PQRS Refresher for Anesthesiologists, CRNAs and Pain Physicians

Participating in Medicare’s Physician Quality Reporting System (PQRS) has taken on a new flavor this year.  While until now participating has meant a potential annual bonus of several thousand dollars, not reporting in 2013 will entail a penalty in 2015.  Losing out on a bonus is less galling than forfeiting a percentage of each remittance.  No anesthesiologist, CRNA or pain physician is doomed to lose money for failing to report the applicable PQRS measure(s).  This Alert will provide a reminder of the steps you need to take to earn the bonus and to avoid future penalties.

It is a testament to the undue complexity of the program that we are now in its seventh year, and yet uncertainty lingers.  As a reminder, the incentive payments and “payment adjustments” for each year are as follows:

Year Payment/Adjustment Made	Reporting Year	Payment or (Adjustment)
2008	2007	1.5%
2009	2008	1.5%
2010	2009	2.0%
2011	2010	2.0%
2012	2011	1.0%
2013	2012	0.5%
2014	2013	0.5%
2015	2014	0.5%
2015	2013	(1.5%)
2016 onward	2014 onward	(2.0%)

 

Transition from a Positive to a Negative Payment:

If you successfully report in 2013, early in 2014 you will receive a bonus payment equal to 0.5% of your 2013 Medicare allowables.  If, however, you do not successfully report the requisite PQRS measures this year, not only will you give up the 0.5% bonus, but two years later, in 2015, your remittances will be reduced by 1.5%—i.e., you will be paid 98.5% of the Medicare Fee Schedule amount that would otherwise apply.  Similarly, failure to meet the minimum reporting requirements in 2014 will result in payments of just 98% of the Medicare amount in 2016.

Earning the Incentive Payment for 2013:

As in previous years, the most familiar way for anesthesiologists, pain physicians and CRNAs to report the PQRS quality measures is via claims-based individual measures.  The “eligible professional” (EP) simply includes the appropriate 5-digit Quality Data Code (QDC) on the claim submitted to Medicare.  The EP must:

• Report at least three PQRS measures; OR
• If fewer than three measures apply to the eligible professional, report 1-2 measures; AND
• Report each measure for at least 50% of the eligible professional's Medicare Part B FFS patients seen during the reporting year to which the measure applies.

The three measures applicable to surgical anesthesia are once again:

• Measure #30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
• Measure #193 Perioperative Temperature Management
• Measure #76 Prevention of Catheter-Related Bloodstream Infections

Pain physicians who do not perform any surgical anesthesia cases can choose from a number of PQRS measures that can be reported with evaluation and management (E&M) services, including the following:

• Measure #130 – Documentation of current medications in the medical record
• Measure #131 – Pain Assessment and follow-up using a standardized tool to measure pain level and follow-up plan.
• Measure #128 – Preventive Care and Screening:  Body Mass Index (BMI) Screening and Follow-up (if the patient is eligible and outside normal BMI limits, must document follow-up plan)
• Measure #226 – Preventive Care and Screening:  Tobacco Use:  Screening and Cessation Intervention

Detailed instructions for reporting all of the measures are available in the 2013 Measure Specifications available on the PQRS website, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/.

The specifications for Measures #30, #76, #193, #130, #131, #128 and #226 can be downloaded from the ABC Website, www.anesthesiallc.com.

One? Two? Or Three Measures?

According to CMS, EPs “who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. For those eligible professionals who satisfactorily submit QDCs for fewer than three PQRS measures, a measure-applicability validation (MAV) process will determine whether they should have submitted QDCs for additional measures.”

Physicians and CRNAs, therefore, can qualify for the PQRS bonus without reporting on all three measures, although the safest course is to attempt to report no fewer than three measures. If an EP reports fewer than three measures, CMS will use the Measure Applicability Validation (MAV) test to determine whether there are other measures that the EP should have reported. The MAV is a two-part test. First CMS will examine whether other services were clinically related and therefore potentially applicable. “Clinical relation,” for these purposes, has been defined in a set of measure “clusters.”  Second, CMS will apply a minimum threshold test to see whether another measure in the cluster was applicable to the EP’s practice because s/he had reported it at least once. If the EP reports any measure 15 or more times throughout 2013, it will apply, and he or she will need to report the measure in at least 50% of eligible Medicare cases in order to earn the incentive payment.

There are still just two anesthesia clusters:

• Cluster 31	Anesthesia Care 1	Measure #30 and Measure #76
• Cluster 32	Anesthesia Care 2	Measure #76 and Measure #193

 

(When reporting #76 alone, without any instances of Measure # 30 or Measure #193, it is not subject to MAV)

Because of the complexities of the MAV process and the possibility that an EP may lose an expected bonus through that process, we believe that the most conservative strategy is for every EP to report at least three measures.  CMS will only apply the MAV test if the EP reports fewer than three measures.  Why take the risk?

Reporting Methods

The most common method of reporting individual PQRS measures is through the use of a five-digit code (“Quality Data Code” or QDC) placed on the claim.  Anesthesiologists may alternatively report through a qualified registry (such as the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry or NACOR).  To earn the incentive through registry reporting, EPs must report at least three measures, and report each measure for at least 80 percent of the EP’s Medicare patients seen during the reporting period to which the measure applies.  A third option involves reporting through an electronic health record (EHR), which we will discuss in a later Alert if reader interest warrants.

PQRS also provides for reporting defined measures groups instead of the individual measures discussed in this Alert.  Measures groups are of marginal relevance to our readers and we will likewise defer that topic to a later discussion.

Avoiding the Payment Penalty in 2015

The good news is that EPs can avoid the 2015 payment adjustment by reporting “at least” one valid measure via claims, registry, or qualified EHR.  Qualifying for the bonus by satisfactorily reporting the applicable number of measures in 2013 will also exempt the EP from the penalty.  As noted above, in the interest of maximum simplicity and income protection, anesthesiologists, pain physicians and CRNAs may want to identify and report on no fewer than three measures.

A third method of avoiding the penalty will involve affirmatively electing to participate in CMS’ new PQRS administrative claims reporting mechanism by October 15, 2013.  CMS will make available details on how to choose this option later in the year.

Groups of 100 or more EPs – Watch out for the Value-Based Payment Modifier (VBM)

Last but not least, new rules impose a new mandate on groups of 100 or more EPs.  Those large groups must sign up in 2013 for one of the three PQRS group reporting options&mdash even if their members choose to participate in PQRS at the individual level—in order to avoid a potential 1% payment penalty under the VPM in 2015.  Group practices with 100 or more physicians that do not participate in PQRS in 2013 will automatically receive a VBM of ?1.0% in 2015, according to CMS. That pay cut would come on top of the 1.5% reduction for not successfully reporting quality data in PQRS in 2013.

We will leave a full discussion of the VBM for next week’s Alert.  The PQRS is sufficiently complex for now.  ABC will work with all of our clients to help you qualify for the PQRS incentive payments, as long as those remain available, and avoid any PQRS or VBM penalties.  We will also continue to publish information on this complex and dynamic subject.