Where to go for Help, Handouts, and Preparing ... - EHR...

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Philip J. Gross, O.D.

Jay W. Henry, O.D., M.S.

Preparing Your Practice for the Future: EHR Incentive Audits, ICD-10, and

Quality Reporting

Disclosures: Dr. Gross and Dr. Henry are affiliated with EHRGURU.NET and have lectured for numerous companies

including Topcon, First Insight, RevolutionEHR, FoxFire, and the AOA.

Where to go for Help, Handouts, and Future Updates

Game Plan

• EHR Incentive Program Audit for Meaningful Use

• ICD-10 Update and Review

• Clinical Quality Measures

– PQRS

• Patient Portals and Secure Messaging

CMS EHR Incentive Audits

Audit Selection

• Providers who receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program are subject to an audit

• 5 – 10% who have attested will be audited

• CMS will oversee Medicare Incentive Audits

• Individual States will oversee Medicaid Incentive Audits

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Audit Selection

• First, random audits are being done

• In addition, risk profile of suspicious / anomalous data will also trigger audits

– CMS is not going to make the risk profile public

• You may be subject to successive audits

Pre- and Post- Payment Audits

• Post-Payment Audits are those which occur after you have received an EHR Incentive Payment. They began in July, 2012.

• Pre-Payment Audits are those which occur before you have received an EHR Incentive Payment. They began in January, 2013.

– If you have a post-payment audit for your first year of participation, you will typically get a pre-payment audit for the following year

Audit Statistics

• In February 2014, a Freedom of Information Act request was filed to obtain information on those audited since the program started

• For unknown reasons, the data is not automatically published by CMS

• The initial look at this data is scary!

Pre Payment Audits as of Sept, 2014

• 5,825 Pre Payment Audits have been undertaken for EPs.

• 3,820 of 5,825 Pre Payment audits have been completed which is 66%

• Over 2000 Pre Payment audits still in process!

• So, how did these entities make out?

Pre Payment Audits as of Sept, 2014

• 821 of 3,820 (21%) pre-payment audits completed did not meet meaningful use and failed!

• CMS is citing two main reasons for failing

– Failure to use a certified EHR (7.1%)

– Failure to meet the appropriate objectives and associated measures (92.9%)

• Take away … Know the measures!

Post Payment Audits as of Sept, 2014

• 4,780 Post Payment Audits have been undertaken for EPs.

• 4,601 of 4,780 Post Payment Audits have been completed which is 96%

• Only about 179 Post Payment audits are still in process but CMS says these are getting ready to gear back up as they catch up on the Pre Payment Audits

• So, how did these entities make out?

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Post Payment Audits as of Sept, 2014

• 1,106 of the 4,601 (post payment audits completed did not meet meaningful use and failed!

• 1 in 4 failed (24%)

• CMS is citing two main reasons for failing

• Failure to use a certified EHR (1.1%)

• Failure to meet the appropriate objectives and associated measures (98.9%)

• You really have to know the measures!

Audits as of Sept, 2014

• CMS is stating that of those EPs who failed audits they are returning between $41.92 and $19,800 per provider

• Average returned incentive was $16,862 per provider

• Those EPs who are audited may have the person responsible for attesting no longer employed! Please have a game plan in place to create and protect your audit information!

Medicare Audit Process

• Figliozzi and Co will send initial request letter

• Letter will be sent electronically from CMS email to email in provider’s EHR registration – Follow-up by phone and mail, as needed

• Providers selected for audits will be required to submit, as soon as possible, supporting documentation to validate their submitted attestation data

• Initial review is a desk review

What you will receive

• Email that contains a number of items

• DR - 1 EP Audit Engagement Letter in PDF format

• DR – 2 Document Request Letter – Eligible Professionals in Microsoft Excel 97 format

• DR – 3 Attachment 1 – Accessing Web Portal in PDF format

• DR – 3.1 Attachment 2 – Web Portal FAQ

Audit Engagement Letter

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Preparing Documentation Requested

• It is the provider’s responsibility to maintain documentation that fully supports the meaningful use and clinical quality measure data submitted during attestation

• Documentation should be retained for six years post-attestation

• Save all electronic or paper documentation that would help support your attestation and support the values you entered in the Attestation Module including the clinical quality measures

How to get Screen Shots

• Window’s free – “Snipping Tool”

– Start, Accessories, and find Snipping Tool

• PrtScn on keyboard which copies to clipboard, holding area, and then past in to Word

• Techsmith’s advanced tool called “Snagit”

Documentation Suggested

• Please have a signed contract / statement from your EHR Vendor showing Proof of Possession of your Certified EHR (CEHRT)

• Statement should include doctor name, certified EHR version number you are using, and date you started using the certified version and that you were using it during the entire reporting period

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Primary Documentation

• The source reports / document(s) from the providers CEHRT which were used during attestation is one of the most important report(s)

• This should provide a summary of the data that supports the information used for attestation – Should show all numerators and denominators used for

attestation – Needs to show specific doctor and time period on report

• Additional documentation can be used if a report is not available or the information entered differs from the report and must demonstrate how the data was accumulated and calculated

• Providers should retain a report from CEHRT to validate all clinical quality measure data

Documentation for EXCLUSION(S)

• Documentation to support each exclusion to a measure claimed by the provider

• Report from the certified EHR system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion

Immunization Exclusion Medicare Audit Determination

• Provider will receive an Audit Determination Letter back from the audit contractor (Figliozzi & Co)

• This will inform the provider whether they are successful in meeting meaningful use

• If the provider is found not to be eligible for an EHR incentive payment then the payment will be recouped

• Providers must use the appeals process if they believe they received an incorrect adverse audit finding

• CMS and ONC personnel cannot intervene in the audit determination process

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Medicare Fraud & Abuse

• CMS may pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment

• It is a crime to defraud the Federal Government and its programs

• Punishment may involve imprisonment, significant fines, or both

• Providers can lose Medicare participation or their licenses to practice

2014 New Final Rule Changes

• Final rule was released 9/4/2014

• Affects which CEHRT you can use for which participation years and the associated Clinical Quality Measures

2014 CEHRT RULE

• On August 29, 2014 CMS and ONC released a final rule that allows providers participating in the EHR Incentive Programs to use the 2011 Edition of certified electronic health record technology (CEHRT) for calendar and fiscal year 2014.

• The rule grants flexibility to providers who are unable to fully implement 2014 Edition CEHRT for an EHR reporting period in 2014 due to delays in 2014 CEHRT availability.

• Providers may now use EHRs that have been certified under the 2011 Edition, a combination of the 2011 and 2014 Editions, or the 2014 Edition for 2014participation.

• Beginning in 2015, all eligible providers will be required to report using 2014 Edition CEHRT.

• http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CEHRT2014_FinalRule_QuickGuide.pdf

Meaningful Use Objectives

• Meaningful use established a core and menu structure for objectives that providers must achieve

• Core objectives are objectives that all providers must meet – Some have exclusions which could exempt you from

having to complete that objective (If you exempt from an objective you get credit as if you did it)

• Menu objectives allow the providers to select from a list a certain number of objectives to meet – Some have exclusions which could exempt you from

having to complete that objective

Stage 1 Core Objectives

1. Computerized provider order entry (CPOE) 2. Drug-drug and drug-allergy checks 3. E-Prescribing (eRx) 4. Record patient demographics 5. Maintain an up to date problem list of current and active diagnoses 6. Maintain active medication list 7. Maintain active medication allergy list 8. Record and chart changes in vital signs 9. Record smoking status for patients 13 years or older 10. Implement clinical decision support 11. Report ambulatory clinical quality measures to CMS / States 12. Provide patients with an electronic copy of their health information,

upon request 13. Provide Clinical summaries for patients for each office visit 14. Capability to exchange key clinical information 15. Protect electronic health information

Stage 1 Core Objectives

1. Drug formulary checks 2. Incorporate clinical lab-test results 3. Generate lists of patients by specific conditions 4. Send reminders to patients for preventive / follow-up care 5. Electronic access to health information for patients 6. Patient specific education resources 7. Medication reconciliation 8. Summary of care record for transitions of care 9. Submit electronic data to immunization registries 10. Submit electronic syndromic surveillance data to public

health agencies

Stage 1 Menu Objectives

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CEHRT2014_FinalRule_QuickGuide.pdf







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Stage 2 Core Objectives 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders

2. Generate and transmit permissible prescriptions electronically (eRx)

3. Record demographic information

4. Record and chart changes in vital signs

5. Record smoking status for patients 13 years old or older

6. Use clinical decision support to improve performance on high-priority health conditions

7. Provide patients the ability to view online, download and transmit their health information

8. Provide clinical summaries for patients for each office visit

9. Protect electronic health information created or maintained by the Certified EHR Technology

10. Incorporate clinical lab-test results into Certified EHR Technology

11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach

12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care

13. Use certified EHR technology to identify patient-specific education resources

14. Perform medication reconciliation

15. Provide summary of care record for each transition of care or referral

16. Submit electronic data to immunization registries

17. Use secure electronic messaging to communicate with patients on relevant health information

1. Submit electronic syndromic surveillance data to public health agencies

2. Record electronic notes in patient records

3. Imaging results accessible through CEHRT

4. Record patient family health history

5. Identify and report cancer cases to a State cancer registry

6. Identify and report specific cases to a specialized registry (other than a cancer registry)

Stage 2 Menu Objectives

START % BASED MEASURES

CPOE: Computerized Provider Order Entry

You must create using CPOE the following: • Measure 1: More than 60% of medication orders • Measure 2: More than 30% of laboratory orders • Measure 3: More than 30% of radiology orders

– You can be excluded individually from meeting each of the above measures for the ones that you have fewer than 100 orders during the reporting period

• More than 30% of all unique patients seen by the EP with at least one medication in their medication list must have at least one medication order entered using CPOE – You can be excluded from meeting this objective if you write

fewer than 100 prescriptions during the reporting period

Suggested Documentation • Report from the EHR system showing numerator,

denominator, and percentage are valid for this measure

• You should have a screen shot showing CPOE • Exclusion(s) should show denominator supports

the exclusion of less than 100

• Report from the EHR system showing numerator, denominator, and percentage are valid for each of the three measures parts

• You should have a screen shot showing CPOE

• Exclusion(s) should show denominator supports the exclusion of less than 100

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Electronic Prescribing

• More than 50% of prescriptions are compared to a drug formulary and transmitted electronically – You can be excluded from meeting this objective if you write

fewer than 100 prescriptions during the reporting period or – Do not have a pharmacy within your organization and there

are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period

• More than 40% of all permissible prescriptions written are transmitted electronically using certified CEHRT – You can be excluded from meeting this objective if you write fewer than

100 prescriptions during the reporting period or (New Starting 2013) Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period



• You should have a screen shot showing eRx for a patient for you as provider in the date range attesting for


• Report from the EHR system showing numerator, denominator, and percentage are valid for this measure

• You should have a screen shot showing eRx for a patient for you as provider in the date range attesting for


Patient Demographics

• More than 80% of all unique patients seen by the EP have demographics recorded. – Preferred language, Race, Ethnicity, Gender,

Date of Birth

– No Exclusion

• More than 50% of all unique patients seen by the EP have demographics recorded – Preferred language, Race, Ethnicity, Gender,

Date of Birth

– No Exclusion

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• You should have a screen shot showing patient demographics recorded, and you as the provider for patient in the date range you are attesting


• You should have a screen shot showing patient demographics recorded, and you as the provider for patient in the date range you are attesting

Maintain an Up-to-Date Problem List

• No longer a separate objective for Stage 2

• It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals

• More than 80% of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data – There is no exclusion for this objective



• You should have a screen shot showing up-to-date problem list recorded, and you as the provider for patient in the date range you are attesting

• Not applicable

Maintain Active Medication List



• More than 80% of all unique patients seen by the EP have at least one medication recorded or an indication that the patient is not currently prescribed any medication recorded – There is no exclusion for this objective.

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• You should have a screen shot showing Active Medication List recorded, and you as the provider for patient in the date range you are attesting

• Not applicable

Maintain Active Medication Allergy List



• More than 80% of all unique patients seen by the EP have at least one medication allergy recorded or an indication that the patient has no known medication allergies recorded.

– There is no exclusion for this objective



• You should have a screen shot showing Active Medication Allergy List recorded, and you as the provider for patient in the date range you are attesting

• Not applicable

Record and Chart Changes in Vital Signs

• For more than 80% of all unique patients seen by the EP, blood pressure (for patients age 3 and over only) and height and weight (for all ages) are recorded as structured data. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years – You may be excluded if you:

– See no patients 3 years or older excluded from recording blood pressure

– Believe that all 3 vital signs of height/length, weight, and blood pressure have no relevance to your scope of practice

– You are excluded from recording blood pressure if you believe that height/length and weight are relevant to your scope of practice, but blood pressure is not

– You are excluded from recording height/length and weight if you believe that blood pressure is relevant to your scope of practice, but height/length and weight are not

• For more than 50% of all unique patients seen by the EP, blood pressure (for patients age 3 and over only) and height and weight (for all ages) are recorded as structured data. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years – You may be excluded if you: – See no patients 3 years or older excluded from recording blood pressure – Believe that all 3 vital signs of height/length, weight, and blood pressure have no relevance to your

scope of practice – You are excluded from recording blood pressure if you believe that height/length and weight are

relevant to your scope of practice, but blood pressure is not – You are excluded from recording height/length and weight if you believe that blood pressure is

relevant to your scope of practice, but height/length and weight are not

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denominator, and percentage are valid for this measure • You should have a screen shot showing height, weight, and

blood pressure recorded. Also, screen shot of BMI calculated and of growth chart for a px with you as the provider for patient in the date range you are attesting

• Exclusion Statement if you feel you can defend it


• You should have a screen shot showing height, weight, and blood pressure recorded. Also, screen shot of BMI calculated and of growth chart for a px with you as the provider for patient in the date range you are attesting

• Exclusion Statement if you feel you can defend it

Record Smoking Status for Patients 13 Years or Older

• More than 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data

– You can be excluded from this objective if you do not see any patients who are age 13 years or older

• More than 50% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data – You can be excluded from this objective if you do

not see any patients who are age 13 years or older

Suggested Documentation • Report from the EHR system showing

numerator, denominator, and percentage are valid for this measure

• You should have a screen shot showing smoking status recorded


• You should have a screen shot showing smoking status recorded

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Patient Electronic Copy and Access • New for 2014 More than 50% of all unique patients are

provided online access to their health information within 4 business days after the information is available to the EP – You can be excluded if you neither order nor create any of the

info listed for inclusion (see next slide) – You can be excluded if you conduct 50% or more of encounters in

a county that does not have 50% or more housing units with 3Mbps broadband availability

• Measure 1: More than 50% of all unique patients are provided timely

(within 4 business days after the info is available to the EP) online access to their health information

• Measure 2: More than 5% of all unique patients view, download, or transmit to a 3rd party their health information – You can be excluded if you neither order nor create any of the info listed

for inclusion (see next slide) – You can be excluded if you conduct 50% or more of encounters in a

county that does not have 50% or more housing units with 3Mbps broadband availability



• You should have a screen shot showing Patient Electronic Access

• Exclusion statement if you can defend it


• You should have a screen shot showing Patient Electronic Access


Provide Clinical Summaries for Patients for Each Office Visit

• Clinical summaries must be provided to patients or authorized representatives within 1 business days for more than 50% of all office visits

– You may be excluded if you have no office visits

• Clinical summaries must be provided to patients within 3 business days of visit for more than 50% of all office visits

– You may be excluded if you have no office visits



• You should have a screen shot showing a Clinical Summary for a patient with you as the provider in the date range you have attested

• Exclusion statement if you can defend it, might be hard!


• You should have a screen shot showing a Clinical Summary for a patient with you as the provider in the date range you have attested

• Exclusion statement if you can defend it … tough!

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Incorporate Clinical Lab-Test Results More than 40% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data

– You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format

More than 55% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data

– You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format



• You should have a screen shot showing a Incorporated Lab Test Results for a patient with you as the provider in the date range you have attested



• You should have a screen shot showing a Incorporated Lab Test Results for a patient with you as the provider in the date range you have attested


Clinical Lab-Test Results Details

• The lab test results must be recorded as structured data in your EHR

• It is important to understand that this data does not have to come back into your EHR directly from the lab in an electronic format

• You may enter the results as structured data through manual entry via typing, option selecting, scanning, or other means

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Patient Reminders (Stage 1) Preventive Care (Stage 2)

• More than 10% of all unique patients who have had 2 or more office visits within the 24 months before the beginning of the reporting period were sent a reminder, per pt. preference when available

– You can be excluded if you have no office visits in the 24 months before the EHR reporting period

• More than 20% of all patients 65 years or older or 5 years or younger were sent the appropriate reminder during the reporting period

– You can be excluded from this objective if you have no patients 65 years or older or 5 years old or younger



• You should have a screen shot showing Patient Reminders were sent for a patient(s) with you as the provider in the date range you have attested



• You should have a screen shot showing Patient Reminders were sent for a patient(s) with you as the provider in the date range you have attested


Electronic Access to Health Information for Patients

• This objective is no longer a measure for Stage 2

• However the concept is covered as part of Patient Electronic Access for Stage 2 (covered earlier)

• At least 10% of all unique patients seen by the EP are provided timely (within 4 business days of being updated in the EHR) electronic access to their health information.

– You can be excluded from this objective if you do not order or create any of the following: Lab results, Problem list, Medication list, Medication allergy list



• You should have a screen shot showing Patient Electronic Access for a patient with you as the provider in the date range you have attested

• N/A

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Patient Specific Education Resources

• Patient-specific education resources identified by the EHR are provided to patients for more than 10% of all unique patients with office visits – You can be excluded if you have no office visits

during the reporting period

• More than 10% of all unique patients seen by the EP are provided patient specific education resources

– No exclusion



• You should have a screen shot showing Patient Education Resource that was provided for a patient with you as the provider in the date range you have attested


• You should have a screen shot showing Patient Education Resource that was suggested for a patient with you as the provider in the date range you have attested

Medication Reconciliation • The EP performs medication reconciliation (including

name, dosage, frequency, and route) for more than 50% of transitions of care in which the patient is transitioned into your care

– You can be excluded if you are not the recipient of any transitions of care during the EHR reporting period

• The EP performs medication reconciliation (including name, dosage, frequency, and route) for more than 50% of transitions of care in which the patient is transitioned into your care

– You can be excluded if you are not the recipient of any transitions of care during the EHR reporting period

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• You should have a screen shot showing Medication Reconciliation for a patient with you as the provider in the date range you have attested


• You should have a screen shot showing Medication Reconciliation for a patient with you as the provider in the date range you have attested

Summary of Care Record for Transitions of Care

• Measure 1: EP who refers or transitions their patient provides a summary of care record for more than 50% of transitions of care and referrals

• Measure 2: EP who refers or transitions their patient provides a summary of care record for more than 10% of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant

• Measure 3: An EP must satisfy one of the following criteria:

– Conducts one or more successful electronic exchanges of a summary of care document, with a recipient who has EHR technology that was developed by a different EHR developer than the sender's EHR technology

– Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period

• EP who refers or transitions their patient to another provider or setting provides a summary of care record more than 50% of the time

– You can be excluded from meeting this objective if you don’t refer or transfer any patients to another setting during the reporting period



• You should have a screen shot showing Summary of Care Record for a patient with you as the provider in the date range you have attested

• Report from the EHR system showing numerator, denominator, and percentage are valid for this measure (all the parts!)

• You should have a screen shot showing Summary of Care Record for a patient with you as the provider in the date range you have attested

• You should also have screen shots showing electronic transfer and a successful exchange

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START NON-% BASED MEASURES

Documentation for Non-Percentage-Based Objectives

• Not all certified EHR systems track compliance for non-percentage-based meaningful use objectives

• These are the objectives that require a “Yes” attestation in order for a provider to meet these for meaningful use

• To validate provider attestation for these objectives, additional documentation is needed.

• The following are examples of how you may support meeting these objectives

Drug-Drug and Drug-Allergy Checks


• It has been incorporated into the Stage 2 Clinical Decision Support measure

• EP has enabled the functionality to automatically check for drug-drug and drug-allergy interactions for the entire EHR reporting period – There is no exclusion for this objective.

Suggested Documentation • One or more screenshots from the certified EHR system

that are dated during the EHR reporting period selected for attestation

• A signed letter from your EHR vendor may also be helpful stating this is available, enabled and active, during the entire reporting period and audit logs show it has not been disabled

• N/A

One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation

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Clinical Decision Support Rule • Implement one clinical decision support rule

that will trigger alerts for providers when they have patients with certain diagnosis or conditions – No exclusion

• Measure 1: Implement five clinical decision support

interventions related to four or more clinical quality measures for the entire EHR reporting period

• Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period – For Measure 2, you can be excluded if you write fewer than

100 medication orders during the reporting period

Suggested Documentation • One or more screenshots from the certified EHR system

that are dated during the EHR reporting period selected for attestation

• A signed letter from your EHR vendor may also be helpful stating this is available, enabled and active, during the entire reporting period and audit logs show it has not been disabled

• One or more screenshots : Five clinical decision support interventions related to four or more clinical quality measures for the entire EHR reporting period

• One or more screenshots : The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period – Exclusion if you can support it

Submit Electronic Data to Immunization Registries

• Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period – You are excluded if:

• You don’t administer immunizations • No immunization registry in your jurisdiction is capable of accepting the

required standards at the start of your reporting period • No immunization registry in your jurisdiction provides information timely on

capability to receive immunization data • No immunization registry in your jurisdiction that is capable of accepting

the standards is enrolling additional EPs at the start of your reporting period

• Perform at least one test of certified EHRs capacity to submit electronic data to immunization registries and follow up submission if the test is successful except where prohibited

– You are excluded from meeting this objective if: • You don’t administer immunizations

• There’s no immunization registry to which you can send information

Suggested Documentation

• Dated screenshots from the EHR that document a test submission to the registry or public health agency (successful or unsuccessful)

• Dated record of successful or unsuccessful electronic transmission (screenshot from another system)

• All reports should identify the provider / practice

• Letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful

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Drug Formulary Checks • EP has enabled functionality for a drug formulary checks and

has access to at least one internal or external formulary for the entire reporting period – You can be excluded from meeting this objective if you write fewer

than 100 prescriptions during the reporting period


• It has been incorporated into the Stage 2 e-Prescribing measure

Suggested Documentation

• One or more screen shots from the certified EHR system that are dated during the reporting period used for attestation


• N/A

Capability to Exchange Key Clinical Information

• This objective is not required for Stage 2

• However this concept is covered under the Summary of Care Record for Transitions of Care Objective in Stage 2

• 2011 and 2012: One test of certified EHR capability to electronically exchange key clinical information to another provider with a distinct certified EHR must be performed

• 2013: This objective is eliminated from Stage 1 and is no longer an objective

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Suggested documentation for 2011 and 2012 only

• Dated screenshots from the EHR that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care during the reporting period. You can also have screen shot from the other provider showing successful or not as well.

• N/A since eliminated

Suggested documentation for 2011 and 2012 only

• A letter or email from the receiving provider confirming a successful exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful

• N/A since eliminated

Protect Electronic Health Information

• Conduct or review a security risk analysis including addressing the encryption/security of data at rest and implement security updates as needed and correct identified security deficiencies as part of the process

– No exclusion

• Conduct or review a security risk analysis and implement security updates as needed and correct identified security deficiencies as part of the process

– No exclusion

Suggested Documentation • Report that documents the procedures performed

during the analysis and the results. Report should be dated prior to the end of the reporting period and should include evidence to support that it was generated for that provider’s system by noting practice Name or providers name

• Report that documents the procedures performed during the analysis and the results. Report should be dated prior to the end of the reporting period and should include evidence to support that it was generated for that provider’s system by noting practice Name or providers name

Security Risk Analysis Help

• You will want to contact your EHR vendor

• Protect Electonic Health Information

– http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/15_Core_ProtectElectronicHealthInformation.pdf

• Guide to Privacy and Security

– http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide.pdf

Generate Lists of Patients by Specific Conditions

• Generate at least one report listing patients of the EP with a specific condition. Should show the provider and be in the date range you attested

– No exclusion

• Generate at least one report listing patients of the EP with a specific condition. Should show the provider and be in the date range you attested

– No exclusion

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/15_Core_ProtectElectronicHealthInformation.pdf










http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide.pdf









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Suggested Documentation • Report from the certified EHR system that is

dated during the EHR reporting period selected for attestation

• Patient-identifiable information may be masked/blurred before submission

• Report from the certified EHR system that is dated during the EHR reporting period selected for attestation

• Patient-identifiable information may be masked/blurred before submission

Report Clinical Quality Measures

• No longer a separate objective but providers must still submit CQM’s to achieve meaningful use

• Starting in 2014, all CQMs will be submitted electronically to CMS

• Beginning in 2013 no longer a separate objective Has been incorporated into the definition of a Meaningful EHR user

• You still must provide aggregate numerator, denominator, and exclusions through attestation or be part of the PQRS Electronic Reporting Pilot

Suggested Documentation • Clinical quality measure data is reported

directly from certified EHR systems

• Report from the certified EHR system to validate all clinical quality measure data entered during attestation

• Clinical quality measure data is reported directly from certified EHR systems

• Report from the certified EHR system to validate all clinical quality measure data entered during attestation

Report ambulatory clinical quality measures to CMS for 2014

• For 2014, CMS is not requiring the submission of a core set of CQMs

– Instead CMS has identified two recommended sets of CQMs, one for adults and one for children

– CMS encourages eligible professionals to report from the recommended set to the extent those CQMs are applicable to your scope of practice and patient population


• EPs must report on 9 out of 64 total CQMs – Providers must select CQMs from at least 3 of the 6 key

health care policy domains (listed below) recommended by the Department of Health and Human Services’ National Quality Strategy

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

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Report ambulatory clinical quality measures to CMS for 2014 Adult Recommended Measures

• Controlling High Blood Pressure • Use of High-Risk Medications in the Elderly • Preventive Care and Screening: Tobacco Use: Screening and

Cessation Intervention • Use of Imaging Studies for Low Back Pain • Preventive Care and Screening: Screening for Clinical Depression

and Follow-Up Plan • Documentation of Current Medications in the Medical Record • Preventive Care and Screening: Body Mass Index (BMI) Screening

and Follow-Up • Closing the referral loop: receipt of specialist report • Functional status assessment for complex chronic conditions


Pediatric Recommended Measures

• Appropriate Testing for Children with Pharyngitis • Weight Assessment and Counseling for Nutrition and Physical Activity for

Children and Adolescents • Chlamydia Screening for Women • Use of Appropriate Medications for Asthma • Childhood Immunization Status • Appropriate Treatment for Children with Upper Respiratory Infection

(URI) • ADHD: Follow-Up Care for Children Prescribed Attention-

Deficit/Hyperactivity Disorder (ADHD) Medication • Preventive Care and Screening: Screening for Clinical Depression and

Follow-Up Plan • Children who have dental decay or cavities

Appeals

• CMS has an appeals process for EPs that participate in the Medicare EHR Incentive Program

• Providers may contact the EHR Information Center at, 888-734-6433, between 9 a.m. and 5 p.m. EST, Monday through Friday, for general questions on how to file appeals and the status of any pending appeals

• States will implement appeals processes for the Medicaid EHR Incentive Program. Medicaid program participants should contact their State Medicaid Agency for more information about these appeals

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International Classification Of Disease

Tenth Edition Clinical Modification (CM)

Will You Be Ready?

ICD-10 Transition

• The ICD-9 code sets used to report medical diagnoses will be replaced by ICD-10 code sets

• You will need to prepare for this transition!

• ICD-10-CM for diagnosis coding (OD’s will use)

• Affects diagnosis coding for everyone covered by HIPAA, not just those who submit Medicare or Medicaid claims

• ICD-10 does not affect CPT coding for outpatient procedures

ICD-10 Transition

ICD-10-CM is for use in all U.S. health care settings

The transition to ICD-10 is occurring because:

• ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures

• ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice

• The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full

ICD-10

• ICD-10 is currently used in all major countries except the US and Italy

• Published by the World Health Organization (WHO)

• Greater number of codes available • ICD-9: approximately 13,600

• ICD-10-CM: approximately 69,000 … forget memorizing

• Codes report not only the disease but its current clinical manifestation

ICD-9 Format vs ICD-10 Format

Example of ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus (deposit of urates)

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One-to-One Mapping

• Some ICD-9 codes map easily to ICD-10 in a simple one-to-one conversion

• Unfortunately, just because a code converts does not mean it matches in all details

One-to-???? Mapping

ICD-10-CM

• H00: Hordeolum: – H00.021: Hordeolum internum right upper eyelid

– H00.022: Hordeolum internum right lower eyelid

– H00.023: Hordeolum internum right eye, unspecified eyelid

– H00.024: Hordeolum internum left upper eyelid

– H00.025: Hordeolum internum left lower eyelid

– H00.026: Hordeolum internum left eye, unspecified eyelid

– H00.029: Hordeolum internum unspecified eye, unspecified eyelid

ICD-10 Transition Plan

• It is important to prepare now for the ICD-10 transition and have a plan! No surprises!

• Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget

• Check with your billing service, clearinghouse, and practice management software vendor about their compliance plans

Interesting ICD-10 Codes

• W04 Fall while being carried or supported by other persons

– Accidentally dropped while being carried

– Different code if dropped ON PURPOSE?

– The appropriate 7th character is to be added to code W04 for: A - initial encounter D - subsequent encounter S - sequela

Interesting ICD-10 Codes

• Y92241 – Hurt at the Library

• Y92253 – Hurt at the opera

• W16.221 - Fall in (into) bucket of water causing drowning and submersion

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Interesting ICD-10-CM Codes

• Burn due to water-skis on fire, initial encounter

– ICD-10 code = V91.07XA

• Stabbed while crocheting

– ICD-10 code = Y93D1


• Sucked into jet engine

– ICD-10 code = V97.33XD

• Problems in relationship with in-laws

– ICD-10 code = Z63.1

• Forced landing of spacecraft injuring occupant, initial encounter

– ICD-10 code = V95.42XA


• And here you have it….. One of our favorites

• Unspecified event, undetermined intent

Hmm……. That sure clarifies things…

• ICD-10 = Y34

ICD-10 Realities

• Electronic Health Records will be key

– Clinical documentation done in EHR

– EHR can suggest ICD-10 codes based on data

– Correct codes based on:

• Condition

• Eye

• Level of disease / condition

– Ask your software vendor if they are working on ICD-10 implementation updates

Clinical Quality Measures (CQMs)

Clinical Quality Measures

• CQMs are tools that help measure and track the quality of health care services provided by eligible professional

• These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care

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• Measuring and reporting CQMs helps to ensure our health care system is delivering effective, safe, efficient, patient centered and timely care


• CQMs measure many aspects of care including:

– Health outcomes

– Clinical processes

– Patient safety

– Efficient use of health care resources

– Care coordination

– Patient engagements

– Population and public health

– Adherence to clinical guidelines


• To participate in the Medicare and Medicaid EHR incentive programs and receive a payment providers are required to submit CQM data from certified EHR technology

• CQMs may be reported electronically or via attestation


• For 2014 - EPs will need to report 9 (of 64 possible) measures

• These 9 measures must cover at least 3 of the 6 National Quality Strategy domains – Patient and Family Engagement

– Patient Safety

– Care Coordination

– Population/Public Health

– Efficient Use of Healthcare Resources

– Clinical Process/Effectiveness


• Samples of 2014 CQMs – Controlling High Blood Pressure

– Use of High-Risk Medications in the Elderly

– Preventive Care and Screening: Tobacco Use

– Documentation of Current Medications in the Medical Record

– Preventive Care and Screening: Body Mass Index Screening and Follow-Up

– Closing the Referral Loop – Receipt of Specialist Report

Need Help Understanding CQMs for 2014?

CQM webpage

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html

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Don’t Forget about: Physician Quality Reporting System

“PQRS”

A Special Type of Clinical Quality Measures that has its own incentive

/ penalty program

Physician Quality Reporting

• Voluntary reporting program

• Provides incentive payments to eligible professionals (EPs) who satisfactorily report data on quality measures

• Applies to covered Physician Fee Schedule services furnished to Medicare Part B beneficiaries

Incentive Percentages

• Physicians who qualify, may earn a bonus payment on all allowable Medicare Charges

• 2014 = 0.5%

• Penalties for not doing PQRS begin in 2015 = 1.5% penalty and continue thereafter

• 2015 Penalty was based on 2013 participation

• 2016 Penalty based on 2014 participation

What really is PQRS?

• For Medicare patients with certain diagnosis and procedures, specific clinical tasks must be completed and documented

• To indicate to CMS, that you completed these clinical tasks, you must then attach a Quality-Data Code (QDC) when billing Medicare Part-B

• Remember … The Diagnosis and Procedures trigger QDC

• In the future, Registry Reporting and EHR Reporting will take over

What really is PQRS?

• Example: – Medicare patient is in for an office visit

– Diagnosis of AMD

– PQRS suggests that you discuss the risks and benefits of AREDS formulation

– If you have documented the discussion of risks and benefits of AREDS formulation in the medical record then

– When submitting your billing (procedure and diagnosis) to CMS you add a PQRS code which states you completed the PQRS requirement

2014 PQRS Participation

Who gets an incentive: – Eligible professionals who satisfactorily report at least

nine applicable measures from three National Quality Strategy (NQS) domains will qualify for a PQRS incentive payment

– Satisfactorily Report: You must have at least 9 measures for which you meet the 50% threshold to be eligible for an incentive payment

– If the Diagnosis indicates the PQRS measure should be done then you would need to complete and report that specific measure on 50% of those patients where it was indicated

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National Quality Strategy (NQS) Domains

• 9 submitted PQRS measures must cover at least 3 of the following domains

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

What are they KEY PQRS Codes?

2014 Active PQRS Measures for all Eyecare

• We have trimmed down the list of the 2014 Active Measures!

• Develop a system to make sure you are: – Submitting these when required

• We will show you the keys to this!

– Checking EOBs / Remittance and making sure they are processed by your carrier

• Let’s look at this list

# Measure Title 2014 Active PQRS Measures for Eyecare

12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination

18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care

110 Preventive Care and Screening: Influenza Immunization

111 Pneumonia Vaccination Status for Older Adults

117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

130 Documentation and Verification of Current Medications in the Medical Record

140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

173 Preventive Care and Screening: Unhealthy Alcohol Use -- Screening

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

317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

EASY STEPS FOR ALL MEDICAL DIAGNOSIS When Billing 99xxx or 92xxx Office Visit

• If you see a Medicare patient: – For a Visit 99xxx or 92xxx AND

– They have ANY MEDICAL DIAGNOSIS

• YOU SHOULD THINK ABOUT PQRS!

• There are 3 PQRS Codes that apply to ANY MEDICARE PATIENT you see for a 92xxx or 99xxx visit with ANY DIAGNOSIS – We recommend you use these when apply!

• There are 4 other PQRS codes that you could use for ANY MEDICARE PATIENT you see with ANY DIAGNOSIS but only with 99xxx office visit codes – These may be used when they apply but we don’t recommend them at this

time

Medicare Patient with ANY Diagnosis 99xxx or 92xxx Office Visit

Measure CPT II Code Description

130 G8427 or G8428 or G8430

List current meds (dosages, frequency, and route) & verification with patient or authorized representative documented Incomplete / no provider documentation of current meds Documentation that patient ineligible for med assessment which includes patient refuses, urgent medical tx, or cognitively impaired

226 4004F or 1036F

Patient screened for tobacco use AND received tobacco cessation counseling , if identified as a tobacco user Current tobacco non-user

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Medicare Patient with ANY Diagnosis 99xxx or 92xxx Office Visit

Measure CPT II Code Description

317

G8783 OR G8950 OR G8784 OR G8951 OR G8785 OR G8952

Normal blood pressure reading documented, follow-up not required Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented Blood pressure reading not documented, documentation the patient is not eligible Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible Blood pressure reading not documented, reason not given Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not

How do we code it on 1500 form?

Dx 1: ANY MEDICAL DX Dx 2:

Date Service

Place Service

Procedure (CPT I) and QDC (CPT II)

Procedure Description

Dx

1/14/2014 11 92014 Exam 1

1/14/2014 11 G8427 List current meds (dosages) & verification with patient

1

1/14/2014

11 1036F Current tobacco non-user 1

1/14/2014 11 G8783

Normal blood pressure reading documented, follow-up not required

1

How about the eye specific measures? EASY STEPS

• If you see a Medicare patient for any VISIT (99xxx or 92xxx) AND they have

– Primary Open Angle Glaucoma

– Age Related Macular Degeneration

– Diabetes

• YOU MUST THINK ABOUT the other PQRS codes that apply?

Medicare Patient with Diagnosis: POAG, AMD, or DM

# Measure Title

12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination

140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care

117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient

EASY STEPS

• Let’s look at the details of these diagnosis

– POAG

– AMD

– DM

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Glaucoma Diagnosis PQRS Measure 12

POAG: Optic Nerve Evaluation

Medicare Patient?

18 years or older?

Glaucoma Diagnosis?

If Diagnosis code is 365.10-365.12 or 365.15 and procedure code is

92002-92014, 99201-99205, 99212-99215, 99304-99310,

99324-99328, or 99334-99337

Did you evaluate the optic nerve once in the past 12

months?

Yes = 2027F

Optic nerve not evaluated use modifiers

2027F - 1P = Medical Reason

2027F - 8P = No Reason Given

AMD Diagnosis – PQRS Measure 140 AMD: Counseling on Antioxident Supplement

Medicare Patient?

50 years or older ?

AMD Diagnosis?

If Diagnosis code is 362.50, 362.51, or 362.52 and

procedure code is 92002-92014, 99201-99205, 99212-99215, 99304-99310, 99324-

99328, 99334-99337

Did you discuss the risks and benefits of AREDS

formula with the patient in the past 12 months?

Yes = 4177F

If you did not discuss AREDS with the patient use modifier

4177F -8P = No Reason Given

Diabetes Diagnosis - PQRS Measure 117 DM: Dilated Eye Exam

Medicare Patient?

Age 18 – 75?

Diabetes Diagnosis?

If Diagnosis code is 250.00-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50–250.53,

250.60–250.63, 250.70–250.73, 250.80–250.83, 250.90–250.93, 357.2, 362.01–362.07, 366.41, 648.01–648.04 and

procedure code is 92002-92014, 99201-99205, 99212-99215, 99304-99310, 99324-99328, 99334-99337, 99341-

99345, 99347-99350, G0270, G0271

Did you do a Dilated Fundus Examination within the past 12

months?

Yes = 2022F

Did you do a Dilated Fundus Examination?

NO = 2022F -8P = No Reason Given

or

3072F = Low Risk of Retinopathy

(No Retinopathy previous year)

Want All The Flow Charts

• Visit www.ehrguru.net click on PQRS at top of page

– Available full size and in color

– Available with ICD-9 codes for use until 9/30/2014

– Available with ICD-10 codes to be used starting October 1st, 2014

The EASY Plan?

• You know the PQRS codes that apply to all Medicare patients .... We suggest you use the 3 that apply to the 92xxx and 99xxx office visits when they apply

• You know the other diagnosis (DM, POAG, AMD) that apply to eyecare … Use all of them every time they apply for each diagnosis!

• Remember, this gives you 10 Measures to worry about and makes it much easier to achieve!

Avoiding the PQRS Penalty in 2016

• If you successfully submit 3 PQRS measures at least 50% of the time the measure applies during 2014 you will not be penalized in 2016 on your Medicare reimbursements!

• But remember to get the incentive payment and be considered a successful PQRS doctor you must submit 9 PQRS measures (from 3 domains) at least 50% of the time the measure applies during 2014

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Patient Portals

Patient Electronic Copy and Access • New for 2014 More than 50% of all unique patients are

provided online access to their health information within 4 business days after the information is available to the EP – You can be excluded if you neither order nor create any of the

info listed for inclusion (see next slide) – You can be excluded if you conduct 50% or more of encounters in

a county that does not have 50% or more housing units with 3Mbps broadband availability

• Measure 1: More than 50% of all unique patients are provided timely

(within 4 business days after the info is available to the EP) online access to their health information

• Measure 2: More than 5% of all unique patients view, download, or transmit to a 3rd party their health information – You can be excluded if you neither order nor create any of the info listed

for inclusion (see next slide) – You can be excluded if you conduct 50% or more of encounters in a

county that does not have 50% or more housing units with 3Mbps broadband availability

Video of Patient Electronic Access

updox 1.mp4

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Patient Secure Messaging

Use Secure Electronic Messaging New Objective for Stage 2

• A secure message was sent using the electronic messaging function of CEHRT by more than 5 % of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period

– You can be excluded if you have no office visits during

the EHR reporting period OR

– You conduct 50% or more of your patient encounters in a county that does not have 50% or more of its housing units with 3Mbps (Megabits per second) broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period

New Stage 2 Core Objective: Secure Messaging Details

• Secure Message: Any electronic communication between a provider and patient that ensures only those parties can access the communication

– This electronic message could be secure email or the electronic messaging function of a PHR, an online patient portal, or any other electronic means that is authenticated (both patient and EHR user) and encrypted

– The EP is not expected/required to personally respond to the electronic message from the patient

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Questions?

Philip J. Gross, O.D.

Jay W. Henry, O.D., M.S.

Where to go for Help, Handouts, and Preparing ... - EHR...

Documents

Transcript of Where to go for Help, Handouts, and Preparing ... - EHR...