PQRS 2014 Submission through the Surgeon Specific Registry

PQRS 2014 Submission through the Surgeon Specific Registry Continuous Quality Improvement Division of Research and Optimal Patient Care American College of Surgeons

About the SSR What is the SSR? The American College of Surgeons (ACS) Surgeon Specific Registry (SSR) is a web and mobile software application and database that allows surgeons to track their cases and outcomes in a convenient, easy-to-use manner. Why use the SSR for PQRS? The ACS recognized a need to help surgeons participate in an increasing number of regulatory programs for the individual provider. The SSR has incorporated surgical measures for PQRS submission for the individual surgeon.

SSR Regulatory Items The SSR addresses and helps surgeons fulfill several regulatory requirements in one registry, such as: - Maintenance of Certification (MOC) Part 4 American Board of Surgery (ABS) includes submission of cases American Board of Colon and Rectal Surgery (ABCRS) - Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS)

PQRS Penalties ± PROGRAM 2014 2015 2016 2017 2018 2019 2020 PQRS Value Based Payment Modifier* 0.5% incentive payment -1.5% -2% -2% -2% -2% -2% ---- -1% -2% up to -4% TBD TBD TBD Total Potential Penalty ---- -2.5-4% -6% TBD TBD TBD ± Penalties are applied two years after the performance year (e.g. lack of participation in 2014 will result in a penalty that will be applied in 2016) *The Value Based Payment Modifier (VM) hinges on PQRS participation. Lack of PQRS participation may also result in a VM penalty depending on group size

PQRS Participation Using the SSR The SSR is a PQRS-qualified registry PQRS Perioperative Care Measures Group was chosen for SSR inclusion because surgeons use it most frequently Surgeons needed more options for measure participation The General Surgery Measures Group was developed by ACS and approved by CMS for PQRS 2014 All measures within the group must be reported Measures must be reported for each of the surgeon s minimum required patients 20 total patients 11 Medicare Part B Fee for Service beneficiaries

2014 Perioperative Care Measures Group The Perioperative Care Measures Group may be submitted through the SSR for PQRS participation. Measure Name Domain 1. Timing of Prophylactic Parenteral Antibiotic Ordering Physician Patient Safety 2. Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin 3. Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) 4. Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Patient Safety Patient Safety Patient Safety

2014 General Surgery Measures Group The General Surgery Measures Group may be submitted through the SSR for PQRS participation. 1 Measure includes: Bariatric Laparoscopic or Open Roux-en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, and Colectomy 2 Measure includes: Ventral Hernia, Appendectomy, AV Fistula, Cholecystectomy, Thyroidectomy, Mastectomy +/- Lymphadenectomy or SLNB, Partial Mastectomy or Breast Biopsy/Lumpectomy +/- Lymphadenectomy or SLNB Measure Name Domain 1. Anastomotic Leak Intervention 1 (New for 2014) Effective Clinical Care 2. Unplanned Reoperation within the 30 Day Postoperative Period 1,2 (New for 2014) 3. Unplanned Hospital Readmission within 30 Days of Principal Procedure 1,2 (New for 2014) Effective Clinical Care Effective Clinical Care 4. Surgical Site Infection (SSI) 1,2 (New for 2014) Effective Clinical Care 5. Patient-Centered Surgical Risk Assessment and Communication (Patient-Specific Risk Calculator) (New for 2014) Person and Caregiver- Centered Experience and Outcomes

General Surgery Measures Group In addition to the General Surgery Measures, the following risk factor variables are required for all cases submitted for PQRS 2014. Risk Factor Variables 1. Age 6. Preoperative sepsis 2. ASA Class 7. Dyspnea 3. Emergent/urgent operation 8. Ascites 4. Functional status 9. Surgical approach 5. Wound class

Registering for the SSR Registration is available on the ACS website and you may access the registration guide in one of two ways: 1. You can either directly go to https://www.facs.org/qualityprograms/ssr/sw-reg/register 2. OR, you can go to https://www.facs.org Click on Quality Programs and under this you will find Surgeon Specific Registry. Under SSR select the Software and Registration link at which point you will be taken to a new page. On the Software and Registration page and at the bottom of the menu at the left-hand corner, select the Registration Guide link which will bring you directly to the Registration Guide page.

Registering for the SSR https://www.facs.org/quality-programs/ssr/sw-reg/register

Registering for the SSR ACS Surgeon Members To get started, click on the login link found under the How to Register section of the Registration Guide page under ACS Surgeon Members. This link will take you to a registration form. Complete the necessary information in the registration form. Upon completion of the registration form, you will automatically be brought to the login page at https://acspbls.resiliencesoftware.com/ If you are not brought directly to this page, you can always go back to the Registration Guide page and find the same link above that will also bring you directly to the login page. Once you are at the login page, enter your username and password. If you have not gone into the system before, it will prompt you to agree to the Participation Agreement and Business Associate Agreement.

Registering for the SSR ACS Surgeon Members https://www.facs.org/quality-programs/ssr/sw-reg/register

Registering for the SSR Non-ACS Surgeon Members To get started, click on the purchase link found under the How to Register section of the Registration Guide page under Non-ACS Surgeon Members. Click the Add to my cart button. Once you have added the SSR to your cart, click on the View Cart tab. Click on the Checkout button to purchase the $299 annual subscription. You will receive an e-mail confirmation after purchasing the subscription. Activation to the SSR will require one business day. When your account is activated, you will receive an e-mail with instructions on next steps. For your reference, the login page is available at https://acspbls.resiliencesoftware.com/

Registering for the SSR Non-ACS Surgeon Members https://www.facs.org/quality-programs/ssr/sw-reg/register

Logging into the SSR https://acspbls.resiliencesoftware.com/

Consenting to PQRS through the SSR Hover your mouse over the PQRS tab at the top and click on the Participation and Submission tab.

Measures Group Specifications You may access important PQRS resources including a link to the specifications manual. The manual includes eligible CPT codes, measures definitions, and other program specifications for your review. Use this document to decide which measures group you will select for PQRS submission.

Measures Group Specifications

PQRS Submission Timeline

Consenting to PQRS through the SSR In order to participate in PQRS you must first go through the consenting process. To get started with that you must access your Participation Management page in the SSR. Select Participation and Submission from the drop-down menu under the PQRS tab (2 nd tab located at the top). This will take you directly to your Participation Management page, which will serve as your home page for PQRS submission. On the PQRS Participation Management page, select the link Agree to Participate found under Configuration. This link will bring you to the required consent form.

Consenting to PQRS through the SSR

Consenting to PQRS through the SSR Scroll to the bottom of the consent form and you will see that there is some required information to be filled in. You must provide the following information: Your Individual National Provider ID (NPI)* Your Taxpayer ID Number (TIN)** The Measures Group you will be selecting The Reporting Period is 2014 for all participants *(NOTE: your Individual NPI must be your own personal NPI and NOT your Hospital s or Group s NPI. If you use the NPI of your Hospital or Group, CMS will deem it as an unsuccessful submission.) **(NOTE: your TIN number must be the one that is used to bill your Medicare Part B Fee for Service beneficiaries. If you submit the incorrect TIN number, CMS will deem it as an unsuccessful submission.)

Consenting to PQRS through the SSR

Consenting to PQRS through the SSR Once you have entered all of the correct information, click on the Register button and you will be brought back to the PQRS Participation Management page. At the top of the page there will be an indication that your PQRS participation has been saved. Also, under Configuration you will see: 1. All of the information you have just entered is now displayed, and 2. You now have the available options to either update or cancel your participation should you choose to do so at a later time.

PQRS Participation Management

Entering Perioperative Care Measures Group Creating a New Case To enter measures data for the Perioperative Care Measures Group, you must create a new case. You can do this by either: 1. Clicking on the Create a new case link under Cases 2. OR, you can go to the first tab at the top of the page labeled Cases and select Create under the drop-down menu. Either of these links will bring you to the case form.

Entering Perioperative Care Measures Group Creating a New Case

Entering Perioperative Care Measures Group Required Data Fields In the case form there are a select number of fields that are minimally required to complete the form for PQRS submission. These fields are: Medical Record Number (MRN) Medicare Part B* Date of Birth Procedure Date *(NOTE: this check box must only be marked if the patient is one of the 11 required Medicare Part B that you have chosen for PQRS submission.) The next required piece of data will be the eligible CPT code.

Entering Perioperative Care Measures Group Required Data Fields

Entering Perioperative Care Measures Group Entering the CPT Code To enter in the eligible CPT code, scroll down the case form until you get to the Procedures section. There are four ways to enter in your CPT code: 1. Browse function selecting this feature will bring up a pop-up menu with all of the CPT codes available. 2. Search box this feature will allow you to directly enter in the CPT code if you already have it available. Simply type in the code, press enter, and the field will automatically be populated. 3. Hotlist this feature will retain all of your most frequently used CPT codes. 4. Nicknames this is a programmable feature that allows surgeons to use familiar clinical language to describe your CPT code.

Entering Perioperative Care Measures Group Entering the CPT Code

Entering Perioperative Care Measures Group Entering the Measures Data Once you have entered an eligible CPT code you will see the four measures for the Perioperative Care Measures Group. At this point you will have to submit the measures data for each of the measures. (NOTE: if you hover the icon over each of the four measures, a small pop-up text box will appear with a brief definition for each measure.)

Entering Perioperative Care Measures Group Entering the Measures Data

Entering Perioperative Care Measures Group Completing/Saving a Case Once you have completed all of the data for the measures, scroll down to the bottom of the case form and select the Case Complete button (also located at the top of the case form). You MUST select this button for PQRS purposes to indicate that you are approving the case for PQRS submission. If you do not select the Case Complete button, then the case will be deemed as incomplete. Below the Case Complete button are three options to save the case. As soon as you save the case, you will be brought back to your View Cases form. From this page you will be able to go back and edit cases as well as manipulate how to sort your cases.

Entering Perioperative Care Measures Group Completing/Saving a Case

Entering Perioperative Care Measures Group

Submitting for Perioperative Care Measures Group Preparing for PQRS Submission After submitting all 20 of your cases, you will want to make sure that you have completed everything correctly. Go back to your PQRS Participation Management page under the PQRS tab. Select View and complete your eligible cases under Cases. This will bring you to a page with a report detailing your eligible cases and missing data. At the top of the page will be a summary of data and below that you will see the individual cases listed out in a table. Any cases with missing data will indicate the missing piece/s of data in red type.

Submitting for Perioperative Care Measures Group Preparing for PQRS Submission

Perioperative Care Measures Group Eligible Cases/Missing Data Report

Submitting for Perioperative Care Measures Group Editing Cases for Completion To edit a case with missing data, click on the pencil icon located in the left most column of the table list. This pencil icon button will take you directly to the case form where you can update the missing case data. REMEMBER, in addition to selecting the Case Complete button, the absolute minimum amount of required data for PQRS submission includes the following fields: Medical Record Number (MRN) Medicare Part B (only if patient is one of the required 11) Date of Birth Procedure Date CPT code Four Perioperative Care measures data

Submitting for Perioperative Care Measures Group Editing Cases for Completion

Submitting for Perioperative Care Measures Group PQRS Submission Once you have updated and completed all of your cases for submission, go back to the PQRS Participation Management page. Select the Approve Submission (deadline: Jan 31, 2015) link under Submissions to approve and complete your PQRS submission for 2014.

Submitting for Perioperative Care Measures Group PQRS Submission

Entering General Surgery Measures Group Creating a New Case To enter measures data for the General Surgery Measures Group you must create a new case using the Speedform. You can do this by either: 1. Clicking on the Create a new case using the speedform link under Cases 2. OR, you can go to the PQRS tab at the top of the page select Speedform from under the drop-down menu. Either of these links will bring you to the Speedform.

Entering General Surgery Measures Group Creating a New Case

Entering General Surgery Measures Group Using the Speedform Once you have been brought to the Speedform you must enter the necessary demographic information under the Patient section. Below you will find the Risk Factors section where you will enter your data. Further below you will see the Procedure section where you will find what Procedure information you will need to collect. This information will include: CPT code Date of procedure Additional risk factor variables

Entering General Surgery Measures Group

Entering General Surgery Measures Group Using the Speedform If you scroll further down to the bottom of the Speedform, you will find the section where you can see the five required measures in the General Surgery Measures Group. Enter in the appropriate data for each measure. After you have filled out the Speedform you must make sure that the case is complete before you save it. At the very bottom of the form you will find the option to select whether or not the case is complete. Once you have indicated that the case is complete, click the Save button and you will be brought back to your View Cases form.

Entering General Surgery Measures Group

Submitting for General Surgery Measures Group Preparing for PQRS Submission Again, from the View Cases page you will be able to go back and edit cases as well as manipulate how to sort your cases. You may go back to a specific case by clicking on the lightning bolt icon in the PQRS column on the left-hand side of the table list. After submitting all 20 of your cases, you will want to make sure that you have completed everything correctly. Go back to your PQRS Participation Management page under the PQRS tab. Select View and complete your eligible cases under Cases. This will bring you to a page with a report detailing your eligible cases and missing data. At the top of the page will be a summary of data and below you will see the individual cases listed out in a table. Any cases with missing data will indicate the missing piece/s of data in red type.

Submitting for General Surgery Measures Group Preparing for PQRS Submission

Submitting for General Surgery Measures Group Editing Cases for Completion To edit a case with missing data, click on one of the two icons (lightning bolt & pencil) in the left most column of the table list. The lightning bolt icon will bring you to the Speedform The pencil icon will take you to the regular case form. It is highly recommended that you use the Speedform to update any missing information to complete the case.

Submitting for General Surgery Measures Group Editing Cases for Completion

Submitting for General Surgery Measures Group PQRS Submission Once you have updated and completed all of your cases for submission, go back to the PQRS Participation Management page. Select the Approve Submission (deadline: Jan 31, 2015) link under Submission to approve and complete your PQRS submission for 2014.

Submitting for General Surgery Measures Group PQRS Submission

Questions SSR Program Questions SSR@facs.org Bianca Reyes breyes@facs.org (312) 202-5635 PQRS Questions Sana Gokak, MPH sgokak@facs.org (202) 672-1517 Resilience Software caseloghelp@facs.org (866) 694-2323