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Clinical Quality Measures and PQRS Reporting with Practice FusionPresented by:Sophie Scheidlinger
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+Emerging movement in healthcare where providers are compensated based on: Quality of the service that they provide to patients How well they can improve health outcomes
+Quality of care is evaluated using evidence-based quality measurement
+Public and private payers participating in Pay for Quality initiatives
Pay for Performance (Pay for Quality)
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+Government-run Pay for Performance Initiatives+ Incentivize or penalize providers to encourage
adoption of health technology and reporting of Clinical Quality Measures (CQMs)
+Examples include: EHR Incentive Program (Meaningful Use) Physician Quality Reporting System (PQRS) Accountable Care Organizations (ACOs) Comprehensive Primary Care initiative (CPCi) Chronic Care Management (CCM)
Physician Quality Programs
+Requirement: Report at least 9 CQMs that relate to at least 3 National Quality Strategy (NQS) domains:
+CMS selected 9 recommended CQMs for adult and pediatric populations Practice Fusion supports the CMS recommended
CQMs for the adult population Practice Fusion’s CQMs cover all 6 NQS domains
Meaningful Use CQM Reporting Requirements
Patient and Family Engagement Patient Safety
Care Coordination Population and Public Health
Efficient Use of Healthcare Resources Clinical Processes/Effectiveness
CQM Reporting Methods
+ Medicare providers will submit CQMs to CMS electronically or via attestation
+ Medicaid providers must submit CQM data to their State Medicaid Agency
+ Reporting period: Entire calendar year or 90 day reporting period
+ Electronic submission for 2015: January 1, 2016 – February 29, 2016 Medicare EPs have the option to submit a full year of data electronically to receive
credit for the EHR Incentive Program and the Physician Quality Reporting System (PQRS) if using the PQRS EHR reporting mechanism.
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+The PQRS is a CMS quality improvement program that uses incentives and penalties to promote reporting of quality data
+Eligibility Providers who see Medicare Part B patients and are
reimbursed under the Medicare Physician Fee Schedule (PFS)
Physicians, chiropractors, dentists, PAs, NPs, and others
+2015 Incentives and Penalties No incentive or -2% penalty in 2017
Physician Quality Reporting System (PQRS)
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+ PQRS is very complex - PQRS requirements vary based on the reporting mechanism that you choose. Complexities mean more options, but you need to become familiar with the requirements that apply to the option that you are using.
+ PQRS requirements are specific to each calendar year – eligible PQRS measures, G-codes, reporting requirements, etc. may change from year to year, so make sure you refer to 2015 resources. The 2015 PQRS reporting period is January 1, 2015-December 31, 2015.
+ PQRS actions don’t roll-over – Reporting for a particular year will affect your reimbursements in 2 years.
Important PQRS Facts
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+ PQRS measures consist of two major components: Denominator: describes the eligible cases for a measure
(the eligible patient population) Numerator: describes the clinical action required by the
measure for reporting and performance + Each component is defined by specific clinical codes
described in each measure specification along with reporting instructions.
+ For measures eligible for EHR reporting, Practice Fusion has implemented the measure according to very specific guidelines (including how data must be collected and how the measure is calculated).
Understanding PQRS Measures
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+ To avoid the 2017 PQRS payment adjustment of 2%, you must use one of the following reporting options:
Avoiding the 2017 PQRS Payment Penalty
Claims-Based Reporting
Registry Reporting
Qualified Clinical Data Registry (QCDR) Reporting
Group Practice Reporting Option (GPRO) Reporting
EHR Reporting*EHR Reporting is the only option that Practice Fusion supports
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+ Measures with a zero value denominator cannot be used for PQRS
+ The PQRS measurement period length is a full calendar year, so for 2015 it would run from January 1, 2015 through December 31, 2015.
+ Practice Fusion will act as a Direct EHR Vendor (EHR Direct) PF will allow providers to generate a file to attest to CMS with as
individuals who choose this reporting option You can do this from the PQRS Clinical Quality Measures
Dashboard
EHR Reporting for PQRS
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+ The following factors should be considered when selecting measures for reporting: Clinical conditions usually treated Types of care typically provided – e.g., preventive, chronic, acute Settings where care is usually delivered – e.g., office, emergency
department (ED), surgical suite Quality improvement goals for 2015 Other quality reporting programs in use or being considered Those available under your selected PQRS reporting option Those that apply to your Medicare patients
PQRS Measure Selection
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+ MAV is a validation process that will determine whether individual eligible professionals or group practices should have reported additional measures OR additional domains.
+ MAV determines 2017 PQRS payment adjustment status for individual providers and group practices.
+ MAV is applied to individual providers and group practices that report less than nine measures OR less than three domains for PQRS. If MAV analytically determines that the provider or group practice could have reported additional measures or domains within the clinical cluster, then the 2017 PQRS payment adjustment may apply.
+ Claims-based MAV is applicable to individual EPs, whereas registry-based MAV is applicable to individual EPs and group practices.
Measure-Applicability Validation (MAV)
+An Enterprise Identity Management (EIDM) account CMS transitioned all IACS accounts to EIDM in July 2015
An individual in your organization (who does not plan to submit) or solo providers will first need to register for an Approver Role
Afterwards, the individuals who plan to submit will need to register for a PQRS Submitter Role
CMS resources include an EIDM toolkit
+ Individual NPI number
+Tax Identification Number (TIN)
Information you will need to attest
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Practice Fusion Product Demonstration
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• The population of patients or encounters for which the measure applies. Denominator
• The population of patients from the denominator who meet the measure specified clinical requirements or the population of encounters from the denominator where the measure specific requirement has been performed.
Numerator
• Specifications that would remove a patient from the denominator of a specific quality measure.
• Includes certain diagnoses that make it clinically unnecessary for the patient to receive the numerator clinical action and/or provider or patient determined reasons for refusing certain clinical actions.
Exclusion/Exception
• This is also known as the EHR reporting period and refers to the time frame for which the CQMs will be calculated.
Measurement Period
CQM Terminology
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• The six NQS domains, one of which is assigned to each CMS eCQM, are: Patient and Family Engagement, Patient Safety, Care Coordination, Population and Public Health, Efficient Use of Healthcare Resources, and Clinical Processes/Effectiveness
National Quality Strategy (NQS)
Domains
• NQF reviews, endorses, and recommends use of standardized quality measures. Not all quality measures are “NQF-endorsed,” but those that are have an assigned NQF number.
National Quality Forum (NQF)
• Lists of specific values (terms and their codes) derived from single or multiple standard vocabularies used to define clinical concepts (e.g. patients with diabetes, clinical visit, reportable diseases) used in clinical quality measures and to support effective health information exchange.
Value sets
• An HL7-based standard document format for reporting clinical quality measure data to CMS for quality improvement programs.
Quality Reporting Document
Architecture (QRDA)
CQM Terminology
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CMS eMeasureID
NQF number
CQM title NQS domain
CMS2v4 0418 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Population and Public Health
CMS22v3 N/A Screening for High Blood Pressure and Follow-Up Documented
Population/Public Health
CMS50v3 N/A Closing the referral loop: receipt of specialist report
Care Coordination
CMS68v4 0419 Documentation of Current Medications in the Medical Record
Patient Safety
CMS69v3 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Population and Public Health
CMS90v4 N/A Functional Status Assessment for Complex Chronic Conditions
Patient and Family Engagement
CMS122v3 0059 Diabetes: Hemoglobin A1c Poor Control
Clinical Process and Effectiveness
CMS123v3 0056 Diabetes: Foot Exam Clinical Process and Effectiveness
Practice Fusion Supported CQMs
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CMS eMeasureID
NQF number
CQM title NQS domain
CMS124v3 0032 Cervical Cancer Screening Clinical Processes/Effectiveness
CMS125v3 0031 Breast Cancer Screening Clinical Processes/Effectiveness
CMS126v3 0036 Use of Appropriate Medications for Asthma
Clinical Processes/Effectiveness
CMS127v3 0043 Pneumonia Vaccination Status for Older Adults
Clinical Processes/Effectiveness
CMS130v3 0034 Colorectal Cancer Screening Clinical Processes/Effectiveness
CMS131v3 0055 Diabetes: Eye Exam Clinical Processes/Effectiveness
CMS138v3 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Population and Public Health
CMS139v3 0101 Falls: Screening for Future Fall Risk Patient Safety
Practice Fusion Supported CQMs
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CMS eMeasureID
NQF number
CQM title NQS domain
CMS144v3 0083 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Clinical Processes/Effectiveness
CMS147v3 0041 Preventative Care and Screening: Influenza Immunization
Population/Public Health
CMS149v3 N/A Dementia: Cognitive Assessment Clinical Processes/Effectiveness
CMS153v3 0033 Chlamydia Screening for Women Clinical Processes/Effectiveness
CMS155v3 0024 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Population/Public Health
CMS156v3 0022 Use of High-Risk Medications in the Elderly
Patient Safety
CMS163v3 0064 Diabetes: Low Density Lipoprotein (LDL) Management
Clinical Processes/Effectiveness
CMS164v3 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
Clinical Processes/Effectiveness
Practice Fusion Supported CQMs
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+PQRS Center www.practicefusion.com/pqrs
Resources for PQRS
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+ PQRS Clinical Quality Measures Dashboard For you to monitor your progress on your Clinical Quality Measures Click on the measure names to get to a detailed knowledge base article
on the CQM Allows you to select CQMs you wish to report Allows you to generate a file to submit to CMS
Resources for CQMs
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+Practice Fusion is not able to offer individual guidance on choosing PQRS measures or reporting options that are not EHR reporting.
+ If you have questions regarding individual measures or how PQRS requirements apply to you, please reach out to the CMS QualityNet Help Desk.
CMS QualityNet Help DeskPhone: 866-288-8912,
TTY: 877-715-6222Email: [email protected]
Need Individual Help with PQRS?
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Frequently Asked QuestionsPQRS and CQMs
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+A: Most health care providers who are reimbursed under the Medicare Physician Fee Schedule are eligible for PQRS.
+For additional details and a list of eligible PQRS providers go to: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html
Q: How do I find out if I’m eligible for PQRS?
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+ A: PQRS offers over 300 quality measures, which can be reported using various reporting mechanisms (although not all measures are available for all reporting options).
+ If you wish to use Practice Fusion, you only have the measures we support available to use for PQRS reporting. You may report less than 9 measures if you meet the other EHR reporting criteria, but you will be subject to the Measure Applicability Validation process which means you may not earn the incentive (although you could avoid the penalty).
+ If you are a specialty provider who wants to report PQRS measures that are not available for EHR reporting, we suggest looking into other reporting mechanisms.
Q: Practice Fusion’s CQMs don’t apply to my specialty. How will I participate in PQRS?
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+PQRS is a separate and distinct program from Meaningful Use. Providers who do not report for PQRS in 2015 will be subject to a 2% payment penalty – regardless of whether or not they successfully participate in Meaningful Use.
Q: I’m participating in Meaningful Use this year,will there be penalties if I don’t also participate in PQRS?
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+A: The EHR reporting option for PQRS require that providers report CQM data for all patients, regardless of their insurance status. Providers will report data for all patients whom the CQM applies that have data in the EHR.
Q: Does PQRS EHR Reporting only apply to Medicare patients?
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+A: Please reach out to the CMS QualityNet Help Desk.
CMS QualityNet Help DeskPhone: 866-288-8912,
TTY: 877-715-6222Email: [email protected]
Q: How do we check if we have completedPQRS successfully with Medicare?
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+A: Unfortunately not. Your participation in 2014 determined your penalty in 2016. To avoid a 2017 penalty, be sure to report successfully for the 2015 reporting period.
Q: I received notification from Medicare that I will be penalized in 2016. Is there anything I cando now to avoid this?
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+We have recorded this session, and will make the slide deck and recording available on our Tutorials Center
Q: Will a recording of the webinar be madeavailable?
