Reporting PQRS Measures: Anesthesiology’s Own Qualified Clinical Data Registry (QCDR)

Until now, claims-based reporting has been the only Physician Quality Reporting System (PQRS) option for most anesthesiologists.  While the method of reporting, inserting the five-digit PQRS codes for the PQRS measures on one’s Medicare claims, has been easy enough, finding enough quality measures that apply to anesthesia practices has been more of a challenge.

The picture changed when the Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) received Qualified Clinical Data Registry (QCDR) status a little more than a month ago.  As stated on the CMS QCDR web page:

A qualified clinical data registry (QCDR) is a new reporting mechanism available for the Physician Quality Reporting System (PQRS) beginning in 2014.  A QCDR will complete the collection and submission of PQRS quality measures data on behalf of Eligible Professionals (EPs).  For 2014, a QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.

The most significant benefit of designation as a QCDR is the ability to develop and deploy performance measures that the entity—in this case, ASA and AQI—considers the most meaningful for its EPs.  In this respect QCDRs differ from the “Quality Registries” that have provided one method of reporting since the beginning of the PQRS program. (NACOR is a Qualified Registry as well as a QCDR.)  The distinct difference is that the QCDR designation gives AQI flexibility to develop measures to best achieve the goal of improving the quality of care furnished by anesthesiologists and allows non-PQRS measures to be reported to CMS.

Eleven new measures “have been developed through the work of the ASA Committee on Performance and Outcome Measures and the ASA Department of Quality and Regulatory Affairs,” according to  AQI’s explanation entitled “The qualified clinical data registry-what it means to anesthesiology,” available at http://www.aqihq.org/PQRSReporting.aspx.  “AQI will be developing methodology for collecting performance data on these measures from diverse practice environments, and will be learning from the process as we implement it.  From both our perspective and that of CMS, 2014 is a pilot year for this program.  We will have the opportunity to add new measures, subtract non-functional ones and otherwise modify this effort in 2015.”

The 11 new NACOR quality measures are:

1. Post-Anesthetic Transfer of Care:  Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
2. Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy (Adults)
3. Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
4. Anesthesiology:  Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit
5. Composite Anesthesia Safety
6. Immediate Perioperative Cardiac Arrest Rate
7. Immediate Perioperative Mortality Rate
8. PACU Reintubation Rate
9. Short-term Pain Management
10. Composite Procedural Safety for Central Line Placement
11. Composite Patient Experience Measure

For measure descriptions, applicable National Quality System (NQS) domains, performance elements and rationales, consult the AQI website.  A second document is expected to be posted by the end of the month that describes in concrete detail the methodology for reporting each of these measures in 2014, including five-digit codes.

In addition to the 11 measures above, anesthesiologists can report eight approved PQRS measures to NACOR.  The approved PQRS measures are the four anesthesia specific measures:

• #30 – Perioperative Care:  Timely Administration of Prophylactic Parenteral Antibiotics
• #44 – Coronary Artery Bypass Graft:  Preoperative Beta-Blocker in patients with isolated CABG surgery
• #76 – Prevention of Catheter-Related Bloodstream Infections
• #193 – Perioperative Temperature Management

plus four generic PQRS measures that apply to anesthesia and/or pain management practice:

• #130 – Documentation of Current Medications in the Medical Record
• #226 – Preventive Care and Screening:  Tobacco Use:  Screening and Cessation Intervention
• #342 – Pain Brought under Control within 48 Hours
• #358 – Patient-Centered Surgical Risk Assessment and Communication

References to QCDR reporting in 2014 notwithstanding, anesthesiologists cannot use NACOR as a QCDR to satisfy PQRS reporting requirements this year.  In order to earn the 0.5 percent bonus payable in 2015, or to avoid the 2.0 percent negative adjustment in 2016, EPs submitting quality measure data to a QCDR must report on at least 50 percent of patients seen during the period January 1-December 31, 2014.  Even those EPs who self-nominate to CMS by ASA’s recommended deadline of July 1st  (CMS has set a deadline of October 1st) will be unable to report on 50 percent of the full year’s patients during the several remaining months of 2014 after NACOR completes their enrollment and the EPs’ technology is updated to include the NACOR non-PQRS measures.  As the AQI stated in the explanation quoted above, “2014 is a pilot year for this program.”

Why, then, should anesthesiologists begin reporting to NACOR-QCDR?  No incentive payment will be available for satisfactory PQRS reporting after the Medicare carriers send out the final checks in early 2015, Meeting the requirements for the incentive—reporting 9 measures from at least three different NQS domains, to include one outcomes measure—will be moot under current program regulations.

To avoid the payment adjustment from 2016 onward, EPs have three options:

1. Meet the requirements to satisfactorily report or satisfactorily participate for incentive eligibility as defined in the 2014 PQRS program (i.e., report on nine measures from three NQS domains including one outcome measure for at least 50 percent of patients seen during the calendar year).
2. Report at least three measures covering one NQS domain for at least 50 percent of the eligible professional’s Medicare patients via claims or qualified registry
   • An eligible professional that reports fewer than 3 measures covering at least 1 NQS domain via claims or qualified registry-reporting will be subject to the Measure-Applicability Validation (MAV) process, which will allow CMS to determine whether additional measures domains should have been reported.
3. Participate via a QCDR in reporting at least three measures covering a minimum of one NQS domain and submit measures for at least 50 percent of applicable patients seen during the participation periods for the individual measures.

It is obvious that EPs who would avoid the adjustment by reporting three or fewer measures on their claims would receive no direct and immediate PQRS-related benefits from participating in NACOR-QCDR and selecting from among the registry’s total of 19 measures.  There are other reasons to participate, however.  First, CMS is coordinating its various quality programs so that EPs will only need to report once for PQRS, for the Value-Based Payment Modifier (VBM) program, which is based on the PQRS data reported in 2014, and for the electronic health record (EHR) incentive program.  See “Reporting Once for 2014 Medicare Quality Reporting Programs,” an interactive tool on the PQRS website.  Second, over the next five years, CMS will phase out claims-based reporting in favor of registry-based reporting, so you may want to start the transition now.  Third, and perhaps most important, QCDRs are required to provide timely feedback at least four times per year on the measures for which the QCDR would report on the individual EPs behalf.  Since those measures have been carefully developed to represent actual quality in anesthesia practice, this feedback should be useful for tracking performance and improving patient care and safety.

Participating in NACOR is free for ASA members ($500/year for non-members).  Practices wishing to submit data through the QCDR mechanism must be active participants in NACOR with the ability to provide a sufficient quantity of correctly coded cases.  The practice will need to enter into an appropriate legal agreement with the AQI to provide for NACOR’s receipt of patient-specific data and allow NACOR to release quality measure data to CMS on behalf of the EPs.  Instructions are available from the AQI. 

In the meantime, you may want to participate in CMS’ National Provider Call on PQRS QCDR Reporting on June 17, 2014 between 1:30 and 3:00 p.m. EST.  The agenda lists the following objectives:

• Learn the Difference between a QCDR and a Qualified Registry
• How to Use a QCDR to Qualify for a 2014 PQRS Incentive Payment
• How to Avoid the 2016 PQRS  Payment Adjustment

A link to the slide presentation will be posted at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-06-17-PQRS-NPC.html prior to the call. To register for this National Provider Call, please visit the CMS MLN Connects Upcoming Calls registration website.

We agree with Richard Dutton, M.D., M.B.A., executive director of AQI, that the designation of NACOR as a QCDR is a very “big deal.”  More formally, Dr. Dutton has said, “The most important aspect of this new mechanism is that it allows ASA to select and develop its own physician performance measures, rather than being limited to three measures approved by CMS.  Who better to know how to measure anesthesia performance than physician anesthesiologists?  Additionally, in the coming years the Society will be able to add measures to address subspecialty areas and related disciplines such as pain medicine and critical care.”

We congratulate AQI on being one of the first registries to be designated a QCDR.