An Update on PQRS (aka Please Quit Revising Stuff)

Last month’s blog entry hinted at some of the impending changes for PQRS in 2014.  CMS finally released the measure specifications in late December.  Let’s take a look at some of the changes that will directly impact providers who are reporting individual measures via claims (the most common reporting method for therapists).

First, as mentioned in the previous blog entry, there will be two levels of successful reporting this year.  One level is for providers who wish to both qualify for the 0.5% bonus payment in 2014 AND avoid the 2.0% negative payment adjustment in 2016.  The other level is for providers who only wish to avoid the negative payment adjustment in 2016.

In order to qualify for the 0.5% bonus payment in 2014, therapists who are reporting individual measures via claims must report at least nine measures covering at least three NQS domains, OR, if less than nine measures covering at least three NQS domains apply to the eligible professional, report 1 – 8 measures covering 1 – 3 NQS domains, AND report each measure for at least 50% of the Medicare Part B patients seen during the reporting period to which the measure applies.  For an eligible professional who reports fewer than 9 measures covering 3 NQS domains via the claims-based reporting mechanism, the eligible professional will be subject to the MAV process, which would allow CMS to determine whether an eligible professional should have reported quality data codes for additional measures and/or covering additional NQS domains.

In order to avoid the 2.0% negative payment adjustment in 2016, the therapist must simply continue to follow the same process as in 2013, that is to report at least three measures for at least 50% of the eligible professional’s Medicare Part B patients seen during the reporting period to which the measure applies.

For PT, there are seven measures available for those who are reporting via claims: Measures 128, 130, 131, 154, 155, 182, and 245.  Measure 245, however, requires a diagnosis of a chronic skin ulcer in order to be reported.  OTs reporting via claims can report those same measures in addition to Measures 134, 181, and 226.  OTs were unable to report Measure 182 in 2013, however, 97003 and 97004 have been added to the denominator for this measure in 2014.  (As a reminder, the Measures Group reporting option is no longer available for therapists reporting via claims.  Furthermore, Measures 126 and 127 are no longer available for reporting via claims.   These can only be reported via registry.)

Several measure numerators and denominators have been modified as well, including changes to how the measure performance must be documented as well as when measures must be reported.  It is advisable to consult the measure specifications for the details.  A few of the more significant measure changes of which therapists should be aware:

– Measure 130:  CPT codes 97110 and 97140 have been added to the denominator, meaning this measure must be reported each visit that these codes are billed in addition to the codes that were already included in the denominator (97001, 97002, 97003, 97004, and 97532).

– Measure 131:  CPT codes 97002 and 97004 have been added to the denominator.  This measure must be reported for each visit that includes these codes as well as 97001 and 97003.

– Measure 155:  The plan of care must include consideration of Vitamin D supplementation, i.e. documentation that Vitamin D supplementation was advised or considered or documentation that the patient was referred to his/her physician for Vitamin D supplementation advice.

– Measure 182:  OTs are now able to report this measure when charging 97003 or 97004.  Also, a new code (G9227) has been added to this measure.

There are also a few things to keep in mind from a claims generation standpoint.  First, it is important to remember that QDCs must be reported on the claim with the denominator billing code(s) that represents the eligible encounter for that beneficiary on the same date of service.  (We have seen instances lately in which the MACs have been splitting claims containing QDCs for PQRS and G-codes for functional limitation reporting and then returning claims unpaid.  CMS is aware of this issue as well.)  Furthermore, CMS advises that QDCs be submitted with a line-item charge of $0.01.  Effective 4/1/2014, PQRS will issue different Remittance Advice codes for providers that bill on claims using $0.01 vs. $0.00.  CMS strongly encourages all eligible providers and practices to begin billing 2014 QDCs with a $0.01 charge.

That’s a lot to take in.  To qualify for the bonus payment, providers must report not only more measures, but report those measures more often.  Case in point: if therapy providers opt to report Measure 130, they will most likely be reporting that measure every visit since 97110 and 97140 have been added to the denominator.  It is advisable to discuss the options with the clinical and billing staff to ensure everyone is on the same page.  Ultimately, for those providers reporting via claims, the decision to shoot for the 2014 bonus versus just trying to avoid the negative payment adjustment in 2016 comes down to weighing the reward against the administrative burden on the providers and the billing staff.