PQRS in TRAKnet 2015 GUIDE TO SUBMIT TING AND REPORTING PQRS IN 2015 THROUGH TRAKNET

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1 PQRS in TRAKnet 2015 GUIDE TO SUBMITTING AND REPORTING PQRS IN 2015 THROUGH TRAKNET

2 What is PQRS? PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of quality information by individual EPs and group practices. Those who do not satisfactorily report data on quality measures for covered Medicare Beneficiaries will be subject to a negative payment adjustment under PQRS.

3 The Penalty The penalty for not reporting 2015 PQRS is 2% for solo providers and groups with 2-9 providers, and 4% for groups with 10 or more providers.

4 How can I avoid this penalty? EPs can avoid the 2017 PQRS negative payment adjustment by satisfactorily participating, according the following criteria: Report on at least 9 measures covering 3 NQS domains for at least 50% of the EP s Medicare Part B FFS patients, one of them must be on the list of the cross cutting measures. EPs that submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures covering less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure Applicability Validation process. EPs that see 1 Medicare patient (face-to face encounter), but do not report on 1cross-cutting measure will be subject to MAV. Measures with a 0% performance rate will not be counted.

5 How do I report? Claims-based reporting is readily accessible to EPs as it is a part of routine billing processes. However, it is not an option for PQRS group practices. There is no need to contact a registry or qualified EHR vendor to submit data, and it s simple to select measures and begin reporting by adding the respective Quality-Data Code [QDC] to the claim.

6 Principles for Reporting QDCs via Claims 1. QDCs must be reported: On the claim(s) with the denominator billing code(s) that represents the eligible Medicare Part B PFS encounter. For the same beneficiary. For the same date of service (DOS). By the same eligible professional (individual rendering NPI) that performed the covered service, applying the appropriate encounter codes (ICD-9-CM, ICD-10-CM, CPT Category I or HCPCS codes). These codes are used to identify the measure's denominator.

7 Principles for Reporting QDCs via Claims 2. QDCs must be submitted with a line-item charge of one penny ($0.01) at the time the associated covered service is performed. The submitted charge field cannot be blank. The line item charge should be $0.01 the beneficiary is not liable for this nominal amount. Entire claims with a $0.01 charge will be rejected. When the $0.01 nominal amount is submitted to the MAC, the PQRS code line will be denied but will be tracked in the National Claims History (NCH) for analysis.

8 Principles for Reporting QDCs via Claims 3. Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs.

9 Principles for Reporting QDCs via Claims 4. The RA/EOB denial code N620 is your indication that the PQRS codes are valid for the 2015 PQRS reporting year.

10 What codes should I submit? EPs must report 9 measures on at least 50% of their Medicare Part B FFS patients to avoid the penalty. A list of our suggested measures follows. Please note that these are simply suggestions and are NOT required. You may report any measure fitting your practice per CMS guidelines. A complete list of measures can be found on the CMS website here: Instruments/PQRS/MeasuresCodes.html

11 NQF 0059: Diabetes: HBa1c Poor Control PQRS # 1 Details: Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Denominator Criteria: Diagnoses of DM 250. and age 18-75, E&M. Numerator Criteria: Patients who's most recent HbA1c level (performed during the measurement period) is > 9.0%.

12 NQF 0059: Diabetes: HbA1c Poor Control Applicable Code: 3046F HbA1c > F w/ modifier 8P Not performed 3044F HbA1c < F HbA1c 7 9 Reporting Instructions: This must be reported once per reporting period.

13 NQF 0041: Screening for Influenza PQRS # 110 Details: Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Denominator Criteria: All patients aged 6 months and older seen for a visit between October 1 and March 31 with an E&M. Numerator Criteria: Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization.

14 NQF 0041: Screening for Influenza Applicable Code: G8482 Influenza administered or previously recorded G8483 Not administered: Patient allergy or declined G8484 Not administered: No reason Reporting Instructions: This must be done a minimum of once per reporting period.

15 NQF 0043: Pneumonia Vaccine PQRS # 111 Details: Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Denominator Criteria: Patients 65 years of age and older with a visit during the measurement period and with an E&M. Numerator Criteria: Patients who have ever received a pneumococcal vaccination.

16 NQF 0043: Pneumonia Vaccine Applicable Code: 4040F Pneumonia vaccine administered or previously recorded 4040F w/ modifier 8P Not administered with no reason Reporting Instructions: This must be done a minimum of once per reporting period.

17 NQF 0421: BMI Screening and F/U PQRS # 128 Details: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m2; Age years BMI 18.5 and < 25 kg/m2. Denominator Criteria: All patients 18 years old and older with an E&M during the reporting period. Numerator Criteria: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.

18 NQF 0421: BMI Screening and F/U Applicable Code: G8420 BMI within normal limits and no follow up G8419 BMI outside of normal limits and no follow up G8418 BMI below normal limits and follow up plan made with doctor G8417 BMI above normal limits and follow up plan made with doctor G8422 BMI not documented: patient not eligible G8938 BMI documented outside normal limits: patient not eligible G8421 BMI not documented with no reason given Reporting Instructions: This must be done a minimum of once per reporting period.

19 NQF 0419: Document Current Medications PQRS # 130 Details: Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)supplements AND must contain the medications name, dosage, frequency and route of administration. Denominator Criteria: All visits for patients aged 18 years and older. Numerator Criteria: Eligible professional attests to documenting, updating or reviewing a patient s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration.

20 NQF 0419: Document Current Medications Applicable Code: G8427 G8430 G8428 Patient medications have been reviewed Patient not eligible Patient medications not document Reporting Instructions: This measure is to be reported each visit during the 12 month reporting period.

21 NQF 0420: Pain Assessment PQRS # 131 Details: Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. Denominator Criteria: All visits for patients aged 18 years and older. Numerator Criteria: Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present. A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect.

22 NQF 0420: Pain Assessment Applicable Code: G8730 Pain (+) and a follow up has been documented G8731 Pain negative and a follow up is not required G8442 Pain not documented G8939 Pain (+) and no follow up documented, patient not eligible G8732 No pain documented, no reason G8509 Pain (+), follow up not documented Reporting Instructions: This measure is to be reported each visit during the 12 month reporting period.

23 NQF 0097: Medication Reconciliation PQRS # 46 Details: Medication Reconciliation: Percentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented. Denominator Criteria: All patients 18 years of age and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care and E&M. Numerator Criteria: Patients who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

24 NQF 0097: Medication Reconciliation Applicable Code: 1111F 1111F w/ modifier 8P Reporting Instructions: Medication Reconciliation Completed Medication Reconciliation not Completed This measure is to be reported at an outpatient visit occurring within 30 days of each inpatient facility discharge date during the reporting period.

25 NQF 0028: Preventative Care and Screening: Tobacco Use PQRS # 226 Details: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Denominator Criteria: All patients aged 18 years and older and E&M visit. Numerator Criteria: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user.

26 NQF 0028: Preventative Care and Screening: Tobacco Use Applicable Code: 4004F 1036F Patient screened for tobacco use AND received tobacco cessation intervention Nonuser 4004F w/ modifier 8P Reporting Instructions: This measure is to be reported once per reporting period. Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified

27 NQF 0101: Fall Risk Assessment PQRS # 154 Details: Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months Denominator Criteria: All patients aged 65 years and older who have a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient. And E&M codes. Numerator Criteria: Patients who had a risk assessment for falls completed within 12 months.

28 NQF 0101: Fall Risk Assessment Applicable Code: 3288F and 1100F Fall Risk Assessment documented and patient screened for future fall risk, documentation of two or more falls in the past year and any fall with injury in the past year 3288F w/ modifier 1P and 1100F 3288F w/ modifier 1P and 1100F w/ modifier 8P 3288F w/ modifier 8P and 1100F Not completed for medical reason and documented in chart, history of fall in the past year Not completed, no history of fall documented Not completed, documentation of falls in chart Other Performance Exclusion: 1101F Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year. If patient is not eligibile, report: 1101F with modifier 8P Reporting Instructions: This measure is to be reported a minimum of once per reporting period. No documentation of falls

29 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up PQRS # 317 Details: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. Denominator Criteria: All patients aged 18 years and older and E&M codes. Numerator Criteria: Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive.

30 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Applicable Code: G8783 G8950 G8784 G8785 G8952 G8951 BP within normal limits, no follow-up required Pre-Hypertensive or Hypertensive BP reading documented, AND the indicated follow-up is documented BP reading not documented, documentation that the patient is not eligible BP reading not documented, no reason given Pre-Hypertensive or Hypertensive BP reading documented, indicated follow-up not documented, reason not given Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation that the patient is not eligible Reporting Instructions: This measure is to be reported a minimum of once per reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow-up plan must be related to the current BP reading as indicated, example: Patient referred to primary care provider for BP management.

31 NQF 0056: Diabetes: Foot Exam PQRS # 163 Details: Percentage of patients aged years of age with diabetes who had a foot exam during the measurement period. Denominator Criteria: Patients aged who had a diagnoses of diabetes with a visit during the measurement period, diagnoses of 250.XX and an E&M code. Numerator Criteria: Patients who received a foot exam (ie, visual inspection, sensory exam with monofilament and pulse exam) during the measurement period.

32 NQF 0056: Diabetes: Foot Exam Applicable Code: G9226 Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam report when all 3 were completed) G9225 Reporting Instructions: Foot examination not performed, reason not given This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period.