How Long Do I Have to Report?

PQRS and You 2014

ABOUT PQRS

PQRS is a reporting program, mandated by federal legislation that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EP’s).

The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

Beginning in 2015, the program also applies a payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.

How long do I have to Report?

You have two options for how long you report.

1 year period (January 1st - December 31st)
6 month period (July 1st – December 31st)

Which one you choose may depend on how long you have been on Falcon Physician and whether you plan on reporting via group or individual measures (more information below).

Do I have to Sign Up

No upfront registration is required.
Falcon will communicate with EP’s in the late summer/early Fall to determine if they would like to consent to have their PQRS data submitted on their behalf by Falcon.
Falcon is considered a certified registry and we submit data via the registry method.

What is the Incentive?

Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data for services furnished during the 2014 reporting period will qualify to earn an incentive payment. If they qualify, they will receive an incentive payment equal to 0.5% of their total estimated Medicare Part B PFS allowed charges for covered professional services furnished during that same reporting period.

What is the Penalty/ Payment Adjustment?

EPs who do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2% payment adjustment to their Medicare PFS amount for services provided in 2016.

What do I have to report?

You have two options for what you report:

Individual Measures:

For the 12 month reporting period, choose at least none (9) measures from all of the individual measures that Falcon EHR offers.

Group Measures:

For the 6 or 12 month reporting period, choose the CKD measure group. Report all measures in the group.

Falcon has chosen measures from each of these categories that are applicable to Nephrologists and made it easy for you to report directly on the Superbill. You do not need to decide in advance whether you will be reporting the group or individual measures.

Reporting Individual Measures

You must have at least one patient “meet performance” or be in the numerator of the measure.

Reporting CKD Group Measures

Instead of picking and choosing measures, you can instead choose to select the CKD measure group. You have a couple of options in regards to reporting.

If you are reporting for the 1-year or the 6-month period:

• Report on minimum of 20 unique sample patients (11 of which need to be Medicare Part Bpatients) (Same 20 patients in the denominator for each measure)

The CKD measure group consists of:

How do I report the measures?

Falcon is a certified registry for reporting PQRS so Falcon Physician will assist you at the beginning of 2015 to collect the appropriate measure data for 2014 PQRS from the Falcon Physician system and format properly and submit to the registry by the stated deadline.

In order to indicate which measures you are meeting for each patient visit during the reporting period, simply check the appropriate checkboxes on the Falcon Physician Superbill for that visit.

If you choose not to use the Superbill then the applicable CPT codes will need to be entered into theencounter note in the Procedures section to record the measure criteria was met.

Medicare Part B Checkbox:

You will also need to indicate in the patient demographics which patients are Medicare Part B.

These E & M encounter codes used on the superbill or in the encounter procedures section will indicatewhich patient visits qualify for the PQRS measures:

CPT VARY BASED ON MEASURE

97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211,99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99455, 99456, G0270, G0271, G0402, G0438, G0439

Measure Specifications Link:

#1 (NQF 0059): Diabetes Mellitus: Hemoglobin A1c Poor Control

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% (reverse measures – so less performance (less in numerator) is better)

Denominator = Seen in the reporting period AND age 18 to 75 yrs AND

One of the Diabetes Mellitus ICD code entered in Problem List:

250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21,

250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51,

250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81,

250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05,

362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04

Numerator = Most recent Hgb A1c >9.0% Quality Measures button in the Superbill- Check box for #1 - OR

Lab Result for Hemoglobin A1c entered in Falcon (Interfaced or Manually entered)

Use 3046F: to indicate the most recent hemoglobin A1c level > 9.0%

#2 (NQF 0064): Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dL)

Denominator = Seen in the reporting period AND age 18 to 75 yrs AND

One of the Diabetes Mellitus ICD code entered in Problem List:

250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21,

250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51,

250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81,

250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05,

362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04

Numerator = LDL-C < 100 mg/dl - Quality Measures button in the Superbill- Check box for #2 OR

Lab Result for LDL-C entered in Falcon (Interface or Manually entered)

OR Use 3048F: to indicate Most recent LDL-C < 100 mg/dL

#110 (NQF 0041): Preventive Care and Screening: Influenza Immunization

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Measure #110 only needs to be reported a minimum of once during the reporting period when the patient’s visit included in the patient sample population is between January and March for the 2014-2015 influenza season OR between October and December for the 2014-2015 influenza season. When the patient’s office visit is between April and September, Measure #110 is not applicable and will not affect the eligible provider’s reporting or performance rate.

Denominator = Patients > 6 mos. old AND Office Visit with valid E & M Code AND Visit is between Jan – Mar 2014 OR Oct – Dec 2014.

Numerator = Quality Measures button in the Superbill- Check box for #110

Use CPT code G8482: Influenza immunization administered or previously received

#111 (NQF 0043): Pneumonia Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

Denominator = Seen in the reporting period AND are age 65 yrs.

Numerator = Patients who have ever received a pneumococcal vaccination

Quality Measures button on the superbill - Check the box in the superbill - Check box for #111

Use CPT II 4040F: Pneumococcal vaccine administered or previously received in the procedures section of your encounter.

Pneumococcal Vaccination not Administered or Previously Received, Reason not Otherwise Specified Use CPTII 4040F with Modifier 8P in the procedures section of your encounter.

#121: Adult Kidney Disease: Laboratory Testing (Lipid Profile

Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period

Denominator = Patient with CKD 3, 4 or 5 diagnosis code AND Patients > 18 yrs. old AND Office Visit w/ valid E & M Code

Numerator = Quality Measures button in the Superbill- Check box for #121

Lab Test Results for Lipid Profile (Interface or Manually entered)

Use CPT code G8725: Fasting lipid profile performed (Triglycerides, LDL-C, HDL-C, and Total Cholesterol)

#122: Adult Kidney Disease: Blood Pressure Management

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy [RRT]) and documented proteinuria with a blood pressure

< 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care

Plan of Care - A documented plan of care should include one or more of the following: recheck blood pressure within 90 days; initiate or alter pharmacologic therapy for blood pressure control; initiate or alter non-pharmacologic therapy (lifestyle changes) for blood pressure control; documented review of patient’s home blood pressure log which indicates that patient’s blood pressure is or is not well controlled

Denominator = Patient with CKD 3, 4 or 5 diagnosis code AND Patients > 18 yrs. old AND Office Visit with valid E & M Code AND Proteinuria (791.0) in the patient Problem List.

Numerator = Enter Vitals into Vitals section OR Quality Measures button in the Superbill- Check box for #122 (checking the box indicates you documented a Plan of Care if required)

Use G8476: to indicate the most recent blood pressure has a systolic measurement of < 130 mmHg and a diastolic measurement of < 80 mmHg

AND

Use CPT 0513F: to indicate elevated BP plan of care documented

#123: Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL

Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT [Renal Replacement Therapy]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy AND have a hemoglobin level > 12.0 g/dL

Denominator = Patient with CKD 4 or 5 diagnosis code AND Patients > 18 yrs. old AND Office Visit with valid E & M Code AND are receiving ESA from you or any provider

Numerator = Quality Measures button in the Superbill- Check box for #123

Lab Result for Hemoglobin entered in Falcon (Interface or Manually entered) > 12

OR G0908: Most Recent Hemoglobin (Hgb) level > 12.0 g/dL

AND

Use CPT 4171F: Patient receiving erythropoiesis-stimulating agents (ESA) therapy

#128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normalparameters, a follow-up plan is documented within the past six months or during the current visit

BMI Parameters:

Age 65 years and older BMI ≥ 23 and < 30

Age 18 – 64 years BMI ≥ 18.5 and < 25

Denominator = patients > 18 Yrs old AND Office Visit with valid E & M Code

Numerator = BMI calculated in range OR if BMI is out of range (document Plan of Care as required) – Quality Measures button in the Superbill- Check box for #128 ORif patient has V65.3 (Dietary Surveillance and counseling) in their problem list OR

G8417: Calculated BMI above normal parameters and a follow-up plan was documented OR

G8418: Calculated BMI below normal parameters and a follow-up plan was documented

Measure #130 (NQF 0419): Documentation of Current Medications in the Medical Record

DESCRIPTION:

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration d route of administration

DENOMINATOR:

All visits for patients aged 18 years and older who had a visit during the reporting period

AND

NUMERATOR:

Eligible professional attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration d route of administration

Select the quality measures button in the superbill – Measures #130

Select the 3rd check box in the Medications/Allergies section in your encounter.

G8427: Current medications documented

#226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months ANDwho received cessation counseling intervention if identified as a tobacco user

Cessation Counseling Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy

Denominator = Patients > 18 Yrs old AND Office Visit with valid E & M Code

Numerator = EnterANY Smoking Status history in the encounter AND

Checkbox in Assessment & Plan section of the encounter to indicate smoking cessation was discussed

ORscreened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user 4004F: Patient screened for tobacco use AND received tobacco cessation intervention, if identified as a tobacco user

OR Patient Screened for Tobacco Use and Identified as a Non-User of Tobacco 1036F: Current tobacco non-user

OR Select the checkbox under Quality Measures in the Superbill select – Checkbox # 226

Measure #236 (NQF 0018): Controlling High Blood Pressure

DESCRIPTION:

Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

DENOMINATOR:

Patients 18 through 85 years of age who had a diagnosis of essential hypertension 401.0, 401.1, 401.9 within the first six months of the measurement period or any time prior to the measurement period

NUMERATOR:

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period

**If you enter the BP in the encounter and put the diagnosis code on the problem list, Falcon will detect this measure automatically.**

G8752: Most recent systolic blood pressure < 140 mmHg OR G8753: Most recent systolic blood pressure ≥ 140 mmHg

AND

G8754: Most recent diastolic blood pressure < 90 mmHg OR G8755: Most recent diastolic blood pressure ≥ 90 mmHg

Patient not Eligible for Recommended Blood Pressure Parameters for Documented Reasons

G9231: Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy.

Blood Pressure Measurement not Documented, Reason not Given

G8756: No documentation of blood pressure measurement, reason not given

OR Check the box on the Superbill- Checkbox # 236

Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

DESCRIPTION:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

DENOMINATOR:

Percentage of patients aged 18 years and older who have an encounter in the reporting period.

AND

NUMERATOR:

Patients who had BP recorded in Falcon AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive

•Check the box under quality measures in the superbill – Checkbox #317

OR G8783: Normal blood pressure reading documented, follow-up not required

OR G8950: Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented

OR G8784: Blood pressure reading not documented, documentation the patient is not eligible

OR G8951: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible OR G8785: Blood pressure reading not documented, reason not given

OR G8952: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given

HOW DO I TRACK MY PROGRESS ON THE MEASURES IN FALCON

Reporting Period Setup

Main Menu->Quality Scorecard->Reporting Period Setup->Add Reporting Period

Falcon displays your PQRS measure denominators and numerators on the Quality Scorecard under Main Menu > Quality Reporting. Note that the Goal and Status columns are notrelevant for PQRS measures. The Denominator and numerator columns are where to focus to track yourprogress. Falcon at this time has no method to track the 50% required for the individual measures.

Maintenance of Certification Program

In 2014, EPs have the opportunity to earn the PQRS incentive and an additional incentive of 0.5% by working with a Maintenance of Certification entity. Here is what is required:

Satisfactorily submitting data, without regard to method, on quality measures under PQRS, for a 12-month reporting period either as an individual physician or as a member of a selected group practice

AND

More frequently than is required to qualify for or maintain board certification:

Participate in a Maintenance of Certification Program and

Successfully complete a qualified Maintenance of Certification Program practice assessment.

Feedback Reports

EPs who report PQRS quality measures data can request to receive National Provider Identifier (NPI)-level Physician Quality Reporting Feedback Reports.

The reports include information on reporting rates, clinical performance, and incentives earned by participating individual professionals, with summary information on reporting success and incentives earned at the practice level. The feedback reports can be accessed through the Web portal in the fall of the year following the reporting (e.g. 2013 feedback reports will be available in the fall of 2014).