Ingenious Med FAQs for PQRS
INDEX
Last Updated: 4/30/2012

GENERAL PARTICIPATION INFO
What is PQRS?
How is it determined which measures apply to a given patient?
Why should my group participate?
Will PQRS participation become mandatory in the future?
Will the PQRS program eventually end?
How is successful participation determined?
What provider types are included in the PQRS program?
How are the participation periods defined?
What if I have providers that just don’t work very often?
Do we need to sign up or register with CMS to start participating?
How is PQRS different from Core Measures?
Does PQRS participation increase the likelihood of an audit?
Where can I find out more about PQRS?

REIMBURSEMENTS AND PENALTIES
How is reimbursement calculated?
Can I wait until 2015 to start participating without being fined?
Who receives the reimbursement?
When are the reimbursements distributed?
What dollar figure would be typical for the reimbursement or penalty amount?
How can I identify my incentive payment when it arrives?
What can you tell me about the additional .5% MOBC reimbursement?

DATA SUBMISSION AND FEEDBACK REPORTS
How is PQRS data reported to CMS?
What is a PQRS registry?
Why is registry-based reporting better than claims-based reporting?
Can I submit both claims-based and registry-based data in the same participation period?
Can we stop the flow of claims data after activating the registry service?
How do we get our participation reports from CMS for PQRS reporting?
Can Ingenious Med assist us in interpreting our CMS reports?
What's the difference between a physician's "Reporting Rate" and "Performance Rate" on a measure (and why does each matter)?
What PQRS reports are available from Ingenious Med?

IM's CERTIFIED PQRS REGISTRY SERVICE
What success has IM's PQRS registry service had?
Is there a fee for using the IM registry service?
What are the requirements for a group to submit through IM's registry?
Can we submit some measures through IM's registry and some measures through another registry?
What is the deadline for PQRS to be activated in order to report through the registry?
What changes appear in the system when the registry service is activated?
Why is there a permission pop-up for each individual provider?
What happens if a provider says "no" or doesn't provide an answer for the registry permission pop-up?
How do we opt into the registry service?

HOW PQRS WORKS WITHIN IM
How does the PQRS module work within Ingenious Med?
What will change for billers when the PQRS module is activated?
Why might my billing company indicate that reporting opportunities are being missed on measures we have activated within IM?
Are mobile platforms supported in the IM Quality Measures module?
Is mid-level billing supported in the IM PQRS module?
Is there a fee for activating the IM Quality Measures module?
Will PQRS pop-ups appear for all patients, or only Medicare patients?
Will physicians need to know the appropriate choices for CPT II codes and modifiers or report PQRS measures, or remember when specific measures apply?
Is date of birth required to activate measures that have an age requirement?
What will the IM billing interface do with CPT II codes for non-Medicare payers?
What should we do with CPT II codes before sending bills to non-Medicare payers if we do not have an IM billing interface?
Are there any problems billing partially within IM and partially outside of IM?
Why does the Advance Care Plan (measure #47) questionnaire pop up for more than one physician on the same patient?
Why do discharge questions appear on admissions and follow-up bills for some stroke measures?

GETTING STARTED
How do we get started with PQRS participation?
How does our start date affect our group's potential for success?
What degree of training does our staff need before activating PQRS?
Do you have a "quick start guide" about the PQRS module for our physicians?
Could you summarize the "best practices" for PQRS participation?

CHOOSING MEASURES
What PQRS measures are available for reporting through IM's quality module?
How many measures should we activate?
Will it overwhelm my physicians if we turn on more than the required minimum of 3 measures?
How can we determine which quality measures are best for our practice to report?
Why can't we just activate any measure that seems like it would apply to our practice?
Can IM analyze our billing to determine which measures best apply to my group?
Why does IM specifically recommend against using certain measures?
Can IM build custom measures for our practice if we would like to report a measure not currently offered?
What are the questions and triggering codes associated with each of the available measures?


GENERAL PARTICIPATION INFO

Q:  What is PQRS?
A:  PQRS (Physician Quality Reporting System) is a volunteer quality reporting program created by CMS in 2007 (known as PQRI until 2011).  Physicians are evaluated on their quality of care by confirming specific services were rendered to patients who met predetermined criteria.  Practices will be reimbursed for successful participation by their physicians through 2014, after which significant penalties for non-participation will be imposed.  It is currently a pay-for-reporting program, but is anticipated to pave the way for future pay-for-performance initiatives by validating the clinical performance measures involved.

Q:  How is it determined which measures apply to a given patient?
A:  PQRS is comprised of over 200 separate quality measures, a much smaller subset of which usually applies to the typical billing patterns of a given provider type.  Measures are usually defined as applicable to patients based on combinations of CPT, ICD, and patient age at the time of the encounter.  Occasionaly, Place of Service and Modifiers can influence the applicability of a quality measure as well.

Q:  Why should my group participate?
A:  There are three primary reasons to participate in PQRS:
  1. Reporting on standardized quality measures allows for both internal and external validation of quality of care.  Administrators can track measure performance by their physicians to validate internal clinical quality initiatives as well as to demonstrate to active/prospective business partners how their providers perform on the standardized measurements.
  2. Reimbursements for successful participation will be available from CMS through 2014, with penalties for non-participation beginning in 2015 and continuing indefinitely from that point.  While the reimbursement rate will be relatively low for 2012-2014, the penalties invoked in 2015 and beyond will aggregate to significant numbers for many practices.  The penalties for failing to participate successfully will be assessed with a 2 year delay, so providers must participate successfully in 2013 in order to avoid the negative payment adjustment in 2015!
  3. CMS already posts on the Physician Compare website whether or not a physician participates successfully in PQRS, but they have also received clearance to publish each provider's individual performance ratings on specific quality measures.  With a public record available to compare provider performance directly, revenues for their associated facility could be significantly affected by a physician's quality rating.
Q:  Will PQRS participation become mandatory in the future?
A:  Once the penalties go into effect, any provider submiting claims to Medicare will be considered to be "participating" in PQRS by default - they just won't be participating "successfully" unless they also report adequately in relation to PQRS measures that apply to those claims.  The imposition of fines and other motivators will likely make active participation in the program a foregone conclusion for the vast majority of organizations.

Q:  Will the PQRS program eventually end?
A:  The current pay-for-reporting program will almost certainly transition into a pay-for-performance program of very similar design in the future.  In this way, the idea of PQRS as a program will not expire, but will become a permanent fixture in the Medicare reimbursement system.

Q:  How is successful participation determined?
A:  Successful participation in PQRS is evaluated on an individual provider basis.  An individual provider (as identified by their NPI) must maintain a minimum reporting rate for at least 3 quality measures during the reporting period.  If they meet their reporting minimum on 3 or more measures, they are considered "successful participants" for the reporting period.  This assessment is applied separately to each provider within a group, and one physician's success or failure does not affect the success or failure of any other physicians within that group.  If a physician bills under multiple Tax IDs, their participation is evaluated separately under each of those separate Tax IDs.

    The minimum reporting rate per measures will be 80% (for 3 or more measures) for registry-based reporting, but CMS has reduced the claims-based minimum reporting rate to 50% (for 3 or more measures) as of 2011, due to the unreliabile nature of claims-based reporting. A physician can be considered successful by reaching their minimum reporting percentage on less than 3 measures if less than 3 measures apply to their Medicare Part B FFS claims during the reporting period, and they reach the minimum reporting rate on all measures that do apply to their billing.

Q:  What provider types are included in the PQRS program?
A:  The following professionals are eligible to participate in Physician Quality Reporting System:
    1. Medicare physicians:
        Doctor of Medicine
        Doctor of Osteopathy
        Doctor of Podiatric Medicine
        Doctor of Optometry
        Doctor of Oral Surgery
        Doctor of Dental Medicine
        Doctor of Chiropractic
    2. Practitioners:
        Physician Assistant
        Nurse Practitioner
        Clinical Nurse Specialist
        Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
        Certified Nurse Midwife
        Clinical Social Worker
        Clinical Psychologist
        Registered Dietician
        Nutrition Professional
        Audiologists
    3. Therapists:
        Physical Therapist
        Occupational Therapist
        Qualified Speech-Language Therapist

Q:  How are the participation periods defined?
A:  Starting with the 2012 participation period, there is only a 12-month participation period offered for the individual measures method of participation.  It begins on 1/1 and ends on 12/31.

Q:  What if I have providers that just don’t work very often?
A:  Moonlighters, part-timers, and employees that join or leave an organization during the participation period can still participate successfully as long as they report on the required percentage of their triggers for the year while billing under your tax ID.  If they are unsuccessful for some reason, their billing totals are usually so low that they affect the reimbursement of penalization of the group minimally.

Q:  Do we need to sign up or register with CMS to start participating?
A:  No. Submitting CPT II bills along with your clinical billing and/or submitting PQRS participation datat through a certified registry automatically indicates a provider is participating.

Q:  How is PQRS different from Core Measures?
A:  PQRS is a CMS program which involves individual physicians submitting quality measure data under their own NPI.  Their participation is evaluated on an individual basis, and their performance is calculated independently of that of their peers.  Core Measures is a program administered by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and is reported and evaluated at the hospital level.  While some Hospital Core Measures are similar to PQRS measures in the clinical measures they assess, participation in the programs and their respective reporting requirements are completely separate.  Reporting Core Measures at the hospital level does not satisfy PQRS participation requirements in any way.

Q:  Does PQRS participation increase the likelihood of an audit?
A:  Any audit resulting from participation in PQRS would focus on validating (only) the data pertaining to PQRS participation.  There is no reason to expect that participation in PQRS would increase the chances of a financial audit for any practice.

Q:  Where can I find out more about PQRS?
A:  The following links may be helpful in learning more about the PQRS program:


REIMBURSEMENTS AND PENALTIES

Q:  How is reimbursement calculated?
A:  Reimbursement is calculated and distributed at the group (tax ID) level.  Once each physician within the group (i.e., billing under the group's Tax ID) has been determined to have participated successfully or not, the Medicare Part B FFS billings of the successful physicians from the group (and only the successful physicians) are then tallied for the year, and reimbursement value is calculated based on that total.  The reimbursement check is then sent to the owner of the tax ID number (not to the individual physicians who successfully participated), usually in October of the following year.  There will be a .5% reimbursement for the program years 2012-2014.  A 1.5% negative payment adjustment will go into effect in 2015, going up to 2% for 2016 and beyond.

Q:  Can I wait until 2015 to start participating without being fined?
A:  No.  The negative payment adjustments indicated for 2015 and beyond are being applied after a 2 year lag in performance evaluation.  This means the 1.5% negative payment adjustment assessed in 2015 will be based on performance during the 2013 reporting period.  The 2% negative payment adjustment assessed in 2016 will be based on performance during the 2014 participation period, and so forth.  To avoid the 2015 negative payment adjustment, providers must participate successfully in the 2013 reporting period!

Q:  Who receives the reimbursement?
A:  The owner of the Tax Id under which the claims are filed will receive the reimbursement payment.

Q:  When are the reimbursements distributed?
A:  Reimbursements are typically distributed in October of the year following the conclusion of the participation period. The delivery date for incentive payments is the same regardless of the method of data submission (claims or registry).

Q:   What dollar figure would be typical for the reimbursement or penalty amount?
A:    Based on recent estimates by SHM, the typical hospitalist could expect to qualify for about $1,466 in reimbursement for each percentage point used in the bonus calculation.  For the .5% reimbursement rate effective in 2012-2014, that would result in $733 for the average hospitalist.  The 1.5% negative payment adjustment in 2015 would be around -$2,200, and the 2% negative payment adjustment in 2016 and beyond would be about -$2,933.   Historical evidence indicates that reimbursements for specialists can be significantly higher (in which case, the fines for non participation would be higher as well). 

Q:  How can I identify my incentive payment when it arrives?
A:  The PQRS incentive payments are received the same way providers receive their regular Medicare payments. If they normally receive their Medicare payments electronically, then the incentive payment would also be sent electronically. There should be a statement that has no claim information and a Remittance Advice Remark Code (RARC) of "PQ" and a two digit year identifier (e.g., "PQ11" for 2011's reimbursement).

Q:  What can you tell me about the additional .5% MOBC reimbursement?
A:  There is an additional .5% bonus available for providers who meet CMS's Maintenance of Board Certification requirements.  The criteria to qualify for this additional reimbursement are more stringent than the standard board recertification process.  Independent Board Certification entities report to CMS about the participation of individual providers within their program (IM is not involved in board certification).  Please click here to learn more information from CMS about how this program works.


DATA SUBMISSION AND FEEDBACK REPORTS

Q:  How is PQRS data reported to CMS?
A:  There are actually several methods by which participation data can be submitted, but the two most common methods are claims-based reporting and registry-based reporting.  In claims-based reporting, CPT II bills are generated to indicate the providers' answers to the PQRS measures and those CPT II bills are submitted through your billing company along with the original encounter to which the PQRS reporting applies.  There are several drawbacks to claims-based data submission, and it has generally proven to be an unreliable method of reporting. Registry-based reporting is a more modern approach to data submission. A certified PQRS registry retrospectively analyzes the data for each provider across the entire participation period and transmits a summary of their participationt data directly to CMS through a secure portal. The registry-based reporting method is considered a much more reliable method of data submission than claims-based reporting.

Q:  What is a PQRS registry?
A:  A PQRS Registries are certified by CMS after an extensive vetting process that includes verification of expertise in measure implementation, validation of processing of physician responses and confirmation of the ability to submit performance data in accordance with established CMS guidelines.  PQRS registries analyze participation data after the reporting period has concluded, then compiles the reporting and performance statistics for each participating provider.  The registry then transmits those figures directly to CMS through a secure online portal.  Registries also provide participation reports to the practices for which they submit participation data.

Q:  Why is registry-based reporting better than claims-based reporting?
A: 
Q:  Can I submit both claims-based and registry-based data in the same participation period?
A:  Yes.  CMS allows data submission by both claims-based reporting and registry-based reporting.  If a provider submits participation data through both methods, CMS will evaluate the data from each submission method separately, and the data that most favorably reflects on the physician's participation will be used (the data received from the registry and through claims will not be combined).  Under these circumstances, filing your PQRS data through IM's certified PQRS registry service can only help your group succeed, and could never hurt your chances for success.  Because of the way the separate data streams are evaluated, submitting participation data through both methods is NOT considered "double dipping" by CMS with respect to reimbursements.

Q:  Can we stop the flow of claims data after activating the registry service?
A:  Claims-based reporting data can be blocked at the billing interface for clients using automated billing feeds, but this would require custom development work at an additional charge.  There are actually several reasons that it is advantageous to continue the flow of claims-based reporting data in addition to filing through the registry.  Claims-based data and registry-based data are evaluated independently by CMS, and the minimum successful reporting requirements for claims-based submission is lower than that of registry-based submission (50% versus 80%, respectively).  In some circumstances, providers who were not successful based on registry data could potentially participate successfully for the entire year's reimbursement based on their claims data submission.

Q:  How do we get our participation reports from CMS for PQRS reporting?
A:  If you do not currently have an IACS account, you will need to establish one in order to access your group's report.  Registration instructions can be found clicking here to access the MLN Matters article by CMS.   The IACS site is not generally considered very "user friendly", and IM can assist you with navigating the registration process if necessary.  Once you have an IACS account, you will be able to log into the QualityNet portal and request participation reports. 

To access their individual feedback reports, providers do not have to have an IACS account. They can also obtain the report by clicking here and requesting it on-line directly from CMS. Each provider needs to complete the request for their individual NPI.  

For providers who participate in IM's PQRS Registry service, an individual participation report will automatically be mailed to the provider if they had a valid email address on record within the Ingenious Med application at the time of data submission.

Q:  Can Ingenious Med assist us in interpreting our CMS reports?
A:  Ingenious Med has extensive experience interpreting the CMS PQRS participation reports, and we invite you to contact us if you would like to spend some time discussing the implications of your report.  Please contact your Account Manager or Technical Support if you would like to set up conference.

Q:  What's the difference between a physician's "Reporting Rate" and "Performance Rate" on a measure (and why does each matter)?
A:  Reporting Rate for a given measure is the percentage of triggers for which we have an answer on record (including our default "unknown" answers, which equates to "did not perform the measure action" for reporting purposes).  Since PQRS is (for the most part) still "pay-for-reporting", Reporting Rate is the criteria reimbursement payments and negative payment adjustments reference.

Performance Rate for a given measure is their ratio of good care to bad care based on the answers provided by the MD.  It is not currently used for reimbursement, but these are the ratings CMS will post to the Physician Compare website, so the physician's Performance Rate could still directly affect the bottom line for their practice.  While PQRS is technically still "pay-for-reporting", any measure with a 0 performance rate for the participation period will not count towards that provider's 3-measure minimum for successful participation.

Q:  What PQRS reports are available from Ingenious Med?
A:  

IM's CERTIFIED PQRS REGISTRY SERVICE

Q:  What success has IM's PQRS registry service had?
A:  100% of groups using IM’s 2010 PQRS registry service qualified for reimbursement checks.
    Over $1 million in combined reimbursements are expected for 2010 registry participants (while only a small percentage of clients took advantage of the registry service!)
    Groups that had never qualified a single provider after years of filing claims-based data had 100% provider success (i.e., getting checks for the first time since they began participation in 2007).
    Groups that had struggled to reach 50% success rates jumped to over 90% success rates (i.e., getting bigger checks than ever before).
    Several 2010 registry clients are anticipating reimbursement checks in the neighborhood of over $200K or even $300K.
    The 100% reimbursement qualification rate was repeated again for IM PQRS Registry clients during the 2011 participation period.

Q:  Is there a fee for using the IM registry service?
A:  No.  Ingenious Med's certified PQRS registry service is available to IM clients at no additional charge.

Q:  What are the requirements for a group to submit through IM's registry?
A: 
Q:  Can we submit some measures through IM's registry and some measures through another registry?
A:  There is no rule against using two separate registries to submit the same participation data, but reporting and performance data submitted by separate registries will NOT be combined to reflect an "overall" participation picture.  The data submitted through each registry would be evaluated separately, and the data source reflecting most positively on the provider's participation would be used by CMS to categorize participation success.  It is important to remember that reporting events by the same provider billed under different tax IDs are considered separate participation events, and different registries could report the participation events under different tax IDs without any deleterious effects on the success of the provider under the separate tax IDs.

Q:  What is the deadline for PQRS to be activated in order to report through the registry?
A:  There is no actual deadline for turning on PQRS in order to file through the registry.  As long as providers are capturing bills in IM by 1/1 of the reporting period, they could use the registry at the end of the year (opting in at any point during the year is allowed, but there are advantages to opting in earlier).  As far as actually activating PQRS and collecting performance data, that becomes a game of percentages, regardless of whether they use the registry or rely on claims-based reporting.  The longer they wait into the year to activate PQRS, the more reporting opportunities they miss as they see patients prior to PQRS activation.  At some point in the year, they will miss so many reporting opportunities that they can't possibly succeed for the year, but that (in and of itself) doesn't preclude our submission of their data through the registry (we'd just submit data that says they missed a lot of reporting opportunities and didn't do very well).   Also, after a certain percentage of missed reporting opportunities for the year, since the registry success requirements are 80% x 3 measures versus the claims-based requirements of 50% x 3 measures, the registry wouldn't be very likely to increase their success rates as it would be expected to for clients who have captured PQRS data throughout the entire reporting period.

Q:  What changes appear in the system when the registry service is activated?
A: 
Q:  Why is there a permission pop-up for each individual provider?
A:  CMS requires that registries secure permission from each NPI owner before submitting their participation data through the registry service.  Even providers who have signed billing agreements with their management company must give their individual approval to have their PQRS participation data included in the registry submission.  Practice administrators cannot give a blanket approval for providers within their organization.

Q:  What happens if a provider says "no" or doesn't provide an answer for the registry permission pop-up?
A:  Physicians without an affirmative answer on file with Ingenious Med will not have their data included in their group's registry submission.  This would not affect their flow of claims-based reporting data, and it does not affect the inclusion of other providers within the group who have given IM permission to include their data in the registry submission.  If a provider says "no", and wishes to change their answer, the flag can be reset by Ingenious Med Technical Support, allowing the provider to see the pop-up again on their next login.  IM Technical Support personnel can only reset the flag so the provider can answer again; they cannot set the provider's answer to "yes" directly.  Administrators should take care to alert all providers to the impending appearance of the permission pop-up and explain that they should answer "yes" prior to the activation of the registry service in order to minimize confusion and the necessity for answer resets.

Q:  How do we opt into the registry service?
A: 

HOW PQRS WORKS WITHIN IM

Q:  How does the PQRS module work within Ingenious Med?
A: 
Q:  What will change for billers when the PQRS module is activated?
A:  Any bill with an unanswered PQRS measure associated with it will appear on the Daily Encounter Log with a yellow triangle/exclamation point icon on the left side.  This serves as an indication to the biller that, if they mark this bill as "sent" (and the group does not have the PQRS Registry Service activated), they are essentially locking in a "measure action not performed" event for that physician's reporting (since unanswered questions are reported as "not performed" events, and answers cannot be changed after the bills are marked "sent" for non-registry groups).

Q:  Why might my billing company indicate that reporting opportunities are being missed on measures we have activated within IM?
A:  Reporting for many PQRS measures only require one reporting event per physician during a single hospital stay by a given patient.  If a physician has already reported a measure for a patient, and enters another bill for that patient during the same stay that (taken alone) also matches that measures trigger scenario, the system recognizes that physician's reporting requirements have already been met and will not require the physician to answer the measure again.  In cases where the reporting requirements are based on patient stay, a billing company looking at individual bills on any given day may not realize that physician's reporting requirement for that patient has already been fulfilled in conjunction with an earlier bill.  In cases where measures require answers each and every time a trigger scenario is encountered (even multiple times by the same physician on the same patient), the system will request an answer each time the measure applies.

Q:  Are mobile platforms supported in the IM Quality Measures module?
A:  Yes.  All current mobile applications offered by Ingenious Med have PQRS capabilities.

Q:  Is mid-level billing supported in the IM PQRS module?
A:  Yes.  Mid-levels who bill under their own NPI can use Ingenious Med to record and report their own PQRS participation. If ownership of a triggering bill is subsequently changed to another provider's name (e.g., their supervising MD), the PQRS reporting associated with that triggering bill will also transfer to the same provider as well.

Q:  Is there a fee for activating the IM Quality Measures module?
A:  No, there is no additional fee associated with activating PQRS.

Q:  Will PQRS pop-ups appear for all patients, or only Medicare patients?
A:  There is currently no filter in the system to distinguish between Medicare and non-Medicare patients.  If the patient meets the target demographics for the measure and an appropriate ICD and/or CPT is entered, the measure will be triggered.  Future enhancements may provide a filter for Medicare patients, though many practices may prefer to continue capturing quality of care data for all patients, Medicare and non-Medicare alike. In relation to PQRS reporting requirements, there is no harm in reporting PQRS data for non-Medicare patients and, likewise, there is no penalty for failing to enter PQRS data for patients who are non-Medicare.  PQRS registry clients will submit a file obtained from their billing company at the end of the year to identify Medicare patients for registry submission, since registry data must be restricted to only Medicare patients.

Q:  How does IM's quality module facilitate high reporting rates to ensure successful participation?
A:  As soon as a measure is triggered, an answer is generated by the system. It defaults to "measure action not performed" until/unless the provider gives an explicit answer of their own.  If they do not change the default answer, the event will be reported as "measure action not performed" in order to maintain the minimum reporting rate requirements for successful participation.  These events will, however, adversely affect the provider's performance (quality) rating, since "measure action not performed" events reflect poorly on physicians.

Q:  Will physicians need to know the appropriate choices for CPT II codes and modifiers or report PQRS measures, or remember when specific measures apply?
A:  PQRS questionnaire window will open automatically when a bill is created that requires a quality measure response.  The system will ask questions and offer answer choices in plain language, so knowledge of specific CPT II codes or modifiers is never required.

Q:  Is date of birth required to activate measures that have an age requirement?
A:  No.  Measures that require an age component only need the chronological age.  If that value already exists in the IM Practice Manager database (either entered directly, or calculated by the system automatically following the entry of a DOB), that value will be used in evaluating the applicability of a measure.  If the patient’s age is not available at the time a measure potentially applies, the physician will be prompted to enter the patient's age.

Q:  What will the IM billing interface do with CPT II codes for non-Medicare payers?
A:  Adjustments can be made to the interface prior to activating the IM Quality Measures module so the quality data codes can be filtered before the bills are sent to non-Medicare payors.

Q:  What should we do with CPT II codes before sending bills to non-Medicare payers if we do not have an IM billing interface?
A:  CPT II codes should be manually stripped from the bills by the billing company before sending to non-Medicare payers to reduce the likelihood of delayed reimbursement or possible rejections for bills accompanied by CPT II codes.  Most billing companies are aware of this need and have taken steps to ensure this occurs automatically.

Q:  Are there any problems billing partially within IM and partially outside of IM?
A:  All of their billing under a given tax ID should be done within IM (possibly with a few very specific exceptions):
Q:  Why does the Advance Care Plan (measure #47) questionnaire pop up for more than one physician on the same patient?
A:  This is related to the way the measure is defined by CMS (not by IM).  CMS requires that each physician entering a bill that matches the trigger scenario of a measure to also report on that measure.  This includes physicians who see the patient after another physician may have already billed the patient and reported an answer for the measure questionnaire.  Since participation in PQRS is evaluated by individual NPI, CMS analytics do not recognize another provider's answer (even for the same patient/measure) as relating to any answers required from other providers.  Whenever the system presents a questionnaire to a provider during billing, it indicates CMS is expecting to see a reporting event related to that bill, and failure to report will negatively affect PQRS performance for the provider.  In the case of measure #47, each physician does not need to question the patient directly; if there is documentation related to the measure in the chart from a previous encounter, subsequent physicians can answer the questionnaire based on existing documentation.

Q:  Why do discharge questions appear on admissions and follow-up bills for some stroke measures?
A:  This is related to the way the measures are defined by CMS (not IM).  When CMS removed the consult codes and replaced them with admission codes for standard billin in 2010, the measure designers for these three measures (#32 - Discharged on Antithromotic Therapy, #33 - Anticoagulant Therapy Prescribed for Atrial Fribrillation at Discharge, and #36 - Rehabilitation Services Ordered) made the same replacements in the definition of their measures.  The measure designers were either unfamiliar with or unconcerned with the typical hospitalist workflow, in which the admitting physician and discharging physician are frequently not the same provider.  Since these questions are inappropriate to answer upon admission in many cases, and failure to answer the question results in an action-not-performed reporting event for the physician, provider performance rates are frequently adversely affected by this measure.  For this reason, IM recommends strongly against using these 3 measures.

GETTING STARTED

Q:  How do we get started with PQRS participation?
A: 
Q:  How does our start date affect our group's potential for success?
A:  There is no definitive cut-off date that automatically results in successful or unsuccessful participation.  Since the criteria for success involves reporting above certain percentages of reportable events, it is obviously more difficult to succeed the later in the year your group begins reporting (i.e., a higher number of reportable opportunities will have already been missed prior to your start date).
Q:  What degree of training does our staff need before activating PQRS?
A:  The PQRS module is very user friendly, and requires very little training for staff use.  A simple introduction to the concept of quality measures, an explanation of how to answer the pop-ups and review their previous answers, then a reminder of the importance of answering the questionnaires diligently is usually enough to get physicians started.

Q:  Do you have a "quick start guide" about the PQRS module for our physicians?
A:  Yes.  Click here to see a one-page introductory level recap of the PQRS module for physicians.

Q:  Could you summarize the "best practices" for PQRS participation?
A: 

CHOOSING MEASURES

Q:  What PQRS measures are available for reporting through IM's quality module?
A: 
    5 - Heart Failure: ACE Inhibitor or ARB Therapy for LVSD (R)
    6 - Coronary Artery Disease: Oral Antiplatelet Therapy Prescribed
    20 - Perioperative Care: Timing of Antibiotic Prophylaxis
    21 - Perioperative Care: Selection of Prophylactic Antibiotics
    22 - Perioperative Care: Discontinuation of Prophylactic Antibiotics
    23 - Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis
    31 - Stroke and Stroke Rehab: DVT Prophylaxis for Ischemic Stroke or Intercranial Hemorrhage
    32 - Stroke and Stroke Rehab: Discharged on Antiplatelet Therapy
    33 - Stroke and Stroke Rehab: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge (R)
    35 - Stroke and Stroke Rehab: Screening for Dysphagia
    36 - Stroke and Stroke Rehab: Consideration of Rehabilitation Services
    47 - Advance Care Plan
    76 - CVC Insertion Protocol: Sterile Barriers
    111 - Preventive Care and Screening: Pneumonia Vaccination for Patients 65 and Older
    130 - Documentation of Current Medications in the Medical Record
    134 - Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
    173 - Preventive Care and Screening: Unhealthy Alcohol Use - Screening

Q:  How many measures should we activate?
A:  The minimum reporting requirement for successful participation is 3 measures.  IM recommends activating at least 4 or 5 measures in order to allow for variation among your combinations of providers and patients throughout the year and afford the best opportunity for each of your providers to trigger at least three measures.  Activation of more than 5 measures is typically not necessary if appropriate measures are selected.

Q:  Will it overwhelm my physicians if we turn on more than the required minimum of 3 measures?
A:  Not likely.  Even when activating closely related measures, each measure typically triggers on a different subset of CPTs, so it is rare for more than a measure or two to trigger on a patient on any given day.  Since many measures also require an ICD component to trigger, the majority of patients seen throughout the day will typically not result in any measure triggering either.  With most measures, providers typically see an extremely low number of triggers during the course of any given week (or month).

Q:  How can we determine which quality measures are best for our practice to report?
A:  IM has extensive experience identifying collections of measures that apply to typical hospitalist and various specialist practices.  Based on your billing patterns, we can recommend an assortment of reporting options to meet your participation needs.

Q:  Why can't we just activate any measure that seems like it would apply to our practice?
A:  In many cases, the title of PQRS measures can be misleading.  References to clinical conditions that a practice typically deals with does not necessarily mean that the measures will apply to the specific billing patterns typical to that practice.

Q:  Can IM analyze our billing to determine which measures best apply to my group?
A:  Yes.  Typically, IM has conducted analyses on enough groups within each of the major specialties that we can recommend a predetermined list of applicable measures based on specialty alone.  In cases where groups may have unusual specialties or unique billing patterns, an analysis specific to that group can be performed.

Q:  Why does IM specifically recommend against using certain measures?
A:  Some measures are reportable only by registry (claims data submitted for those measures will be ignored by CMS).  Those measures are not recommended for groups that do not intend to submit their participation data through IM's registry service.  Other measures have specific aspects of their definitions (as adopted by CMS) that make answering the measure questions difficult for many providers.  One example of this type of situation would be stroke measures that ask clinical questions related to discharge orders, but trigger (and, therefore, require answers in order to meet reporting requirements) on admission or follow-up codes.  Relying on the provider to remember a measure triggered on admission still needs answering at discharge can be problematic (especially when they may not end up being the discharging physician). Charge lag settings for concurrent billing practices and/or registry participation can mitigate some of these effects, but cannot automatically correct for all of them.  Other measures are defined in ways that don't allow the physician to indicate a valid reason for a measure action not having been performed, other than take the blame themselves as simply not having done it, which damages their individual performance ratings.  As each year's measures are defined and updates by CMS, IM will review the measure options and make specific recommendations about measures that have favorable and unfavorable definitions for participating groups.

Q:  Can IM build custom measures for our practice if we would like to report a measure not currently offered?
A:  IM can create custom measures, but we would need to analyze the group's billing history to validate their ability to participate with the requested measure. In the event we determine measures already available through the application better meet the participation requirements of the group, there may be a fee associated with the custom development of any additional measures.  We have yet to find a practice, hospitalist or specialty, that require measures outside of the list already offered within IM.

Q:  What are the questions and triggering codes associated with each of the available measures?
A:  The definitions for measures potentially change with the start of each participation period.  We keep this information in a separate document so it can be updated whenever measure definitions change or new measure choices are added.  Please click here to access the list of measure details grouped by practice type.