THE 2013 PROPOSED MEDICARE PHYSICIANS FEE SCHEDULE AND THE PHYSICIAN QUALITY REPORTING SYSTEM

Transcription

1 September VOLUME 22 No. 9 THE 2013 PROPOSED MEDICARE PHYSICIANS FEE SCHEDULE AND THE PHYSICIAN QUALITY REPORTING SYSTEM CMS regards physicians as the prime movers in healthcare and firmly believes that in order to improve quality physicians must be fully engaged in the Physician Quality Reporting System (PQRS). Physician participation in the PQRS is the core element of the soon to be implemented Value Based Payment Modifier (VBPM). Under current regulations there will be a financial penalty of 1.5% of their total allowed Medicare charges for physicians who do not report CMS quality metrics in the 2013 calendar year. This penalty would be levied against their 2015 billings. CMS has also established CY 2013 as the performance period for the determination of the Value Modifier to be applied in CY In the first phase of VBPM implementation, CMS is proposing that groups of physicians with 25 or more eligible professionals would be subject to the payment adjustment. These groups would be identified by the number of individuals, characterized by their National Provider Identifier (NPI), billing under a single Tax Identification Number (TIN). Physician groups can avoid all negative adjustments simply by participating in the PQRS. Groups of physicians with 25 or more eligible professionals that fail to meet the PQRS satisfactory reporting criteria in 2013 would be subject to downward adjustments on their total estimated Medicare Part B PFS allowed charges for covered professional services during 2015 of 1.5 percent for not being a satisfactory reporter under the PQRS and 1.0 percent for the Value Modifier. There are two ways a physician or other eligible professional can participate in the PQRS, as an individual or as part of a group practice participating in the PQRS group practice reporting option (GPRO). In the current CMS notice, CMS is proposing to change the number of eligible professionals comprising a group practice from 25 or more to 2 or more to allow groups of smaller sizes to participate in the GPRO. The proposal would define group practice as a single Tax Identification Number with two or more eligible professionals, as identified by their individual National Provider Identifier. An Individual may choose between reporting on individual measures or on a measures group. The WASHINGTON WATCHLINE is published monthly and provides timely information to NAMDRC members on pending legislative and regulatory issues that impact directly on the practice of pulmonary medicine NAMDRC s primary mission is to improve access to quality care for patients with respiratory disease by removing regulatory and legislative barriers to appropriate treatment. INSIDE THIS ISSUE About NAMDRC NAMDRC Application NAMDRC Leadership....7 Product and Technology News...8 NAMDRC 8618 Westwood Center Drive, Suite 210 Vienna, VA Phone: Fax: ExecOffice@namdrc.org "NAMDRC will directly affect your practice more than any other organization to which you belong."

2 September 2012 VOLUME 22 NO 9 PAGE 2 Reporting may be on Medicare Part B claims, to a qualified Physician Quality Reporting registry, to CMS via a qualified electronic health record (EHR) product or to a qualified Physician Quality Reporting data submission vendor Program reporting requirements for individuals: Claims-based Reporting Options: Report at least 3 individual measures, OR, if less than 3 measures apply to the eligible professional, report 1 2 measures, AND report each measure for at least 50 percent of the Medicare Part B FFS patients for12 months or: Report at least one measures group for 30 unique Medicare Part B FFS patients for12 months or: Report at least one measures group for 50% or more of applicable Medicare Part B FFS patients of each eligible professional with a minimum of 15 patients for12 months. Registry-based Reporting Options: Report on at least 3 individual measures for 80% or more of applicable Medicare Part B FFS patients for12 months or: Report at least one measures group for 30 unique Medicare Part B FFS patients for12 months or: Report at least one measures group for 80% or more of applicable Medicare Part B FFS patients with a minimum of 15 patients for12 months or: Report at least one measures group for 80% or more of applicable Medicare Part B FFS patients with a minimum of 8 patients for 6 months (July 1 to December 31). Direct EHR-based Reporting Options: Report at least 3 individual Physician Quality Reporting measures for 80% or more of applicable Medicare Part B FFS patients for12 months or: Report a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures for 12 months. EHR Data Submission Vendor Reporting Options: Report at least 3 individual Physician Quality Reporting measures for 80% or more of applicable Medicare Part B FFS patients for 12 months or: Report a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures for 12 months. Program reporting requirements for those choosing to report as a group: Claims-based Reporting: Report at least 3 individual measures, AND Report each measure for at least 50 percent of the group practice s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Registry-based Reporting: Report at least 3 measures, AND Report each measure for at least 80 percent of the group practice s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Direct EHR-based Reporting: Option 1: Eligible professionals in a group practice must report on three Medicare EHR Incentive Program core or alternate core measures, plus three additional measures. Option 2: Report at least 3 measures, AND Report each measure for at least 80 percent of the group practice s Medicare Part B FFS patients seen during the reporting period to which the measure applies. EHR Data Submission Vendor Reporting: Option 1: Eligible professionals in a group practice must report on three Medicare HER Incentive Program core or alternate core measures, plus three additional measures. Option 2: Report at least 3 measures, AND Report each measure for at least 80 percent of the group practice s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

3 September 2012 VOLUME 22 NO 9 PAGE Individual Quality Measures: For the 2013 reporting period CMS is proposing to remove 14 measures from the 2012 PQRS, including: CMS #57 Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation. CMS #58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status. CMS #124 Adoption/Use of Electronic Health Records (EHR). CMS #196 Coronary Artery Disease (CAD): Symptom and Activity Assessment. CMS #199 Heart Failure: Patient Education. CMS #235 Hypertension (HTN): Plan of Care. CMS is proposing a total of 264 measures in Of these proposed measures, 250 were previously established for reporting under the 2012 PQRS. The 14 newly proposed measures include: CMS #TBD Participation by a Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality. CMS #TBD Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy. For the 2014 reporting period, CMS is proposing to retire 8 measures that were previously established for reporting under the 2012 PQRS including. CMS # 200 Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation. CMS # 237 Hypertension (HTN): Blood Pressure Measurement. CMS #308 Medical Assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies. 34 new measures are being proposed for the 2014 reporting period. These include: CMS # TBD Preventive Cardiology Composite: Blood Pressure at Goal, Low Density Lipids (LDL) Cholesterol at Goal, Timing of Lipid Testing Complies with Guidelines, Diabetes Documentation or Screen Test, Correct Determination of Ten- Year Risk for Coronary Death or Myocardial Infarction, Counseling for Diet and Physical Activity, Appropriate Use of Aspirin or Other Antiplatelet/Anticoagulant Therapy, Smoking Status and Cessation Support. CMS #TBD Hypertension: Improvement in blood pressure. CMS # TBD Closing the referral loop: receipt of specialist report. CMS # TBD Prevention and Monitoring: Warfarin Time in Therapeutic Range. To align with the proposed measure domains provided in the EHR Incentive Program, CMS is now grouping all proposed individual PQRS measures into six domains based on the National Quality Strategy s six priorities: (1) Patient and Family Engagement (2) Patient Safety (3) Care Coordination (4) Population and Public Health (5) Efficient Use of Healthcare Resources (6) Clinical Processes/Effectiveness For the 2013 reporting year individual measures related to chest medicine include: Patient safety: CMS #23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis. CMS #46 Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility. CMS #76 Prevention of Catheter-Related Bloodstream Infections: Central Venous Catheter Insertion Protocol. CMS #130 Documentation of Current Medications in the Medical Record.

4 September 2012 VOLUME 22 NO 9 PAGE 4 Care Coordination: CMS #TBD Participation by a Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality. CMS #TBD Coordination of Care of Patients with Co-Morbid Conditions - Timely Follow-Up. Clinical Process/Effectiveness: Cardiac CMS #5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD). CMS #6 Coronary Artery Disease (CAD): Antiplatelet Therapy. CMS #7 Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI). CMS #8Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD). CMS #28 Aspirin at Arrival for Acute Myocardial Infarction (AMI). CMS #197 Coronary Artery Disease (CAD): Lipid Control. CMS #198 Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment. CMS #228Heart Failure (HF): Left Ventricular Function (LVF) Testing. CMS #200 Heart Failure: WarfarinTherapy for Patients with Atrial Fibrillation. CMS #242 Coronary Artery Disease (CAD): Symptom Management. Hypertension CMS #236 Hypertension: Blood Pressure Management. CMS #237 Hypertension (HTN):Blood Pressure Measurement. CMS #295 Hypertension: Appropriate Use of Aspirin or Other Antiplatelet or Anticoagulant Therapy. CMS #296 Hypertension: Complete Lipid Profile. CMS #297 Hypertension: Urine Protein Test. CMS #298 Hypertension: Annual Serum Creatinine Test. CMS #299 Hypertension: Diabetes Mellitus Screening Test..CMS #301 Hypertension: Low Density Lipoprotein (LDL-C) Control: CMS #300 Hypertension (HTN): Controlling High Blood Pressure. Asthma CMS #53 Asthma: Pharmacologic Therapy for Persistent Asthma. CMS #64 Asthma: Assessment of Asthma Control. CMS #232 Asthma: Tobacco Use: Intervention - Ambulatory Care Setting. CMS #231 Asthma: Tobacco Use: Screening - Ambulatory Care Setting. CMS #311 Use of Appropriate Medications for Asthma. Chronic Obstructive Pulmonary Disease CMS #51 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation. CMS # 52 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy. Pneumonia CMS #56 Community-Acquired Pneumonia (CAP): Vital Signs. CMS #59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic. CMS #111Pneumonia Vaccination for Pa Sleep Apnea CMS #276 Sleep Apnea:Assessment of Sleep Symptoms. CMS #277 Sleep Apnea: Severity Assessment at Initial Diagnosis. CMS #278 Sleep Apnea: Positive Airway Pressure Therapy Prescribed. CMS #279 Sleep Apnea:Assessment of Adherence to Positive Airway Pressure Therapy. Anticoagulation CMS #252 Anticoagulation for Acute Pulmonary Embolus Patients. CMS #31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage.

5 September 2012 VOLUME 22 NO 9 PAGE 5 Population/Public Health CMS #317 Preventive Care and Screening: Screening for High Blood Pressure. CMS #110 Preventive Care and Screening: Influenza Immunization. CMS #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up. CMS #308 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. Efficiency CMS #116 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Antibiotic Use. A chart with the corresponding Quality-Data Codes to be entered on claims is available from the NAMDRC Executive Office. To obtain a copy, please the Executive Office at vickie@namdrc.org. Please be aware that reporting fewer than 3 individual measures via the claims-based reporting mechanism will subject the physician to the Measures Applicability Validation (MAV) process, which will allow CMS to determine whether additional related measures should have been reported. Under the MAV process, if an eligible professional reporting on fewer than 3 measures reports on a measure that is part of an identified cluster of closely related measures in the opinion of CMS, then the eligible professional would not qualify as a satisfactory reporter for the 2013 incentives. As an alternative to the individual measures, one could elect to report a single Measure Group. For 2013 the Measures Groups available for reporting include: Asthma Measures Group: This measures group is reportable through both claims and registry-based reporting. CMS #53 Asthma: Pharmacologic Therapy for Persistent Asthma: Percentage of patients aged 5 through 50 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment. CMS #64 Asthma: Assessment of Asthma Control: Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms. CMS #231 Asthma: Tobacco Use: Screening - Ambulatory Care Setting: Percentage of patients (or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were queried about tobacco use and exposure to second hand smoke within their home environment at least once during the one-year measurement period. CMS #232 Asthma: Tobacco Use: Intervention - Ambulatory Care Setting: Percentage of patients (or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were identified as tobacco users (patients who currently use tobacco AND patients who do not currently use tobacco, but are exposed to second hand smoke in their home environment) who received tobacco cessation intervention at least once during the one-year measurement period. Chronic Obstructive Pulmonary Disease Measures Group: This measures group is reportable through both claims and registry-based reporting. CMS #51 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented. CMS #52 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy: Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70 percent and have symptoms who were prescribed an inhaled bronchodilator. CMS #110 Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older who received an influenza immunization during the flu season (October 1 through March 31). CMS #111Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older: Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine. CMS #226 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.

6 September 2012 VOLUME 22 NO 9 PAGE 6 Sleep Apnea Measures Group: This measures group is reportable through registry-based reporting only CMS #276 Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness. CMS #277 Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis. CMS #278 Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy. CMS #279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured. To initiate reporting of measures groups by claims-based submissions submit by using the measures group-specific intent G-codes which will indicate your intention to begin reporting on a measures group. It is not necessary to submit the measures group-specific intent G-code on more than one claim. It is not necessary to submit the measures group-specific intent G-code for registry-based submissions. Claims G-codes G8546: I intend to report the Community-Acquired Pneumonia (CAP) Measures Group G8645: I intend to report the Asthma Measures Group G8898: I intend to report the Chronic Obstructive Pulmonary Disease (COPD) Measures Group When choosing to report on a measures group you may report quality-data codes on each of the measures within the measures group for each patient included in the sample population or you can report one composite G-code if all quality actions for the applicable measures in the measures group have been performed. The applicable G-codes are: Composite G-code G8646: All quality actions for the applicable measures in the Asthma Measures Group have been performed for this patient. Composite G-code G8757: All quality actions for the applicable measures in the COPD Measures Group have been performed for this patient. Composite G-code G8759: All quality actions for the applicable measures in the Sleep Apnea Measures Group have been performed for this patient. The Electronic Prescribing Incentive Program Hardship Exemptions: From 2012 through 2014, The Electronic Prescribing (erx) Incentive Program applies a payment adjustment to those physicians who do not meet CMS criteria as successful electronic prescribers. For purposes of this program, physicians are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN). In the 2012 Physicians Fee Schedule CMS recognized four circumstances under which an eligible professional could request consideration for a hardship exemption for the erx payment adjustments: The eligible professional or group practice practices in a rural area with limited high speed internet access. The eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing. The eligible professional or group practice is unable to electronically prescribe due to local, state, or Federal law or regulation. The eligible professional or group practice has limited prescribing activity, as defined by an eligible professional generating fewer than 100 prescriptions during a 6-month reporting period.

7 September 2012 VOLUME 22 NO 9 PAGE 7 After further review, CMS is proposing two additional exemptions for the 2013 and 2014 erx payment adjustments. CMS believes that in certain circumstances it may be a significant hardship for eligible professionals and group practices who are participants of the EHR Incentive Program to comply with the successful electronic prescriber requirements of the erx Program EXECUTIVE COMMITTEE AND BOARD OF DIRECTORS OFFICERS Lynn T. Tanoue, MD President Dennis E. Doherty, MD President-Elect Timothy A. Morris, MD Secretary/Treasurer Steve G. Peters, MD Past President BOARD OF DIRECTORS Charles W. Atwood, MD Peter C. Gay, MD Nicholas S. Hill, MD James P. Lamberti, MD Thomas M. Siler, MD Maida V. Soghikian, MD PRESIDENT S COUNCIL George G. Burton, MD John Lore, MD Louis W. Burgher, MD, Ph.D. Alan L. Plummer, MD E. Neil Schachter, MD Joel M. Seidman, MD Frederick A. Oldenburg, Jr., MD Paul A. Selecky, MD Neil R. MacIntyre, MD Steven M. Zimmet, MD Joseph W. Sokolowski, MD Peter C. Gay, MD Steve G. Peters, MD Eligible professionals or group practices who achieve meaningful use of EHR during certain erx payment adjustment reporting periods. Eligible professionals or group practices who demonstrate intent to participate in the EHR Incentive Program and adoption of Certified EHR Technology. CMS is proposing a deadline of October 15, 2012 for the submission of these exemption requests. However, they confess that they may be unable to finalize the proposals by that date. If such is the case, they plan to extend the October 15, 2012 deadline to the effective date of the CY 2013 Medicare PFS final rule which would be January 1, For the 2014 erx payment adjustment they are proposing that the deadline for submitting the exemption requests would be June 30, The current avenue for submitting the hardship exemption requests is via the Communication Support Page: communications_support_system/234 In the 2013 proposed rule, CMS is considering accepting significant hardship exemption requests through the Registration and Attestation System for the EHR Incentive Program and via a mailed letter to CMS using the following address: Centers for Medicare & Medicaid Services, Office of Clinical Standards and Quality, Quality Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S , Baltimore, MD ************************************************************* EXECUTIVE DIRECTOR Phillip Porte ASSOCIATE EXECUTIVE DIRECTOR Karen Lui, RN, MS DIRECTOR MEMBER SERVICES Vickie Parshall Don t forget.mark you calendars for the 36th NAMDRC Annual Meeting and Educational Conference to be held March 21 March 23, 2013 at the US Grant Hotel in San Diego, CA!!

8 September 2012 VOLUME 22 NO 9 PAGE 8 PRODUCT AND TECHNOLOGY NEWS! NAMDRC is providing this space to our benefactors and patrons who provide us with information about new products and innovations related to pulmonary medicine. NAMDRC reserves the right to edit this copy as appropriate. THE FOLLOWING INFORMATION HAS BEEN SUBMITTED BY GREG SPRATT, DIRECTOR OF CLINICAL MARKETING AT ORIDION CAPNOGRAPHY. Joint Commission Releases Sentinel Event Alert on Safe use of opioids in hospitals Opioids, frequently given to patients for pain management, may be associated with increased risk for dangerous complications from respiratory depression. The Joint Commission s newly published Sentinel Event Alert on Safe use of opioids in hospitals addresses these risks by urging hospitals to establish procedures for accurate pain-level assessment as well as continuous monitoring of patients blood oxygenation and ventilation through pulse oximetry and capnography. The Joint Commission s guidelines align with recommendations issued by the Anesthesia Patient Safety Foundation (APSF) and the Institute for Safe Medication Practices (ISMP) calling for continuous monitoring of ventilation of hospitalized patients receiving opioids postoperatively.

9 September 2012 VOLUME 22 NO 9 PAGE 9 NAMDRC MEMBERSHIP BENEFITS AT A GLANCE... Monthly publication of the Washington Watchline, providing timely information for practicing physicians; Publication of Current Controversies focusing on one specific Pulmonary/Critical Care Issue in each publication; Regulatory updates; Discounted Annual Meeting registration fees; The Executive Office Staff as a resource on a wide range of clinical and management issues; and The knowledge that NAMDRC is an advocate for you and your profession. One of NAMDRC s primary reasons for existence is to provide both clinicians and patients with the most up-to-date information regarding pulmonary medicine. Bookmark this page! The complexity of our nation s health care system in general, and Medicare in particular, create a true challenge for physicians and their office staffs. One of NAMDRC s key strengths is to offer assistance on a myriad of coding, coverage and payment issues. In fact, NAMDRC members indicate that their #1 reason for belonging to and continuing membership in the Association is its voice before regulatory agencies and legislators. That effective voice is translated into providing members with timely information, identifying important Federal Register announcements, pertinent statements and notices by the Centers for Medicare and Medicaid Services, the Durable Medical Equipment Regional Carriers, and local medical review policies. ABOUT NAMDRC: Established over three decades ago, the National Association for Medical Direction of Respiratory Care (NAMDRC) is a national organization of physicians whose mission is to educate its members and address regulatory, legislative and payment issues that relate to the delivery of healthcare to patients with respiratory disorders. NAMDRC members, all physicians, work in close to 2,000 hospitals nationwide, primarily in respiratory care departments and critical/intensive care units. They also have responsibilities for sleep labs, management of blood gas laboratories, pulmonary rehabilitation services, and other respiratory related services.

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