Physician Quality Reporting System (PQRS) · Claims-based Reporting Eligible Medicare B claims:...
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4010 Moorpark Avenue, Suite 222 San Jose, CA 95117 www.prognocis.com [email protected] Copyright 2014 – Bizmatics, Inc. Physician Quality Reporting System (PQRS) 2014 Edition, PrognoCIS v3b1
Transcript of Physician Quality Reporting System (PQRS) · Claims-based Reporting Eligible Medicare B claims:...
4010 Moorpark Avenue, Suite 222 San Jose, CA 95117
www.prognocis.com [email protected] Copyright 2014 – Bizmatics, Inc.
Physician Quality Reporting
System (PQRS) 2014 Edition, PrognoCIS v3b1
Some features are dependent upon settings/configuration
Local Admin user
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Housekeeping Bullets
Exclusion: Any EP who…
MU Impact
TOC a *property.set
http://...
Important/FYI
By the way…
*User must click OK
Trigger
Documentation Conventions
1. The 2. Vitals
Indicates when the feature is related to or has an impact on meaningful use compliance.
Web site/suggested links to bookmark for reference
Identifies when conversion will automatically apply conditions as relevant during the upgrade.
Provides additional details/references or training steps relevant to the measure
Indicates the specific screen, tab, menu option, or icon within PrognoCIS where the measure occurs
Lists configuration/properties applicable to the measure
Indicates conditions, instructions, or cautionary details that may impact compliance with the measure
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS
Physician Quality Reporting System
• Incentive program that is a combination of payments and adjustments as applicable
• Measure specifications & requirements for the current program year may differ from previous ones
• Multiple different reporting options available; however, we support only Individual ,Claims-based Reporting
• Group Reporting is N/A with PrognoCIS • PrognoCIS is not a PQRS Registry • PrognoCIS is not a qualified EHR Product in this context • PrognoCIS is not a PQRS Data Submission Vendor • PrognoCIS is not a CMS Certified Survey Vendor
PQRS is not the same as Meaningful Use; NQF
measures apply to both.
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/List-of-EligibleProfessionals_022813.pdf
Eligibility, Participation Timeline, & Payment
• Payments go to EPs as identified on claims by their individual NPI/TIN • Incentive payment = 0.5% total estimated PFS allowed charges for the
reporting period (2014) • Payment adjustments will be applied in 2016 to qualifying EPs who do
not comply • Dec. 31, 2014 = reporting period for 2014 ends • Feb. 28, 2015 = last day for 2014 PQRS claims submission to qualify
Applicable for Med-B PFS services Railroad + MSP included Medicare C is N/A for Claims-based
No registration or sign-up required EP must bill individually (not Group) N/A for services billed through an
institution/facility
Measures & Reporting Options http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
Claims is the only option we
support.
Sample CMS-1500 Claim w/qualifying codes List of all PQRS Measures & Requirements Development specifications PQRS FAQs (w/CMS)
Downloads Available from CMS
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014PQRS_WhatsNew_F01-09-2014.pdf
2014 Requirements/Changes
MAV process may apply for EPs who fail
to report minimum measures
EP Requirements:
45 total measures
retired 2014
9 measures covering at least 3 NQS domains OR 1-8 measures covering 1-3 NQS domains as applicable AND at least 50% of Medicare-B FFS patients seen during reporting period
Measure Applicability Validation (MAV) http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html
MAV Requirements/Facts: EP reports < 9 measures per 3 domains Submitted QDCs will be reviewed to determine if
EP should have submitted additional ones EPs who fail MAV will not earn 2014 incentive
and are subject to payment adjustment
Claims-based Reporting http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
Eligible Medicare B claims: DOS 1/1/2014 – 12/31/2014 Submitted to Medicare prior to Feb. 28, 2015
EP Quality Checklist: All claim-level ICDs included in analysis QDC line-items can have only 1 ICD pointer Audit/verify all Assessment data Minimum of 3 measures on at least 80% of all
Medicare-B PFS claims
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_sampleCMS1500claim_12-19-2012.pdf
Claims-based Reporting (cont’d)
QDC must be reported on applicable lines Service Provider must be identified by
individual NPI/TIN (Rendering Provider n/a) Automated with PrognoCIS PM/Billing PQRS Report available for external PM
Eligible Medicare B claims: DOS 1/1/2014 – 12/31/2014 Submitted to Medicare prior to Feb. 28, 2015
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
PQRS Measures Master Setup
Settings Configuration Codes/Drugs PQRS Measures
Inactive measures will display here but will not be applied at
the encounter level.
• Not all measures may be pre-loaded in the Master but can be added upon request
• Send your requests to: [email protected]
• Active measures will be applied in conjunction with the Attending Provider’s PQRS Categories defined
• Fuchsia color represents Dr. Cooper • Purple color represents Dr. Koothrapalli
Practice-level master of all measures for all providers
Provider Master Setup Each provider’s record must be configured for the Categories he/she wants to report
All Active measures defined within the assigned Categories will be validated on each Medicare
encounter for which the provider is the Attending Provider
EPILEPSY is n/a for Dr. Cooper; however, measures are left Active for Dr. Koothrapalli
User/Role Permissions Each provider should have appropriate security permissions for documenting PQRS
Patient Encounter PQRS allows you to document under the PQRS screen from encounter TOC
PQRS PQRS Measures allows you to assign measures as Active/Inactive under Configuration
Settings Configuration Admin Role
Only EMR Admin or EP requires these
rights.
EP & applicable clinical staff requires
these rights.
For an encounter to be PQRS-eligible, Insurance Type must = Medicare under Patient Insurance
Patient Insurance
Patient Insurance
Patient Register Patient Insurance ( )
Insurance Type
PQRS option will display on TOC* for all encounters but will be disabled when not applicable
All Active measures will display; Status will be based upon qualifying provider & documentation
PQRS Encounter
For non-Medicare encounters, the TOC option will display grayed-out, and the encounter will not be part of PQRS Reporting. Option will be enabled for Medicare encounters.
*Settings Configuration Admin Properties encounter.toc.options
DBM, AKD, POC defined in Provider
Master for Dr. Cooper
EPILEPSY not defined in Provider Master for Dr.
Cooper; but they remain Active for Dr. Koothrapalli
EPILEPSY is n/a for Dr. Cooper, so it will
show as FAIL (Missing ICD & CPT/HCPC)
Info Button This displays the Denominator requirements for the selected measure in a table format; including the
applicable Patient Age, Gender, ICDs, and CPT/HCPCs
At least one ICD and one CPT/HCPC from this table must be entered under Assessment or status will = FAIL.
• PQRS Reporting is based upon these values as compared to the Assessment data of every Medicare encounter.
• Status of PASS or FAIL is based upon one or more of these values being part of the assessment data
Assign ICD Button Displays all valid ICD codes as defined within the Denominator for the selected measure
Flows automatically to Assessment ICD tab if not already assigned
System will prompt when valid code already exists under Assessment (button is not available)
This button only works when status = FAIL. A valid ICD is required for status to = PASS.
• Status will = PASS when a valid ICD has been posted to the Assessment. This does not necessarily mean the claim qualifies for incentive.
Assign CPT/HCPC Button Displays all valid CPT/HCPC codes as defined within the Denominator for the selected measure
Flows automatically to Assessment CPT/HCPC tab if not already assigned
System will prompt when valid code already exists under Assessment (button is not available)
This button only works when status = FAIL. A valid code will show status as PASS.
• Status may = PASS and yet display an error (such as: . This indicates that the Denominator requirements are satisfied (ICD & CPT/HCPC); however, a QDC (G-code) is required on the claim in order to be counted in the Numerator for incentive credit.
G-Code Button – QDC Codes Displays all valid Quality Data Codes as defined within the Numerator for the selected measure
If using PrognoCIS PM/Billing, the selected G-Code automatically populates on the applicable line-item
of the CMS-1500 when generated as per Claims-based reporting requirements
This button only works when status = PASS. An error will display if status = FAIL.
QDC Codes are what will qualify the claim for the
incentive along with valid ICD and CPT/HCPC codes.
Simply having a PASS status is not enough.
QDC Codes are different for each
measure and may not have a “G” in it
PQRS and Assessment/Plan screens are bi-directional; hence each one feeds the other
Info, ICD, and CPT/HCPC buttons provide the requirements for compliance of each measure
Magnifying glass provides table of valid QDC (G-codes) required on the claim for incentive payment
Encounter TOC PQRS
PQRS Data at Encounter-level
Lists all active measures per PQRS Measures master Status reflects the current encounter’s assessment Not every measure will apply to every encounter;
hence, FAIL status may not require intervention A G-code is required hence, PASS
status requires user intervention
Active groups not assigned to Attending Doc will always
show as FAIL.
Auditing PQRS Data/Verifying Codes PQRS and Assessment/Plan screens are bi-directional; hence each one feeds the other
Source identifies where the information originated within the chart
Encounter TOC Assessment CPT/HCPC Source
AP = provider chose codes directly on Assessment screen
PQRS = codes flowed over from PQRS screen
PQRS Report By provider, measures group, and date range
Share with external Billing Service when not using PrognoCIS PM/Billing module
Reports PQRS Report
Can specify individual or multiple providers and PQRS
qualifiers for date range.
Charge Code = G-Code = QDC Codes
Decide what 9 measures you want to report & ensure they are Active in master Note: Only Individual, Claims-based measures are applicable within PrognoCIS.
Associate PQRS Category to each Provider as applicable Add menu option PQRS to Encounter TOC property Remind Patient Registration to assign Ins Type = Medicare to patient insurance Document all clinical codes (ICD, CPT/HCPC, etc.) to the Assessment Review/Validate your data under PQRS screen from encounter Assign appropriate QDC (G-code) as per measure criteria Submit claims before Feb. 28, 2015
Remember: Reporting period is Jan 1 – Dec 31, 2014 All claims must be submitted by Feb 28, 2015 Payment Adjustments will be applied 2016 (if applicable)
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