologists and other providers. As you can imagine, working with CMS is a slow process.

Written by: Dori Ann Bischmann PHD

on behalf of the Advocacy Cabinet, Wisconsin Psychological Association.

 

 

PQRS Questions

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

Advocacy Cabinet

Wisconsin Psychological Association