October 27, 2014

Numerous anesthesiologists have expressed confusion about the requirements for reporting Physician Quality Reporting System (PQRS) measures next year. It is very important that every eligible professional (EP) successfully participate in the PQRS program in 2015; failure to do so will mean a two-percent reduction in their Medicare payments in 2017.

There are five methods for submitting PQRS data to CMS:

1. Claims-based reporting (on Medicare Part B claims)
2. Registry-based reporting
3. Electronic health record (EHR) reporting using certified EHR technology (CEHRT) or a data submission vendor
4. Qualified clinical data registry (QCDR) reporting
5. Group practice reporting

While these methods have all been established previously, and none of them are new for 2015, CMS has proposed significant changes to the numbers and types of measures that must be reported to avoid the penalties. We will not know for certain whether it will suffice to report one measure, three measures or nine measures as proposed until CMS issues the Final Rule on the Medicare Fee Schedule for 2015 next month. We will address those potential measure changes in connection with the two reporting methods of greatest interest to anesthesiologists, claims-based reporting and reporting to a QCDR.

Claims-Based Reporting

What we do know is that the method that has been used by most anesthesiologists, claims-based reporting, will continue to be available in 2015 (and probably longer). For 2014, EPs can earn a 0.5 percent incentive payment by reporting on a minimum of nine measures covering three National Quality Strategy (NQS) domains for at least 50 percent of the EP’s Medicare patients seen during the 2014 participation period. At least one of the nine measures submitted must be an outcome measure. Also in 2014, EPs can avoid the 2016 payment adjustment by meeting one of the following criteria:

• Satisfactorily participate and earn the 2014 PQRS incentive, or
• Report at least three measures covering one NQS domain for at least 50 percent of the EP’s Medicare patients

Both the 9/3 measures/domains required for the incentive payment and the 3/1 measures/domains required to avoid the penalty for 2014 are subject to the Measure Applicability Validation (MAV) process—see below—so one measure may be sufficient, if that is all that applies to the individual EP’s practice.

Beginning on January 1, 2015, there will be no further PQRS incentives available. In the Proposed Rule on the 2015 Fee Schedule, issued last July, CMS proposed that in order to avoid the 2017 penalty, EPs would be required to report on at least nine measures covering at least three NQS domains for at least 50 percent of Medicare Part B fee-for-service patients seen during the reporting period to which the measure applies (unless fewer than nine measures and three domains apply, again subject to the MAV process noted below). Additionally, if the EP sees at least one Medicare patient in a face-to-face encounter, the EP would need to report on at least two of the 18 measures contained in a proposed “cross-cutting” measure set that includes tobacco screening and pain assessment. These two cross-cutting measures would count toward the nine measures required to avoid the 2017 PQRS penalty.

Until CMS releases the Final Rule, we will not go into the details of the cross-cutting measures, because these could change—as could the other PQRS measures, as well as the number required to be reported. CMS has proposed to add 28 new individual measures and to remove 73 measures from the program. Among those proposed for deletion is Measure #30, the antibiotic prophylaxis measure reported by anesthesiologists, CRNAs and AAs, “due to eligible professionals consistently meeting performance on this measure with performance rates close to 100% suggesting there is no gap in care.” CMS also proposed to delete Measure #109, Osteoarthritis: Function and Pain Assessment.

The potential removal of Measure #30 and Measure #109 from the set that can be reported on claims (and through registries) makes it all the more important that CMS has proposed to continue to allow EPs to avoid the penalty by reporting one to eight measures, if those are all that apply to their individual practices. As explained in the Proposed Rule,

an eligible professional reporting on less than 9 measures would still be able to meet the satisfactory reporting criterion via claims and registry if the eligible professional reports on 1–8 measures, as applicable, to the eligible professional’s practice. If an eligible professional reports on 1–8 measures, the eligible professional would be subject to the MAV process, which would allow us to determine whether an eligible professional should have reported quality data codes for additional measures.

Readers will recall that the MAV process involves a two-part test. In the first phase, CMS will apply the clinical relation/domain test to determine whether closely-related measures in a predefined “cluster” could also have been submitted. Removal of Measure #30 would leave anesthesiology with just one cluster (Cluster Number 18: Anesthesia Care 2), and thus only if an anesthesiologist/CRNA/AA reported Measure #193, perioperative temperature management, would CMS check to see if that EP should also have reported Measure #76, the central venous catheter insertion protocol. The answer would depend on the second phase of the MAV process, the minimum threshold test. If the EP reported central venous catheter insertion codes in fewer than 15 cases during the relevant period, then reporting Measure #193 alone, in at least 50 percent of the Medicare cases to which it applied, would suffice to avoid the penalty for 2015—assuming that there are no surprise changes to these principles in the Final Rule.

One other PQRS principle that will remain constant in 2015 is the requirement that EPs report either having performed the applicable measures or having a valid reason for non-performance (modifier 1P) in order to avoid the penalty. Any claim with modifier 8P (which means that the measure wasn’t done and no reason is offered) will not count toward the threshold requirement of reporting the measure on 50 percent of the EP’s Medicare cases.

QCDR Reporting

With good reason—not least because of discussions at the recent ASA Annual Meeting—there is much excitement in the anesthesiology community about the new QCDR option.

The Anesthesia Quality Institute (AQI) received certification for the National Anesthesia Clinical Outcomes Registry (NACOR) as a QCDR in April 2014. A QCDR offers, among other things, an alternative method of reporting quality measures and avoiding the PQRS penalty for 2015 and beyond.

The greatest advantage of NACOR as a QCDR is that it includes 19 measures selected for their applicability to anesthesia practice. CMS launched the QCDR program partly in response to the concerns of specialties such as anesthesiology that do not have more than a handful of quality measures on the PQRS list. In their first year of operation, 2014, QCDRs were able to add up to 20 non-PQRS measures to the existing PQRS measures, and under the Proposed Rule the new maximum would be 30. The AQI initially added 11 measures developed with the involvement of ASA’s Committee on Performance and Outcome Measures to the eight PQRS measures identified as reportable by anesthesiologists. The NACOR/QCDR measure set is as follows:

Existing PQRS Measures:

Non-PQRS Measures:

1. Use of a checklist for post-anesthesia transfer of care, OR to ICU
2. Use of a checklist for post-anesthesia transfer of care, OR to PACU
3. Prophylaxis against postoperative nausea and vomiting, adults
4. Prophylaxis against postoperative nausea and vomiting, children
5. Composite anesthesia safety rate (outcome)
6. Perioperative cardiac arrest rate (outcome)
7. Perioperative mortality (outcome)
8. Rate of reintubation in the postanesthesia care unit (outcome)
9. Management of postoperative pain
10. Safety rate for central venous access (outcome)
11. Composite anesthesia patient satisfaction (outcome)

Detailed definitions and instructions for coding these measures can be found at http://www.aqihq.org/PQRSOverview.aspx.

Under the Proposed Rule, in order to avoid the penalty, EPs using the QCDR option for their PQRS reporting would report at least nine measures covering at least three NQS domains for at least 50 percent of their patients. CMS also proposes to increase the number of outcomes measures that EPs report from one, in 2014, to three out of the nine total measures going forward. These three outcomes measures would be counted toward the nine measures required to avoid the 2017 PQRS penalty. If three outcomes measures are not available, the EP would report on two outcomes measures and at least one of the following types of measures: resource use, patient experience of care and/or efficiency/appropriate use. As can be seen from the list above, NACOR has established six outcome measures, and the various NQS domains are well enough represented that an anesthesiologist participating in NACOR would have no difficulty meeting the requirement.

Other benefits of participating in the QCDR include receiving regular feedback as well as positioning for the phase-out and ultimate elimination of claims-based reporting. QCDR is also a way to meet the requirements of the Value-Based Payment Modifier program, which we will cover in next week’s Alert.

AQI participation is free to ASA members and any EPs working with them in the care team model. There is a fee for non-ASA members.

For more information, see Dr. Richard Dutton’s article The Qualified Clinical Data Registry in the Fall 2014 issue of the ABC Communique. You may also wish to participate in the ASA/AQI webinar Understanding PQRS and the new ASA QCDR on Tuesday, October 28, 2014 from 12:00 to 1:00 p.m. CDT. To register, enter your information at https://www2.gotomeeting.com/register/624752882. This webinar will be recorded and made available via http://asahq.org/qcdr and http://aqihq.org/qcdr for viewing at your convenience. It is open to anyone in an anesthesia practice concerned with the PQRS penalties.

Anesthesiologists who are already sending data to NACOR and who wish to take advantage of the QCDR option should create a process for collecting clinical outcomes intra-operatively and in the PACU, and should sign up with ASA (which will ascertain membership and the fee for participation, if any). Those who are not yet participating in NACOR should arrange preliminarily with the AQI to do so.

ABC is preparing to assist clients who wish to begin participating in the NACOR QCDR next year with both their registration and data collection. Although claims-based reporting remains a viable way to avoid the penalty, clients may be interested in exploring the QCDR option. To do so, they should begin by considering which nine of the 19 QCDR measures they will want to report and how they will go about collecting the data, and then contact their account managers.

We congratulate the AQI on launching its QCDR and look forward to helping our readers to understand the program as it evolves.

With best wishes,

Tony Mira
President and CEO