CMS PQRS Bonus

PQRS (Formerly Known as PQRI) – FACTS

The Physician Quality Reporting System is;

♦ PQRS reporting is voluntary, not mandatory.
♦ There is no need to sign-up. Simply begin reporting the measures you’ve selected.
♦ There are two reporting periods in 2011. Jan 1 through Dec. 31 for an incentive payment of 12 months of reporting. July 1 through Dec. 31 for an incentive payment of 6 months of reporting.
♦ The bonus, or payment incentive is contingent upon:

1. Achieving 50 percent success for individual measures via claims reporting or 80 percent success via a CMS approved registry.
2. Achieving that success rate for three quality measures. OR
3. Achieving success of reporting on a measure group on 30 individual Medicare patients via claims OR 80% success via a qualified registry.

♦ The bonus will be paid out as a lump sum in the fall of 2012.
♦ The bonus will be paid to each tax identification number but it will be based on, as well as reported by using, the individual national provider, identification number (NPI).
♦ No dollar amount is listed in the Medicare Fee Schedule for the Category II codes. Since some physician systems won’t accept a zero charge, post 1 cent. This amount will need to be adjusted when the claim is processed.
♦ Not everyone in the practice has to select the same measures. Nor does everyone in the practice need to participate. Since the individual reporting is based on the NPI, only those patients treated by that physician will count towards the 50 or 80 percent and the bonus calculation. However, the more participating physicians in the practice, the greater the total bonus.
♦ If a patient qualifies for more than one of the measures you have selected to report, report all that qualify.
♦ The payment incentive applies to Medicare Part B, Medicare as a secondary payer, Railroad Medicare and a few Medicare Advantage plans, depending on the contract.

Year	Bonus	Comments Maintenance of Certification (MOC)
2011	1.0%	if no MOC, 1.5% if MOC
2012	0.5%	if no MOC, 1.0% if MOC
2013	0.5%	if no MOC, 1.0% if MOC
2014	0.5%
2015	-1.5%	HHS could begin requiring MOC after 2014
2016	-2.0%

Getting Started - 2011 Reporting

Two Ways to Report PQRS:

1. Claims Reporting: Reported by your office at the same time exams are submitted or
2. Registry Reporting: Giving your data to an approved CMS registry (speak to your chosen registry for their pricing).
3. Both claims and registry and CMS will give you credit for the report method that is successful.
4. Determine whether you will be reporting individual measures OR a measure group.

- Individual Measures: Choose a minimum of three measures that pertain to your practice. When reporting via claims, many offices choose four or more measures as a buffer to increase the chances of successful reporting on a minimum of three measures.
-Measure Group: Choose a measure group that pertains to your practice. To select a measures group reporting option via claims, the first step requires that eligible professionals identify their intent to report a measures group by submitting a measures group-specific intent G-code on a claim for covered services.  The submission of the intent G-code serves as the indication that a physician is choosing to report on a measures group and will initiate measures group analysis. It is NOT necessary to submit the measures group-specific intent G-code on more than one claim. If the G-code for a given group is submitted multiple times during the reporting period, only the submission with the earliest date of service will be included in the Physician Quality Reporting analyses; subsequent submissions of that code will be ignored.

♦ For claims based submissions, all the applicable measures within the group must be reported during the reporting period (January 1 through December 31, 2011), according to each measures group's reporting instructions.
♦ The relevant measure groups for otolaryngology and their intent codes are;
G8492: I intend to report the Perioperative Care Measures Group
OR
G8645: I intend to report the Asthma Measures Group

5. Decide whether to report via claims or registry AND whether reporting individual measures or a measure group.
6. If reporting via claims:

♦ Add the measures you've selected into your computer system just like adding a new CPT code.
♦ Add the modifiers into your computer system just like adding a new CPT modifier.
♦ Submit the measure along with the appropriate level of exam code.
♦ If your computer system won't allow a blank charge field, put $0.01 charge to be written off when processing the remittance advice (RA).
♦ The remittance advice with denial code N365 or CO-96 is your indication that the Quality Data Claim (QDC) for PQRS were passed in the National Claims History (NCH) file for use in calculating incentive eligibility. This remark does not confirm whether or not the QDCs were accurately submitted. The remark message should read: "This procedure code is not payable. It is for reporting/information purposes only." If no remark code present  the RA, please follow-up with the Carrier/MAC or billing softer/vendor clearinghouse.
♦ Remember there is only one opportunity to submit the claim correctly. One way to assure success is to have your IT person establish edits so that every time you report a qualifying diagnosis with an associated exam, the claim will not process without adding a measure code.

Measure Specifics - Definition of Terms

Numerator: CPT Category II codes designed for PQRS. They are numeric-alpha, such as 2027F. They could also be a HCPCS code such as G8627.

Denominator: The diagnosis code that pertain to each Category II code.

Modifiers: A set of HCPCS modifiers have been developed by PQRS. They identify reasons why a measure could not be completed. Not all modifiers apply to each measure.
Modifier 1P: Documentation of medical reason(s) for not performing a measure.
Modifier 2P: Patient declined for economic, social, or religious reasons.
Modifier 8P: Reason(s) not otherwise specified.

2011 Measure Specifications

2011 Measures	Definition
Measure 20	Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
Measure 21	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Measure 22	Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)
Measure 23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Measure 30	Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
Measure 46	Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility
Measure 47	Advance Care Plan
Measure 53	Asthma: Pharmacologic Therapy
Measure 64	Asthma: Asthma Assessment
Measure 65	Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use
Measure 66	Appropriate Testing for Children with Pharyngitis
Measure 91	Acute Otitis Externa (AOE): Topical Therapy
Measure 92	Acute Otitis Externa (AOE): Pain Assessment
Measure 93	Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Measure 94	Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of Tympanic Membrane Mobility
Measure 110	Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
Measure 111	Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older
Measure 124	Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)
Measure 128	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Measure 130	Documentation of Current Medications in the Medical Record
Measure 143	Oncology: Medical and Radiation – Pain Intensity Quantified
Measure 144	Oncology: Medical and Radiation – Plan of Care for Pain
Measure 154	Falls: Risk Assessment
Measure 155	Falls: Plan of Care
Measure 188	Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear
Measure 189	Referral for Otologic Evaluation for Patients with a History of Active Drainage From the Ear Within the Previous 90 Days
Measure 190	Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly Progressive Hearing Loss
Measure 193	Perioperative Temperature Management
Measure 226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure 231	Asthma: Tobacco Use Screening - Ambulatory Care Setting
Measure 232	Asthma: Tobacco Use Intervention - Ambulatory Care Setting

2011 Measure Groups

Measure 20. Perioperative Care: Timing of Antibiotic Prophylaxis - Ordering Physician
Measure 21. Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin
Measure 22. Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)
Measure 23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

Measure 53. Asthma: Pharmacologic Therapy
Measure 64. Asthma: Asthma Assessment
Measure 231. Asthma: Tobacco Use: Screening - Ambulatory Care Setting
Measure 232. Asthma: Tobacco Use: Intervention - Ambulatory Care Setting