Transcript Physician Quality Reporting Initiative (PQRI) National

Physician Quality
Reporting System & the
Electronic Prescribing (eRx)
Incentive Program
2011 Overview
December 9, 2010
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Disclaimers
This presentation was current at the time it was published or uploaded onto the
web. Medicare policy changes frequently so links to the source documents have been provided within the
document for your reference.
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose
obligations. Although every reasonable effort has been made to assure the accuracy of the information
within these pages, the ultimate responsibility for the correct submission of claims and response to any
remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS)
employees, agents, and staff make no representation, warranty, or guarantee that this compilation of
Medicare information is error-free and will bear no responsibility or liability for the results or consequences of
the use of this guide. This publication is a general summary that explains certain aspects of the Medicare
Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant
laws, regulations, and rulings.
CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark
of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the AMA,
are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly
practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein.
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2011 Overview
Toward Value-Based Purchasing
VBP
2007
2008
2009
2010
2011
• TRHCA
• MMSEA
• MIPPA
• MIPPA
• ARRA and ACA
• 74
measures
• 119
measures
• 153
measures
• 175 individual
measures
• 190 individual measures
• Claims
• Claims
• 7 Measures
Groups
• 13 Measures
Groups
• Registry
• Registry
• EHR-testing
• EHRs
• eRx
• eRx
• Claims• Claims
based only • 4
Measures
Groups
• Registry
• Large Groups
• Claims
• 14 Measures Groups
• Registry
• EHRs
• eRx
• Large Groups
• Small Groups
• Maintenance of Certification
• Physician Compare Web Site
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2011 PFS Final Rule
• Requirements and measures for the 2011 Physician
Quality Reporting System, the 2011 eRx incentive, the
2012 eRx payment adjustment, and 2013 eRx payment
adjustment are described in the 2011 PFS final rule with
comment period
• The 2011 Medicare PFS final rule with comment period
was published in the Federal Register on November
29, 2010.
• To view the entire rule, go to:
http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf
• Public comment period ends January 3, 2011
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Physician Quality Reporting
System
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2011 Physician Quality Reporting
System Overview
• 1% Incentive Payment
• Reporting Mechanisms for Individual Eligible Professionals
– Claims
– Qualified Registry
– Qualified EHR
• Reporting Periods for Individual Eligible Professionals
– 12 months - Jan. 1, 2011 - Dec. 31, 2011
– 6 months - Jul. 1, 2011 - Dec. 31, 2011 (claims and registrybased reporting only)
• Individual eligible professionals may report individual
Physician Quality Reporting System measures or measures
groups
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2011 Criteria for Satisfactory
Reporting of Individual Measures
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting
of Individual Measures
Claims
Jan 1, 2011Dec 31, 2011
Report at least 3 Physician Quality
Reporting System measures, (or 1-2
measures if fewer than 3 apply*); and
or
Jul 1, 2011Dec 31, 2011
Report each measure for at least 50% of
applicable Medicare Part B FFS patients
seen during the reporting period
(revised)
*Eligible professionals who report on fewer than 3 measures may be
subject to the Measure Applicability Validation process.
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2011 Criteria for Satisfactory Reporting
Individual Measures (cont)
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting of
Individual Measures
Registry
Jan 1, 2011 Dec 31, 2011
Report at least 3 Physician Quality
Reporting System measures*; and
or
Jul 1, 2011Dec 31, 2011
EHR
Jan 1, 2011Dec 31, 2011
Report each measure for at least 80% of
applicable Medicare Part B FFS patients
seen during the reporting period
Report at least 3 Physician Quality
Reporting System EHR measures*; and
Report each measure for at least 80% of
applicable Medicare Part B FFS patients
seen during the reporting period
*Measures with a 0% performance rate will not be counted (new)
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2011 Criteria for Satisfactory
Reporting of Measures Groups
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting
of Measures Groups
Claims or
Registry
Jan 1,
2011- Dec
31, 2011
Report at least 1 Physician Quality
Reporting System measures group*;
and
Report each measures group for at
least 30 Medicare FFS patients seen
during the reporting period**
*For registry-based reporting, measures groups with a 0% performance rate will not be
counted (new)
**Eligible professionals reporting measures groups using the registry-based reporting
mechanism will no longer be able to report on non-Medicare FFS patients (new)
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2011 Criteria for Satisfactory Reporting
of Measures Groups (cont)
Reporting
Mechanism(s)
Reporting
Period
Criteria for Satisfactory Reporting of
Measures Groups
Claims
Jan 1,
2011- Dec
31, 2011
Report at least 1 Physician Quality
Reporting System measures group;
Report each measures group for at least
50% of applicable Medicare Part B FFS
patients seen during the reporting period
(revised); and
Report each measures group for at least
15 Medicare Part B FFS patients seen
during the reporting period
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2011 Criteria for Satisfactory Reporting
of Measures Groups (cont)
Reporting
Mechanism(s)
Reporting
Period
Criteria for Satisfactory Reporting of
Measures Groups
Claims
Jul 1, 2011Dec 31,
2011
Report at least 1 Physician Quality
Reporting System measures group;
Report each measures group for at
least 50% of applicable Medicare Part B
FFS patients seen during the reporting
period (revised); and
Report each measures group for at
least 8 Medicare Part B FFS patients
seen during the reporting period
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2011 Criteria for Satisfactory Reporting
of Measures Groups (cont)
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting of
Measures Groups
Registry
Jan 1,2011Dec 31,
2011
Report at least 1 Physician Quality
Reporting System measures group*;
Report each measures group for at least
80% of applicable Medicare Part B FFS
patients seen during the reporting
period; and
Report each measures group for at least
15 Medicare Part B FFS patients seen
during the reporting period
*Measures groups with a 0% performance rate will not be counted (new)
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2011 Criteria for Satisfactory Reporting
of Measures Groups (cont)
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting of
Measures Groups
Registry
Jul 1,
2011- Dec
31, 2011
Report at least 1 Physician Quality Reporting
System measures group*;
Report each measures group for at least 80%
of applicable Medicare Part B FFS patients
seen during the reporting period; and
Report each measures group for at least 8
Medicare Part B FFS patients seen during the
reporting period
*Measures groups with a 0% performance rate will not be counted (new)
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2011 Physician Quality Reporting
System Measures
• Retirement of 5 measures: #114, #115, #136, #139,
#174
• 194 measures*, including 5 new measures for
claims and registry reporting, 11 new registry-only
measures, and 4 new measures for EHR-based
reporting only
• 20 EHR measures
• 14 measures groups – Includes 1 new measures group (asthma)
* This includes the 4 measures in the Back Pain Measures Group, which cannot be reported individually
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2011 Options for Group Practice ReportingGPRO I
• For self-nominated groups with 200 or more eligible
professionals
Reporting
Mechanism
Reporting
Period
Criteria for Satisfactory Reporting
Completion of prepopulated data
collection tool for
an assigned set of
Medicare
beneficiaries
Jan 1, 2011Dec 31, 2011
Report on all 26 measures included in
tool, which address diabetes, HF,
CAD, preventive care, and HTN; and
Complete tool for at least 411
consecutively assigned beneficiaries
per disease module and preventive
care module
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2011 Options for Group Practice Reporting GPRO II (new)
• Pilot for approx. 500 self-nominated groups
with less than 200 eligible professionals
• Reporting Mechanism - claims (or, if the
only measures groups that apply to the
practice are the registry-only measures
groups, registry)
• Reporting Period- Jan 1, 2011- Dec 31,
2011
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2011 Options for Group Practice Reporting GPRO II (cont)
Group size
(# of eligible
professionals)
# of
measures
groups
required to
be
reported
Min. # of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
measures
groups
# of
individual
measures
required to
be reported
% of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
individual
measures via
claims
% of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
individual
measures via
registries
2-10
1
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3
50%
80%
11-25
1
50
3
50%
80%
26-50
2
50
4
50%
80%
51-100
3
60
5
50%
80%
101-199
4
100
6
50%
80%
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Additional 0.5% Incentive
• Under the Affordable Care Act, physicians who
satisfactorily report Physician Quality Reporting
System measures for the Jan 1, 2011-Dec 31, 2011
reporting period can qualify for an additional 0.5%
incentive for 2011, if the physician more frequently
than is required to qualify for or maintain board
certification status:
– Participates in a Maintenance of Certification
Program and
– Successfully completes a qualified Maintenance of
Certification Program practice assessment
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Informal Review Process
• The Affordable Care Act requires CMS to establish
an informal process for eligible professionals to
seek a review of the determination that an eligible
professional did not satisfactorily submit data on
Physician Quality Reporting System measures.
• Requests for an informal review must be emailed
to the QualityNet Help Desk at
[email protected] within 90 days of the
release of the professional’s 2011 feedback report.
• A written response will be provided within 60 days
of receiving the original request.
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Public Reporting of Physician Quality
Reporting System Data
• MIPPA requires CMS to post on a website the
names of eligible professionals and group
practices who have satisfactorily reported
under the Physician Quality Reporting System
• This information, for 2011, will be posted on the
Physician Compare Website (the Affordable
Care Act requires CMS to develop this website
by January 1, 2011) after the 2011 incentive
payments are made in 2012
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Other Affordable Care Act
Provisions
• Physician Quality Reporting System incentives through 2014
– 1% for 2011
– 0.5% for 2012- 2014
• Physician Quality Reporting System payment adjustment
beginning 2015
– 1.5% payment adjustment for 2015
– 2% payment adjustment for 2016 and each subsequent year
• Develop plan to integrate reporting under the Physician Quality
Reporting System and reporting under EHR Incentive Program
by 1/1/2012
• Timely feedback
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Electronic Prescribing (eRx)
Incentive Program
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2011 eRx Incentive Program
•
•
An eligible professional or group practice must have a qualified eRx
system to participate
Report the 2011 eRx measure
- Numerator - G8553:At least one prescription created during the
encounter was generated and transmitted electronically using a
qualified eRx system
- Denominator - 90801, 90802, 90804, 90805, 90806, 90807,
90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150,
96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211,
99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101,
G0108, G0109
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2011 eRx Incentive
• 1% Incentive Payment (not available to
professionals receiving 2011 incentive
from Medicare EHR Incentive Program)
• Reporting Period
– Jan 1, 2011- Dec 31,2011
• Reporting Mechanisms
– Claims, qualified registry, qualified EHR
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How Individual Eligible Professionals
Can Qualify for the 2011 Incentive
• Become a successful e-prescriber
– Report the eRx measure for at least 25
unique eRx events for patients in the
denominator of the measure
• At least 10% of eligible professional’s
charges based on codes in the
denominator of the measure
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How Group Practices Can Qualify
for the 2011 Incentive
• Participate in the 2011 Physician Quality
Reporting System under GPRO I or GPRO II
• Become a successful e-prescriber
– Depending on the group’s size, report the eRx
measure for 75-2,500 unique eRx events for
patients in the denominator of the measure
• At least 10% of eligible professional’s charges
based on codes in the denominator of the
measure
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2012 eRx Payment Adjustment
• The PFS amount for covered professional services furnished
by an eligible professional (or group practice) who is not a
successful e-prescriber will be reduced by 1% in 2012
• Reporting Period: Jan 1, 2011- Jun 30, 2011
• Reporting Mechanism: Claims
• Payment adjustment does not apply if <10% of an eligible
professional’s (or group practice’s) allowed charges for the Jan
1, 2011 – Jun 30, 2011 reporting period are comprised of
codes in the denominator of the 2011 eRx measure
• Earning an EHR incentive for 2011 will not exempt an eligible
professional or group practice from the payment adjustment
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How an Individual Eligible Professional Can
Avoid the 2012 eRx Payment Adjustment
• The eligible professional
– is not a physician (MD, DO, or podiatrist), nurse
practitioner, or physician assistant as of Jun 30, 2011
- Based on primary taxonomy code in NPPES or
- The eligible professional reports the G-code indicating
that (s)he does not have prescribing privileges once on
claims prior to Jun 30, 2011 (G8644)
– does not have at least 100 cases containing an encounter
code in the measure denominator
– becomes a successful e-prescriber
– Report the eRx measure for at least 10 unique eRx
events for patients in the denominator of the measure
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How a Group Practice Can Avoid the
2012 eRx Payment Adjustment
• For group practices that are participating in
eRx GPRO I or GPRO II during 2011, the
group practice must become a successful eprescriber
- Depending on the group’s size, report the eRx
measure for 75-2,500 unique eRx events for
patients in the denominator of the measure
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Hardship Exemption for eRx
Payment Adjustment
• CMS may, on a case-by-case basis, exempt an eligible
professional from the application of the eRx payment
adjustment if compliance with the requirement for being a
successful e-prescriber would result in a significant hardship.
• This exemption is subject to annual renewal.
• For the 2012 eRx payment adjustment, the following
circumstances would constitute a hardship:
– The eligible professional practices in rural area with limited
high speed internet access or
– The eligible professional practices in an area with limited
available pharmacies for electronic prescribing
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Hardship Exemption for eRx
Payment Adjustment (cont)
• G-codes have been created to address the 2
hardship circumstances (G8642 and G8643)
• To request a hardship exemption for the 2012
payment adjustment,
– An eligible professional must report the
appropriate G-code on claims prior to Jun 30,
2011
– A group practice must submit this request at the
time it self-nominates to participate in eRx
GPRO I or GPRO II
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2013 eRx Payment Adjustment
• The PFS amount for covered professional services
furnished by an eligible professional (or group
practice) who is not a successful e-prescriber will
be reduced by 1.5% in 2013
• Reporting Period: Jan 1, 2011- Dec 31, 2011
• An eligible professional or group practice that is a
successful e-prescriber for the 2011 eRx incentive
will be considered a successful e-prescriber for
purposes of the 2013 payment adjustment
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Public Reporting of eRx Data
• MIPPA requires CMS to post on a website the
names of eligible professionals and group practices
who are successful e-prescribers
• This information for 2011 will be posted on the
Physician Compare Website, which CMS is required
to develop by Jan 1, 2011 under the Affordable Care
Act, after the 2011 incentive payments are made in
2012
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Important Dates
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2010 Submission Deadlines
• January 2, 2011 - January 31, 2011 – Test submission
period for registries and eligible professionals utilizing the
EHR-based reporting mechanism for the 2010 Physician
Quality Reporting System and/or eRx Incentive Program
• February 1, 2011 - March 31, 2011 – Data submission
period for registries, GPROs and eligible professionals
utilizing the EHR-based reporting mechanism for the
2010 Physician Quality Reporting System and/or eRx
Incentive Program
• February 28, 2011 – Date by which 2010 claims must be
processed to be included in 2010 Physician Quality
Reporting System and eRx Incentive Program analyses
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Self-Nomination Deadlines
• January 31, 2011 – Registry self-nomination deadline for
the 2011 Physician Quality Reporting System and eRx
Incentive Program
• January 31, 2011 – EHR vendor self-nomination
deadline for the 2012 Physician Quality Reporting
System and eRx Incentive Program
• January 31, 2011 – GPRO I and II self-nomination
deadline for the 2011 Physician Quality Reporting
System and eRx Incentive Program
• January 31, 2011 – Maintenance of Certification
Program self-nomination deadline for the 2011 Physician
Quality Reporting System
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Upcoming Calls/Meetings
•
•
•
•
•
•
December 13, 2010 - National Provider Call (2:30pm-4:00pm)
December 15, 2010 - Special Open Door Forum (1:00pm – 3:00pm). The call will
describe and provide an overview of :
– changes to GPRO for the 2011 program year and
– the eRx payment adjustment
(Dial 1-800-837-1935 Conference ID 24749053)
February 9, 2011 – 2012 Physician Quality Reporting System Town Hall Meeting
(10:00am-4:00pm)
See the CMS Sponsored Calls page of the Physician Quality Reporting System
website for more information:
http://www.cms.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage
December 17, 2010 – deadline for submitting 2012 measure suggestions, for more
information on the 2012 Call for Measures see the CMS Measures Manager
website: http://www.cms.gov/MMS/13_Call%20for%20Measures.asp#TopOfPage
**March 2011 - Special Open Door Forum- We are seeking Eligible Practitioners to
present Physician Reporting and eRx Success Stories. Please contact:
[email protected] if you would like to present.
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Questions?
QualityNet Help Desk
Phone: 1-866-288-8912
TTY: 1-877-715-6222
Email: [email protected]
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