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CMS PQRS and VBPM Incentive/Penalty Programs
Devin Detwiler
Manager Quality Improvement
Telligen
Free Resource to you – Join our Network
Engage providers and stakeholders in improvement initiatives
through Learning and Action Networks including:
Learning Events
Spreading successful improvements/Best Practices
Discussion forums - encourage peer sharing
Resource library
Recorded events
Videos/Webinars
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Cardiovascular Health and Million Hearts
Meaningful Use
PQRS – Physician Quality Reporting System
Value Based Payment Modifier – Providers, ASCs, IPFs,
Hosp
Everyone with Diabetes Counts
Hospital Healthcare-Associated Infections
Nursing Home Quality Improvement
Hospital Readmissions/Care Transition/Community
Organizing
Medication Safety
PQRS Incentives – None
PQRS Incentive Payments
2015: 0%
Additional .5% for Maintenance of Certification
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Penalties – Payment Adjustments
PQRS Payment Adjustments
2016: -2.0% Based on 2014 reporting
If you did not report PQRS in 2014 you will see a 2% cut in
Medicare Part B Reimbursement on every line item
charge/payment on your EOB)
2017: -2.0%
2018: -2.0%
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2% Penalty Cost to MCB total payment
on allowable charges
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MC Part B
Allowable Charges
$50,000
2% Penalty
$75,000
$1,500
$100,000
$2,000
$125,000
$2500
$150,000
$3,000
$175,000
$3,500
$200,000
$4,000
$1,000
Eligible professionals who MUST participate in
Physician Quality Reporting*
– Physicians
MD, DO, Doctor of Podiatric Medicine, Doctor of Optometry,
Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of
Chiropractic
– Practitioners
PA, NP, Clinical Nurse Specialist, Certified Registered Nurse
Anesthetist (and Anesthesiologist Assistant), Certified Nurse
Midwife, Clinical Social Worker, Clinical Psychologist, Registered
Dietician, Nutrition Professional, Audiologists
– Therapists
Physical Therapist, Occupational Therapist, Qualified SpeechLanguage Therapist
*if they bill Medicare under their own NPI
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Eligible professionals who MUST participate in
Physician Quality Reporting in 2016
Beginning 2018 (reporting year 2016), the
payment adjustments will also apply to
non-physician EPs who are solo
practitioners or are in groups of 2 or more
EPs.
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Reassigned Benefits to Critical Access Hospitals
In 2015 professionals who have reassigned benefits
to Critical Access Hospitals and bill professional
services at a facility level such as CAH Method II
Billing may participate in PQRS using any reporting
method
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2015 PQRS Reporting Requirements
9 individual measures in 3 Domains
OR
1 Diagnostic Measure Group
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What is a Domain?
1. Patient and Family Engagement
2. Patient Safety
3. Care Coordination
4. Population/Public Health
5. Efficient Use of Healthcare Resources
6. Clinical Processes/Effectiveness
*Each measure listed has domain in 4th column
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Clinical Quality Measures that qualify for both
PQRS and Meaningful Use 2015
4 Clinical Quality Measures count as both
#46 – Medication Reconciliation
Domain: Patient Safety
#128 – Adult BMI – Assessment and Counseling
Domain: Community/Population Health
#130 – List Current Meds – Include sig for OTC
Domain: Patient Safety
#226 – Tobacco Use and Cessation Counseling
Domain: Community/Population Health
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Measurement Requirement – at least ONE of
these Cross Cutting Measures
PQRS
Number
Description
PQRS
Number
Description
1
HbA1c Control
226
Tobacco Use & Plan
46
Med Rec
236
Controlling High Blood
Pressure
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Care Plan
240
Childhood Immunizations
110
Influenza
317
HTN Screening & Plan
128
Pneumovax
318
Fall Risk Screening
130
BMI and Plan
321
CAHPS
131
Current Medications
374
Receipt of Specialist Report
134
Pain Assessment &
Plan
400
Hepatitis C Screening
182
Functional Outcome
Assessment & Plan
402
Tobacco Use & Plan in
Adolescents
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PQRS Reporting Requirements
Full Year of Data Required
OR
Diagnostic Measure Group on
20 MCB Patients
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Using CHAPS for 3 PQRS Measures
• Complete CAHPS Survey to receive credit for 3
PQRS Measures
• Must still report 6 additional measures from 2
domains
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What information is collected from CAHPS
• Getting timely care, appointments, and information
• How well providers Communicate
• Patient’s rating of provider
• Access to specialists
• Health promotion & education
• Shared decision making
• Health status/Functional status
• Courteous and helpful office staff
• Care coordination
• Between visit communication
• Helping patient to take medication as directed
• Stewardship of patient resources
Reference: http://acocahps.cms.gov/Content/Default.aspx#aboutSurvey for more
information on the CG CAHPS survey modules
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2015 PQRS Data Submission Deadline
March 31 Annually
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PQRS Reporting 2015
1.
2.
3.
4.
5.
Claims
Qualified Registry
Clinical Quality Registry*
EHR Direct
CEHRT using Data Submission Vendor
*MU Registry Qualification???
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2015 Changes Continued
Reporting Option
• Claims Measures
• Registry Measures
• EHR Measures
• GPRO Web Interface
• Measures Groups
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2014
110
201
64
22
25
2015
70
173
63
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Claims Based Reporting
• Medicare providers submit claims (via CMS-1500
Form) for reimbursement on payable services
rendered to Part B beneficiaries
• Eligible professionals use their individual NPI to
submit for services on Medicare Part B
beneficiaries
• Standardized reporting codes
Provider documents Quality Data Codes (QDC) on
claim
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How to Start Claims-Based Reporting
• Select measures most applicable to your practice (see
Measures List and Measures Specifications Manual)
• No registration is required, simply bill as you normally
would on the CMS-1500 form (or electronic equivalent)
• Add the applicable code for the measures you have
selected, Medicare Part B claims
• If you are using an EHR, speak to vendor about
functionality around claims submission
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Claims Based Example
Pneumonia Vaccination Example PQRS #111
DENOMINATOR:
Patients 65 years of age and older with a visit during the
measurement period (E&M code)
NUMERATOR:
CPT II Code 4040F: Pneumococcal vaccine administered or
previously received
OR
CPT II Code 4040F8P: Pneumococcal vaccine was not administered
or previously received, reason not otherwise specified
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Claims Based PQRS Coding
2
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3rd Party Registry Reporting
• What is a registry?
o Entity that captures and stores clinically related data
o Submits on behalf of providers (cost $250-$500)
o Some offer data mining tools (additional charge)
• PQRS “Participating” registries are updated
annually
• Data on applicable beneficiaries is reported to
registry via secure portal manually, data mining
software, or through EHR vendor
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Clinical Data Registry
New Qualified Clinical Data Registry
• These specialty societies can report up to 20 non-PQRS
measures as approved
•
A QCDR is different from a qualified registry in that it is
not limited to measures within PQRS
- Measures used by boards or specialty societies, and
-Measures used in regional quality collaborations
-CG CAHPS-Clinician & Group Consumer Assessment of Healthcare
Providers and Systems
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Clinical Data Registry
Examples of Clinical Registries
Asthma
Anesthesia
Cardiology
Metabolic and Bariatric
Radiology
Urological Surgery
Rheumatology
Osteoporosis
Gastroenterology
Renal
Surgery
Thoracic Surgeons
Oncology
Wound Care
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EHR Direct Reporting
• Report on ≥ 9 PQRS quality measures for 2015
calendar year using qualified EHR Vendors
– eMDs, Aprima, Success EHS, Vitera,
• Practice submits measures to CMS via secure portal
– IACS (Individual Authorized Access to the CMS Computer Services)
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Data Submission Vendor
• EHRs that are 2014 CEHRT must have the
capability to do CQM reporting for MU and PQRS
– NextGen, Greenway, eCW, Athena, Allscripts
• PQRS measures are pulled from the EHR - they
are not pulled from claims data or the PMS
(billing system)
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What if I can’t find 9 Applicable Measures?
MAV
Measure-Applicability Validation
• Eligible Professionals or Groups who satisfactorily report
on fewer than 9 PQRS measures and/or fewer than 3
domains will be subject to the MAV Process
• The MAV Process determines if additional measures or
measures in other domains should have been submitted
to be considered for incentive eligibility
• All EPs and Groups that have submitted PQRS via claims
or registry could be subject to MAV
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Individual vs Group PQRS Reporting
PQRS Group Practice Reporting Option (GPRO)
• A “group practice” under 2014 PQRS consists of a
physician group practice, as defined by a single
Tax Identification Number (TIN), with 2 or more
individual EPs, as identified by individual National
Provider Identifier or NPI
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GPRO PQRS Reporting 2015
Practices must register to participate in PQRS through the
GPRO
Registration will be held April 1 - June 30, 2015
Registration is completed through the Physician
Value (PV)-PQRS registration system:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service
Payment/PhysicianFeedbackProgram/Self-NominationRegistration.html
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PQRS Group Practice Reporting Option
(GPRO)
• Determine Reporting Method
• Group practices will need to determine the best reporting
method for the group.
• Groups 2+
Qualified Registry – 3rd party (not clinical)
Electronic Health Record (EHR) Direct Reporting
Data Submission Vendor
GPRO Web Interface Reporting (all 19 measures)
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PQRS Group Practice Reporting Option
(GPRO)
• One TIN/Individual EP NPIs
• Agree to have the results on performance of their
PQRS measures publicly posted on the Physician
Compare Website
• Once you sign up as a group you cannot change
your mind
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PQRS and Maintenance of Certification
Additional 0.5% Incentive Payment
Satisfactory PQRS Submission
AND
More Frequent participation and reports to MoC program
Information on the survey of patient’s experience, MoC
methods, measures and data for practice assessment
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VBPM
Quality Tier Approach in 2014
• In 2015 each group receives two composite scores (quality
of care and cost of care), based on the group’s
standardized performance (e.g. how far away from the
national mean). This approach identifies statistically
significant outliers and assigns them to their respective
cost and quality tiers.
• Eligible for an additional +1.0% Incentive if: Reporting
quality measures via the web based interface or registries
AND −Average beneficiary risk score in the top 25% of all
beneficiary risk scores
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Composite Score – VBPM Program
• Composite Quality Score – based on reported
PQRS data
• Composite Cost Score – Total Cost for the
Medicare Beneficiary under Part A and Part B
programs
• Composite Risk Score – Assigned Patient Panel
with risk scoring (above the 75% qualifies for
additional incentive payments)
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Composite Score – VBPM Program
• Total per capita costs for beneficiaries with 4 chronic
conditions:
 Chronic Obstructive Pulmonary Disease (COPD)
 Heart Failure
 Coronary Artery Disease
 Diabetes
• All Cause 30 Day Hospital Readmission
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The Value Based Payment Modifier
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2015 VBPM Quality-Tier Approach
10+ Providers 2015 Reporting Year/2017 Adjustment Applied
3
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Quality/Cost
Low Cost
Average Cost
High Cost
High Quality
+2.0%
+1.0%
+0.0%
Average Quality
+1.0%
+0.0%
-0.5%
Low Quality
+0.0%
-0.5%
-1.0%
2015 VBPM Quality-Tier Approach
All Providers 2017 Based on 2015 Data
Quality/Cost
Low Cost
Avg Cost
High Cost
High Quality
+2%*
+1%*
0
Average Quality
+1%*
0
0
Low Quality
0
0
0
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Incentive/Penalty Value Based Payment
Modifier
All Providers 2018 Based on 2016 Data
Quality/Cost
Low Cost
Avg Cost
High Cost
High Quality
+2%*
+1%*
0
Average Quality
+1%*
0
-.5%
Low Quality
0
-.5%
-1%
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Incentive/Penalty Value Based Payment
Modifier
All Providers 2019 Based on 2017 Data
Quality/Cost
Low Cost
Avg Cost
High Cost
High Quality
+2%*
+1%*
0
Average Quality
+1%*
0
-1%
Low Quality
0
-1%
-2%
*Eligible for an additional +1.0x if reporting clinical data for quality measures AND
average beneficiary risk score in the top 25 percent of all beneficiary risk scores.
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QUALITY AND RESOURCE USE REPORT
• QRUR
– Report to see your Value Based Payment Modifier
Score. Will detail each of the measures and how you
scored.
– Will come out in September of each year and include a
providers patient panel.
– 85% will receive no adjustment. 15% will either
receive an incentive OR a penalty
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Physician Compare Website and Resources
•Website URL:
–http://www.medicare.gov/physiciancompare
•Data on Physician Compare comes from PECOS
–https://pecos.cms.hhs.gov/pecos/login.do
•Specialty is as reported on your Medicare Enrollment Form
•Physician Compare support team
–PhysicianCompare@Westat.com
Physician Compare information and updates
–http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/physician-compare-initiative/
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Bringing it all together – MU, PQRS, VBPM
• Chronic Care Mgmt - $42 Reimbursement for 2
chronic conditions – MU Stage 2 - Generate at least 1
patient list by specific condition. Use secure
messaging to patients. Patient Education.
• 5 Clinical Decision Support Tools in EHR for stage 2 –
related to 4+ clinical quality measures
• Clinical Data Registries – also count for MU Stage 2?
• MU Stage 2 - Patient Reminders – use this to improve
clinical quality measure. Use patient portal
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Will you join us?
Thank You for your time!
Devin Detwiler
303-875-9131
Devin.Detwiler@HCQIS.org
For more information or to sign up for the program!
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This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado,
under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS
policy. 11SOW-CO-B1-09/14-004