Laura W. Groshong, LICSWDirector, Government Relations

April 26, 2014, 12-1 pm EDT

PQRS for LCSWs

Disclaimer CSWA has done its best to collect accurate

information on the information provided in this webinar. There will undoubtedly be changes to the Physician Quality Reporting System going forward, which will modify the information presented here in the future. CSWA will provide additional information as it becomes available.

Get Ready for a Wild RideLearning about the new concepts which will

anchor mental health and health care reimbursement will revise many concepts we have worked by for decades

Areas to be Covered

Business Plans for LCSWs as Context

Physician Quality Record Systems (PQRS)

Changes to Health Care

The End of the World as We Know It?

Therapists considering dropping out of solo practice to join groups: “The increasing complexity of running a practice has meant more therapists are taking down their shingles or forming groups with other therapists to share the burden, executives at national mental health groups say. Others have joined large medical groups that offer mental health services as part of comprehensive care.” (NPR.org, 10/24/13) http://www.npr.org/blogs/health/2013/10/24/234737302/therapists-explore-dropping-solo-practices-to-join-groups?goback=%2Egde_4267431_member_5799134027814297601#%21

Biggest Health Care Changes

Massive changes in health care delivery

‘Out of network’ reimbursement likely to end in next 5 years; instead in-network, new risk sharing systems (ACOs, health homes) or private pay

In 5-10 years LCSWs working with third-party payers are likely to be required to do record keeping through interoperable electronic systems

Impact of Affordable Care Act and

Mental Health Parity Act“Integrated care” in ACA likely to lead to

LCSWs working in virtual clinic-like organizations in capitated systems

Cost of hiring billers and/or buying EHRs may make joining groups more appealing to cover administrative costs

Parity will make mental health more integrated into medical care, but up to LCSWs to explain what mental health treatment needed

More marketing necessary for clinicians who want to remain in private pay system

From FFS to P4P –Underlying Goal

Medicare goal to end fee-for-service (FFS) payment, go to pay for performance (P4P) – likely to be adopted by private insurers

Less treatment and better outcomes lead to higher reimbursement rates

Role of insurers unclear as ACOs/health homes roll out

For now, LCSWs need to learn how to explain mental health treatment needs, esp. long-term

LCSWs and Overall Changes to Health Care Reimbursement

We feel that we are being locked into systems which are at odds with being in control of our own practices

Unlock the Changes:New Business Plans for LCSWs

Business plan good base for all new health service delivery changes

Courses offered by SAMHSA: Strategic Business Planning; Third-party Billing and Compliance; Eligibility and Enrollment; Third-party Contract Negotiation; and Meaningful Use of Healthcare Technology (not for clinicians at this time)

Go to http://bhbusiness.org/Special-pages/Home.aspx to register!

New Business Plans for LCSWs (cont.)

Another option for learning to navigate new business models:

Behavioral Health First Aid at http://bhbusiness.org/Special-pages/Home.aspx

Consultants on Clinical Business Practices

Rob Reinhardt, LPC – EHRs – www.tameyourpractice.com

Steve Walfish, PsyD – business practices - Financial Success in Mental Health Practice:  Essential Tools and Strategies for Practitioners (2008); Earning a Living Outside of Managed Mental Health Care: 50 Ways to Expand Your Practice (2010) - http://thepracticeinstitute.com/the-tpi-team

On to Physician Quality Reporting System (PQRS)

Climbing the PQRS mountains…..

PQRS is Part of MedicareLCSWs are automatically part of the Medicare

provider network HOWEVERTo become eligible for reimbursement, LCSWs

must “opt in” through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf

LCSWs Can Opt Out of Medicare

If an LCSW decides not to become part of the Medicare provider network, the LCSW must do two things:

- The LCSW must send an “Opt Out Form” to the Medicare Administrative Center (MAC) that oversees the LCSW’s region (see CSWA website)

- The LCSW must send an exact copy of the “Medicare Private Contract” that the LCSW will use with any Medicare beneficiary to guarantee that no claims will be submitted by the LCSW or the beneficiary for the LCSW’s services

LCSWs Can Opt Out of Medicare (cont.)

No templates of Opt Out Form or Private Medicare Contract provided by CMS

Editable templates of the Opt Out Form and the Private Medicare Contract can be found in the Members Only Section of the CSWA website: (www.clinicalsocialworkassociation.org)

Go to CSWA Templates to downloadCan join CSWA on website and access

Templates

Physician Quality Reporting System (PQRS)

Started as Physician Quality Reporting Initiative in 2007

Changed to PQRS in 2010PQRS which will provide ‘incentive’ (bonus)

for data submitted in 2013 and 2014 two years later, i.e., 2015 and 2016 of .5%

PQRS will also provide ‘payment adjustment’ (penalties) if reporting threshold is not met

CMS Guidelines for PQRS

“We urge solo practitioners and physicians in smaller groups to participate in the PQRS now, because we will propose in future rulemaking to apply the value-based payment modifier to smaller groups and solo practitioners. (CMS, 2012)” http://www.ama-assn.org/amednews/2012/11/12/gvsa1112.htm

Translation: clinicians do not use PQRS measures by 2015 will see increasing penalties in payments

CMS Contact Information on PQRS

Telephone: 866-288-8912, x3

Email: qnetsupport@sdps.org

‘Eligible’ Mental Health Professionals for PQRS

“Eligibility” for PQRS

“Eligibility” actually misnomer – requirement for all “eligible” groups or will have reimbursements penalized

Will have “eligibility” for bonus in 2015 and 2016 – in 2017 will be only penalty (1.5 in 2015 for 2013 data; 2% for 2016 for 2014 data)

Starting in 2017 will only be penalties of 2% per year if PQRS data not submitted

Reason for PQRS PQRS designed to reduce costs of most

expensive disorders, e.g., diabetes, congestive heart failure, major depressive disorder, chemical dependency, to provide assessments and preventive care

HOWEVER:PQRS not lined up with DSM/ICD codes –

must be creative to implement as mental health clinicians (see below)

PQRS and Mental HealthPQRS is not easily applied to chronic disorders,

including mental health, more for assessment

PQRS concept started in Medicare but likely be used by all insurers/health care delivery systems within next 5 years

Most important general document for finding PQRS data that applies to LCSWs: 2013 Physician Quality Reporting System (PQRS) Claims/Registry Measure Specifications Manual (637 pp.)

Mental Health Diagnoses and PQRS

Remember: DSM/ICD Diagnoses not linked to PQRS Measures!

Mainly assessment and prevention measures for LCSW patients, i.e., depression assessment, suicide risk assessment, smoking assessment, substance use assessment, etc., regardless of actual ICD-9 diagnoses

List of codes for LCSWs to follow

PQRS Effect on Medicare Payments

PQRS will affect Medicare reimbursement rates with bonus (.5% in 2015 and 2016) or penalty (1.5% in 2015, 2% in 2016) for 2015 and 2016 claims

PQRS bonuses end in 2016, then only penalties

Must have three QDCs for 50% of Medicare patients to be eligible for PQRS bonus in 2016 (from 2014 data submitted) and be MAV compliant

Six Areas of PQRS Usage

Denominator and Numerator – information that must be included to be PQRS compliant

Measures – 350 areas that are ‘measured’ by Medicare as Denominator and Numerator (9 for LCSWs)

Quality Data Codes (QDCs) – codes entered on CMS-1500 representing the use of a measure

Six Areas of PQRS Usage cont.

Domains – 11 areas that assess the overall reason for including a given measure

Medicare-Applicability Validation (MAV) – validates that there are less than 9 measures available to the provider (applies to LCSWs) and leads to

Clusters – 27 ‘clusters’ of CPT codes that should be included if one is used

PQRS ‘Denominator’Denominator= patient

group/encounter/dx, i.e., CPT and ICD Codes, treatment location, i.e., what LCSWs already submit

ICD-9 Codes for mental health disorders, especially major depressive disorder, AND

CPT Codes for LCSWs: 90791, 90832, 90834, 90837, 90839, 90845, 90846, 90847, 90849, 90853

PQRS ‘Numerator’Numerator = treatment according to

Quality Data Codes (QDCs) using new G-codes and F-codes for measures

Can be submitted if new ‘episode’, i.e., patient not treated for diagnosed condition for at least 4 months

Go to Clinical Social Work Association link for complete list of connected G-codes and F-codes: http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20PQRS%20Options%20for%20LCSWs%20(revised)%20-%209-24-13%20(2).pdf

PQRS DomainsSix general areas which are used to describe

underlying goal of measure: - Efficiency and Cost Reduction (ECR)- Effective Clinical Care (ECC)- Community/Population Health (CPH)- Patient Safety (PS)- Communication and Care Coordination (CCC)- Person/Caregiver-Centered Outcomes (PCCO)Use as many as possible!

PQRS Measures Purpose

PQRS Measures created to ‘measure’ most expensive diagnostic categories and contain costs

Measures reported on CMS-1500 forms as Quality Data Codes once a year for most Measures used by LCSWs

Exception: Measure #130, Documentation of All Medication, must be submitted for each session

List of PQRS Measures

Go to http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs

Then go to “Educational Resources” (left side)

Then go to http://www.cms.gov/2014_PQRS_MeasuresList_12132013.pdf

Change every year!

PQRS Quality Data Codes

PQRS Measures are like general categories, i.e., depression

PQRS Quality Data Codes (QDCs) are like specific categories, i.e., a new specific code

Again, QDCs get reported on CMS-1500!

PQRS Clusters (MAV)

Medicare-Applicability Validation (MAV)

Automatically used when less than 9 measures available, as with LCSWs

27 ‘Clusters’ to make sure all possible measures reported on

PQRS Clusters (MAV) cont.

Based on CPT codes, e.g., 90791, 90834, 90837

If any CPT code used by LCSW in a cluster, all other measures must be reported if in scope of practice

Three clusters for LCSWs: #1 (General Preventive Care); #11 (Depression); #22 (Substance Use Disorders)

PQRS Clusters (MAV) cont.

Cluster 1 (General Preventive Care) = Measures #130 (Medications), #226 (Tobacco Use)

Cluster 11 (Depression) = Measures #106 (Depression Screening), #107 (Suicide Assessment), #134 (Follow Up Plan), #226 (Tobacco Use)

Cluster 22 (Substance Use Disorders) = Measures #130 (Medications), #226 (Tobacco Use), #247 (Treatment for Alcohol Dependence), #248 (Treatment for Depression with Substance Dependence)

Measures Used by LCSWs

The next 9 slides summarize the QDC, Domain, Cluster, and reporting schedule for each measure used by LCSWs

PQRS Measures =Major Depression Evaluation

#106 Adult Major Depressive Disorder Comprehensive Depression Evaluation: Diagnosis and Severity

Domain: ECCQDC: G8930 (for assessment of depression severity at

the initial evaluation)Clusters: #11Report: Once a year or every new episode (must be four

months since end of last treatment for MDD)

 

PQRS Measures = Suicide Risk

#107 (Suicide Risk Assessment)Domain: ECCQDC: G8932 for suicide risk assessed at the

initial evaluation; 3092F for major depressive disorder in remission; or G8933 for suicide risk not assessed at the initial evaluation

Clusters: #11Report: Once a year or every new episode

(must be four months since end of last treatment)

PQRs Measures - Medications

#130 (Medication Documentation)Domain: PSQDC: G8427: Current Medications

Documented; G8430: Current Medications not

DocumentedClusters: #1 and #22Report: EVERY SESSION

PQRS Measures – Depression Treatment Plan

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

Domain: CPHQDC: G8431: Positive screen, documented follow-up

plan; G8510: Negative screen, follow-up not

required; G8433: Screening not done, patient not

eligibleClusters: #11Report: Once a year or every new episode (must be

four months since end of last treatment)

PQRS Measures – Unhealthy Alcohol Use

#173 Preventive Care and Screening: Unhealthy Alcohol Use

Domain: CPHQDC: 3016F: Patient screened for unhealthy

alcohol use using a systematic screening method

3016F-1P: unhealthy alcohol use screening not performed,

Clusters: #22Report: Once a year or every new episode (must

be four months since end of last treatment)

PQRS Measures – Elder Maltreatment

#181 Elder Maltreatment Screen and Follow-Up Plan

Domain: PSQDC: G8733: Documentation of a positive

elder maltreatment screen and follow-up plan

G8734: Elder maltreatment screen documented as negative

Clusters: NoneReport: Once a year

PQRS Measures – Tobacco Use

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

Domain: CPHQDC: 4004F: Patient screened for tobacco use

AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user

1036F: Current tobacco non-user; patient screened for tobacco use and Identified as a non-user of tobacco

Clusters: #1, #22Report: Once a year

PQRS Measures – Alcohol Dependence

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

Domain: ECCQDC: 4320F: assessment of psychosocial

and pharmacologic treatment options for alcohol dependence

Clusters: #22Report: Once a year

PQRS Measures – Depression and Substance Dependence

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

Domain: ECCQDC: 1220F: screening for depression among

patients with substance abuse or dependence 1220F-1P: screening for depression among

patients with substance abuse or dependence not completed for medical reasons, documentation required.

Clusters: #22Report: Once a year

Two Ways to Submit PQRS

Claims reporting – through CMS-1500 – most practical way for private practitioners

Must be submitted once a quarter for most QDCs

Easiest way to submit QDCs every time bill

Registries – will collate PQRS information – to use must have 80% of all Medicare cases with 3 measures reported OR a 20 patient sample

PQRS Claims Reporting – CMS-1500 Details

Put G-codes into 24D - right under CPT codesPut in ‘pointer’ for each DSM/ICD diagnosis in

24EBe sure to add $.01 in 24F for each G-codeFor more information on CMS-1500 go to:

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

For sample new CMS-1500 form (02/12), go to:

http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20CMS-1500%20Changes%20-%203-14.pdf

Reactions to Past 20 Slides

PQRS and EHRs

PQRS will be automatically loaded into approved programs

LCSWs not required to use EHRs by 2015, as physicians are, but may be required after 2015 to avoid payment penalties or to even receive third-party reimbursement

No incentives or meaningful use requirements at this time

Important to become ‘literate’ in EHR systems for future

Considerations in Choosing an EHR

EHRs have 18 areas which should be reviewed to make best decision – not all LCSWs will want all functions, which include:

Record keeping (see below)Billing Outcomes toolsInteroperable system

Considerations in Choosing an EHR (cont.)

Business Associate AgreementWebsite IntegrationClient ‘Portal’ for RecordClient FormsView appointmentsSchedule AppointmentsEncrypted Messaging/Emails

Considerations in Choosing an EHR (cont.)

Data PortabilityBill Paying OptionGraphic User InterfaceUser ExperienceTablet FriendlyServer SupportReliability

Problems with EHRs

EHRs were designed to prevent fraud but not successful so far

Privacy still issue – no required auditing of who logs on to records and encryption – breaches exploding (http://www.healthcareitnews.com/news/cms-called-out-ehr-fraud-failings?goback=.gde_4172177_member_5828467181918134276#!)

HHS and CMS trying to address

Online Billing Systems

Hard to find online billing system that is as reliable as direct payment

Currently Paypal, Square, and Intuit most widely used

Be prudent when choosing online billing/payment system

The Future in Mental HealthThere are no absolutes, but here are some

likely changes that LCSWs can expect:

The Future:Personal Health Records

(PHR)

http://www.cms.gov/Medicare/E-Health/PerHealthRecords/downloads/SummaryofPersonalHealthRecord.pdf

Designed to give patients control of health records but not as robust as CMS hoped

May become record model over next 10 years

The Future: Integrated Care

Medicare goal - 'integrated care' systems, i.e., care provided in health homes and ACOs which operate on capitated cost management

Integrated care systems will promote communication between medical professionals working with a patient

LCSWs may see better communication with other health care professionals

The Future: New Medicare Rate Formula

Sustainable Growth Rate (SGR) ties Medicare reimbursement to Consumer Price Index, long been seen as flawed

Implementation has been delayed 17 times since it was established in 1996, as potential cuts rose to 27%

Congress delays at last minute (currently delayed until March 31, 2015)

New formula for reimbursement needed to replace ‘doc fix’

The Future: Health (Medical) Homes

New systems which provide capitated funding for integrated care

Mainly connected to Medicaid in Affordable Care Act

Require balancing mental health costs with medical costs

The Future:Accountable Care

Organizations

Accountable Care Organizations – identify high cost conditions and assure that steps are taken to treat conditions early

Must be approved by the Office of National Certification (ONC) and oversee 5000 Medicare or Medicaid beneficiaries – currently @200 ACOs

The Future: ACOs

Will seek clinicians in next 2-5 years

ACOs will look something like Cleveland Clinic, except will have capitation, profit-sharing/loss-sharing

Go to http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2013-04-09-MSSP-NPC.pdf to get information on becoming a provider for ACOs

The Future: Outcome Tools

Outcome Tools (2-5 years)PQRS data tip of the iceberg in terms of

required outcome data of all kindsProvide a baseline for what kinds of

treatment work with what kinds of treatment goals

CSWA hopes to offer guidance about the way to integrate outcome tools into our practices in the near future.

Many QuestionsHow do we choose our practice model,

private practitioner or group practice?How do we choose to have a private pay or

third-party pay?What is the right way forward for each

LCSW?

Difficult But Necessary Choices –

Time Frame

All choices likely to be necessary in next five years

Mental health world different from todayPossible changes will be:- inclusion of LMHCs and LMFTs in Medicare; - national licensure standards (already true

in military); - decisions about working in ‘clinic’ systems

and/or privately

Difficult But Necessary Choices - PQRS

If we choose to work in Medicare after 2015, LCSWs will need to incorporate PQRS and EHRs into our practices to avoid reimbursement penalties

May be necessary for private insurers as well

ACOs/health homes may be a useful option in terms of administering the new requirements for health care reimbursement

Difficult But Necessary Choices –

Interoperable Record-Keeping

Interoperable electronic record keeping systems will be required for third-party reimbursement

May be provided by ‘clinic’ systems which pay ‘salary’ based on outcomes, possible bonus/penalty

Systems must be certified by ONC

Difficult But Necessary Choices –

Practice Only Record-Keeping

If private practice, may only use practice electronic systems or stay with paper record keeping

Must still have dual record-keeping if want to keep psychotherapy notes private

Probably need to do more branding and marketing to build practice privately

Difficult But Necessary Choices –

Health Care Systems

Move from 3rd party fee-for-service to pay-for-performance

Role of insurers as exist today unclear for reimbursement

In-network systems only – Out-of-network likely to be eliminated in next five years

Difficult But Necessary Choices – Health Care

Systems

For future 3rd party payments, will need to join one or more of following:

- Health/Medical Homes- Accountable Care Organizations - Medicare- Independent Practice Organizations

Be Prepared to EducateLCSWs will need to explain to other health care

professionals why mental health treatment needed as follows:

1)  treatment needed for chronic mental health conditions, especially ones like personality disorders and substance abuse, that for decades have been given short shrift in terms of coverage

2)  the importance of integrating psychotherapy with medication as a primary treatment, rather than medication alone as a primary intervention

Thanks for Participating! CSWA hopes that this information will

make navigating the new health care delivery changes easier.

Clinical Social Work Association

P.O. Box 10Garrisonville, VA 22463

1-703-522-3866www.clinicalsocialworkassociation.org