A POPULATION HEALTH MANAGEMENT COMPANY

FAQ

PQRS (11)

What is an inverted measure?

Inverted Measures:

  • Measures included: 1, 123, 146, 164, 165, 166, 167, 168, 192, 322, 323, 324, 328, 329, 330, 331, 333, 334, 345, 346, 347, 348, 388, 392, 393
  • Desired Performance Rate: 0.00%
  • Performance Rates that will count toward reporting: 0.00% – 99.99%
  • Null Performance Rate = 0/0, will count toward reporting
  • 100% Performance Rate: A rate of 100.00% disqualifies the measure and it will not count towards reporting

Non-inverted Measures:

  • Desired Performance Rate: 100.00%
  • Performance Rates that will count toward reporting: 0.01% – 100%
  • Null Performance Rate = 0/0, will count toward reporting
  • 0% Performance Rate: A rate of 0.00% disqualifies the measure and it will not count towards reporting

Group Reporting vs. Individual Reporting

We help you decide which works better and/or which is required for your practice.

How do I submit for PQRS?

We do it for you.

How do I determine reporting results?

In the fall of the year following the reporting year, CMS will post feedback reports on their website, which tell the practice how they performed on their PQRS reporting.  You must have an EIDM account to see the feedback report for a given provider or practice.  You can access feedback reports at the following website:

https://www.qualitynet.org/

How do I read the CMS Individual Specification Manual?

Use the following outline to determine how to read the specifications.

Denominator Data

Eligible Instances: The number of instances (patients, visits, episodes, etc.) that meet all eligibility criteria for a specific measure of interest, as explained in the 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures (2015 PQRS Measure Spec Manual).

Example of a measure denominator description, from the 2015 PQRS Measure Spec Manual:

  • Measure #12 (NQF 0086): Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Numerator Data

The numerator must detail the clinical quality action expected that satisfies the condition(s) and is the focus of the measurement for each patient, procedure or event established by the denominator. The numerator options are “MET” and “NOT MET” for all measures with some measures having the additional option of “EXCLUDED”. Under “Numerator” in the 2015 PQRS Measure Spec Manual, the options will be separated by “OR”. The order will be MET, NOT MET if there is no EXCLUDED option. The order will be MET, EXCLUDED, NOT MET if there is an EXCLUDED option.

Performance Met: The number of eligible instances that meet the “MET” criteria. The “MET” criteria is listed first under “Numerator” in the 2015 PQRS Measure Spec Manual.

Performance Exclusion: The number of eligible instances that meet the “EXCLUDED” criteria. The “EXCLUDED” criteria is listed between the “MET” and “NOT MET” criteria under “Numerator” in the 2015 PQRS Measure Spec Manual. *This does not apply to every measure.

Performance Not Met: The number of eligible instances that meet the “NOT MET” criteria. The “NOT MET” criteria is listed last under “Numerator” in the 2015 PQRS Measure Spec Manual.

What is a TIN?

TIN stands for Tax Identification Number.

Can GPROs report on Measures Groups?

No, GPROs can only report on individual measures for PQRS.

What is the difference between GPRO and Measures Groups?

GPRO stands for Group Practice Reporting Option and is a method for a practice/TIN to submit Individual Measures to CMS for PQRS reporting. As a GPRO, a TIN can report and submit Individual PQRS Measures that are aggregated at the TIN level. GPROs can only report on Individual Measures for PQRS and must follow the same requirements.

Measures Group reporting is a different method for PQRS reporting. There are 22 Measures Groups that are measures grouped by specialty or diagnosis. If a provider reports on a Measures Group, he/she must report on 1 Measures Group for at least 20 patients (at least 11 of which must be Medicare Part B patients) that are eligible for the Measures Group. Then, the provider must answer the quality action for each patient for each measure that is included within the Measures Group. Each Measures Group has at least 6 measures, and each measure must have a satisfactory performance rate in order to avoid the PQRS penalty. Providers that are part of a GPRO cannot report on Measures Groups.

What does MAV stand for?

Measures Applicability Validation; this is a process that CMS undertakes when a provider/practice has not met the minimum reporting criteria for a specific reporting year.

What if I can’t report the minimum number of measures?

The Measures Applicability Validation (MAV) process will be invoked by CMS to review the data that has been submitted and will determine whether or not the practice/provider has submitted satisfactorily for the reporting year.

Meaningful Use (2)

Who are eligible professionals and hospitals?

UNDER MEDICARE

Eligible Professionals

  • Doctor of medicine or osteopathy
  • Doctor of dental surgery or dental medicine
  • Doctor of podiatry
  • Doctor of optometry
  • Chiropractor

Eligible Hospitals

  • “Subsection (d) hospitals” in the 50 states or DC that are paid under the Inpatient Prospective Payment System (IPPS)
  • Critical Access Hospitals
  • Medicare Advantage (MA-Affiliated) Hospitals

UNDER MEDICAID

Eligible Professionals

  • Physicians
  • Nurse practitioner
  • Certified nurse-midwife
  • Dentist
  • Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant

Eligible Hospitals

  • Acute care hospitals (including CAHs and cancer hospitals) with at least 10% Medicaid patient volume
  • Children’s hospitals (no Medicaid patient volume requirements)

Reference: EHR Incentive Programs: Eligibility.  CMS.gov. Center for Medicare & Medicaid Services. Last Modified May 17, 2012.

How do I know which EHR products are certified to report meaningful use?

The Office of the National Coordinator for Health Information Technology (ONC) maintains the Certified Health IT Products List (CHPL). On this list you will find a complete list of EHRs and EHR Modules that have been tested and certified.

ReportingMD has been tested and is ONC Certified to report Meaningful Use.

Value Based Payment Modifier (8)

What is the VBM?

The VBM Program evaluates the performance of a provider or groups of providers on the quality and cost of care provided to FFS Medicare attributed beneficiaries.

Where can I obtain the cost and quality performance information?

CMS disseminates the cost and quality performance for the solo practitioner or the practice TIN in the Quality and Resource Use Reports (QRURs), which can be obtained via an EIDM account. QRURs are released in the fall of the year following the program year.

How are beneficiaries attributed to me or my TIN?

There is a 2-step attribution process.

Step 1: Beneficiaries are assigned to the group who had a plurality of primary care services (as measured by allowed charges) rendered by primary care physicians, NPs, PAs, or CNSs in the group. If a beneficiary is non-assigned under Step 1, proceed to Step 2.

Step 2: Beneficiaries are assigned to the group practice whose affiliated non-primary care physicians provided the plurality of primary care services (as measured by allowed charges).

I am part of an ACO. Does the VBM apply to me?

Yes. The VBM will apply to physicians in TINs that participate in the Shared Savings Program, Pioneer ACO Model, CPC Initiative, or other similar Innovation Center models or CMS initiatives during the CY 2015 performance period.

What is a TIN’s maximum VBM penalty if I report PQRS?

The maximum downward adjustment depends on the size of the TIN.

Groups with 2-9 EPs and physician solo practitioners are held harmless from any downward adjustments under quality-tiering in 2017.

Groups with 10 of more EPs, under quality-tiering in 2017, can receive a maximum downward adjustment of -4.0%.

What is the maximum VBM penalty if I do not report PQRS?

For groups 2-9 EPs, solo practitioners and non-physician practitioners, an automatic -2.0% VBM downward adjustment will be applied for failing to meet the satisfactorily reporting criteria to avoid the 2017 PQRS penalty. This is -2.0% VBM downward adjustment is in addition to the automatic PQRS penalty of 2.0%.

For groups of 10 or more EPs, an automatic -4.0% VBPM downward adjustment will be applied for not meeting the satisfactory reporting criteria to avoid the 2017 PQRS payment adjustment. This is -4.0% VBM downward adjustment is in addition to the automatic PQRS penalty of 2.0%.

Can my TIN receive an upward adjustment from the VBM?

Yes, depending on the TIN’s standardized cost and quality composite scores as compared to the national average. The standardized cost and quality scores are displayed as the distance, in standard deviations, from the national average. Depending on how far each score is, in standard deviations, from the national average, either upward, neutral or downward adjustments are given. The maximum upward adjustments also depend on the size of the TIN.

Groups with 2-9 EPs and physician solo practitioners, under quality-tiering in 2017, can receive a maximum upward adjustment of 2.0%.

Groups with 10 of more EPs, under quality-tiering in 2017, can receive a maximum upward adjustment of 4.0%.

Please note that this program is budget neutral, so the upward adjustments are taken from the penalty pull and may not result in the full 2.0% or 4.0% of Medicare claims.