PQRS Requirements for 2014

Despite recommendations to the contrary by many provider associations, CMS (12/13/13) made major changes to PQRS reporting starting in 2014.   Most PQRS eligible providers (EPs) will be required to report 9 PQRS measures covering at least 3 National Quality Strategy Domains (NQS).  There are a variety of ways to report measures, but I will only address claims based reporting because this is the only mechanism currently available to psychologists.  Note that CMS would like to move all EPs in the direction of registry reporting, but according to APA, there are currently no registries available to psychologists.  NQS domains are categories that CMS determined to be important in meeting the overall goal of improved medical services and outcomes.  The NQS domains are:  patient safety, person and caregiver centered experience and outcome, communication and care coordination, effective clinical care, community/population health, efficiency and cost reduction.

To avoid a 2% penalty in 2016 AND achieve a .5% incentive payment in 2015

• In 2014, report 9 measures covering at least 3 NQS domains on 50% of eligible fee for service (FFS) Medicare recipients (Medicare advantage plans are excluded).

To avoid a 2% penalty in 2016

•  In 2014, report at least 3 measures covering at least 1 NQS domain.

Medicare does provide a provision for those providers who have fewer than 9 available measures.  It is my opinion, that Medicare does not adequately spell out how they will distinguish EPs who are reporting less than 9 measures because of lack of availability versus those EPs who just don’t submit enough measures for one reason or another.

I have reviewed the measures list for 2014 and have found the following measures to be appropriate for psychologists.  My criteria included:  clinical procedures that we are trained to provide and claims based reporting.   I have grouped these measures by the NQS domain:

Effective Clinical Care

#106 Adult Major Depressive Disorder (MDD): comprehensive Depression Evaluation:  Diagnosis and Severity.

#107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

#247 Substance Use Disorders:  Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence

#248   Substance Use Disorders:  Screening for Depression Among Patients with Substance Abuse or Dependence

Patient Safety

#130 Documentation of Current Medications in the Medical Record

#181 Elder Maltreatment Screen and Follow-Up Plan

Community/Population Health

#131 Pain Assessment and Follow-Up

#134 Preventive Care and Screening:  Screening for Clinical Depression and Follow-Up Plan

#226 Preventive Care and Screening:  Tobacco Use:  Screening and Cessation Intervention

In summary, we have 9 measures appropriate for our discipline that cover 3 NQS domains.  There were a couple other measures that might be appropriate for specialized practices with Asthma and weight control.
Additional information to be aware of:

1.  If you don’t report on a particular measure during the year because you didn’t have an appropriate patient to report on, this measure will not be counted toward your goal of reporting 9 measures over 3 NQS domains.  For example, if none of your Medicare patients are over the age of 65, you are not eligible to screen for Elder Maltreatment and thus can not report this measure.  Likewise if you have no Medicare patients who have alcohol dependence, you would not be able to use the Substance Use disorders measures.

2.  Psychologists are currently not eligible to report measures via registry (we have no registry), Electronic Health Record (EHR: we are not eligible for EHR meaningful use at this time) or measures groups (changes were made in how measures groups are reported this year).

3.Please make sure your biller uses a charge of “$.01” rather than “$.00” when listing the PQRS measure.  As of 4/14, Medicare will treat these differently and they are encouraging all EPs to use “$.01” charge.

I will continue to research this information and bring you updates as I become aware of them.

Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)

Resources:

CMS (12/13/13).  2014 physician quality reporting system (PQRS) implementation guide.

CMS (12/13/13). 2014 Physician quality reporting system (PQRS) measures list.

Rosett, Amy (1/3/14).  2014 PQRS Reporting Summary.  Personal communication.

PQRS: Physicians Quality Reporting System-Part 5

Revised 3/13/13 to reflect new information received from APAPO state leadership conference (March, 2013)

This is part 5 of a series of blogs discussing PQRS.  In this blog, I will review one measure:  Elder Maltreatment Screen and Follow-Up Plan. 

Note:  PQRS is currently only mandatory for Medicare Providers.  Note also that these measures are subject to change without notice.  Please continue to check the AMA (American Medical Association) and CMS (Centers for Medicare & Medicaid services) website to make sure the measures you are using have not expired.  CMS is the source document for all measures and associated codes.  I found that AMA gives more detail and provides a worksheet for working on the measure.  I recommend the AMA information for new PQRS providers.

Medicare providers are required to “successfully” participate in PQRS in 2013.  Unsuccessful participation in 2013 will cause 1.5% and 2% penalties to be imposed in 2015 and 2016, respectfully.  For more information on the general aspects of PQRS, please consult the previous blog.

All PQRS measures can be found on the CMS and AMA website.  I reviewed the website and selected measures that I thought might be pertinent to my clinical practice.  I will present one measure here and explain how to use it.

General Instructions for all Measures:

1. Select measure(s) you will use.  If you are new to PQRS, you may choose to use only one measure.  If you are a continuing user of PQRS, you will continue to select 3 measures.
2. Follow the instructions for completing the measure.  Most measures require one assessment point, utilizing a standard measurement tool and at times a follow-up plan. 
3. Complete the measure with the patient. Complete the measure with enough patients to meet criteria, currently 50% per year.  I complete the measure on all patients which creates a routine and allows for missed assessments and/or missed coding without risk of missing the 50% completion criteria.
4. Document completion of the measure appropriately in the clinical record and send measure completion codes to your billing entity.  Medicare provides a Collection Sheet for each measure — or you can integrate the measure completion codes into your existing billing form.
5. Billing entity sends in measure completion codes with billing.
6. Keep all documents for your records.
7. Periodically double-check that your billing entity is sending in the measure completion codes.

Measure Options

Elder Maltreatment Screen and Follow-Up Plan (AMA, PQRS 2011 measure 181).

This measure is used for persons aged 65 years and older.  The provider assesses for elder maltreatment AND documents a follow-up plan. This measure should be reported at least once during the reporting period, but if reported via CPT assessment codes (96116), it should be reported each time the assessment code is submitted (use the G8535 code “pt not eligible” when reporting the second and subsequent times that you bill 96116). The maltreatment screen should include the following:  physical abuse, emotional or psychological abuse, neglect (active or passive), sexual abuse, abandonment, financial or material exploitation, self-neglect, and unwanted control.

Codes for reporting measure completion (Elder Maltreatment Screen and Follow-up Plan)

G8733:  Patient is screened for elder maltreatment covering all of the above areas and evidence of elder maltreatment is found and a follow-up plan is documented.  Clinician gets credit for completion.

G8734:  Maltreatment screen reveals no evidence of elder maltreatment, no follow-up plan is needed. Clinician gets credit for completion.

G8535:  Elder Maltreatment screen not completed. Patient is not eligible, e.g. patient refused or it is an urgent or emergent situation and screening at this time is not appropriate.  Clinician gets credit for completion.

G8536:  No documentation of elder maltreatment screen, reason not specified.  Clinician gets credit for completion of this measure.

G8735:  There is documentation of positive elder maltreatment screen, but there is no follow-up plan documented, reason not specified.  Clinician gets credit for completion of this measure.

Clinical Vignette

I assess an 80 y.o. woman in the hospital who is here after having fallen at home. Among other issues, the patient reports that she is depressed and anxious and has some concerns about home and her caregivers.  I complete an elder maltreatment screen and the patient indicates that she has frequent arguments with her caregivers and she believes that they are stealing money.  I also complete a mental status evaluation and determine that the patient is disoriented in some areas, forgetful and confused.  I determine that the patient is suffering from delirium, most likely related to a bladder infection.  In my initial eval, I note the patient’s stated concerns about her caregivers.  I also note that she is confused with probable delirium and that I cannot be certain that her report is reliable.  Nevertheless, I establish a plan to follow-up on possible elder maltreatment.  My plan would look something like this:  1. Continue to assess confusion and cognition and determine to what extent this impacts her reporting reliability.  As the bladder infection resolves, I would expect her delirium to resolve and perhaps her report of maltreatment resolves or perhaps it becomes even clearer. 2.  Since we are in a hospital setting, I would talk the issue over with the social worker so that we are both addressing and assessing this possible concern.  3.  With the patient’s permission, I would talk to collaterals, perhaps family if they weren’t the direct caregivers, to determine if they are aware of possible issues that might be pertinent,  4.  If the patient is cognitively capable, I would discuss strategies she could implement to keep herself safe such as doing a power of attorney for finances and healthcare, getting a trusted cosigner for her checkbook,  5. I might explore reporting this to formal authorities depending on the outcome of the prior steps. 

This vignette is not meant to exhaust all options, but rather to explore a common type of occurrence and provide a few follow-up examples.   I would use the following codes when billing:  90791 (for initial assessment, note that we have new codes in 2013, I used the new codes in this example), G8733 (this code indicates that I screened for elder maltreatment, the screen was positive and I documented a follow-up plan. Of course, I will continue to document any outcomes related to my ongoing assessment of this patient.  

Keep following this blog for more information on PQRS.

The Advocacy Cabinet

(Post by Dori Bischmann, PhD)

Resources:

CMS (2012).  2013 Physician Quality Reporting System (PQRS) measures list.  Available from CMS website. 

www.ama-assn.org:  Physician Quality Measure Reporting

www.apapracticecentral