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4010 Moorpark Avenue, Suite 222 San Jose, CA 95117
www.prognocis.com [email protected] Copyright 2015 – Bizmatics, Inc.
PQRS - Physician Quality
Reporting System 2016 Edition PrognoCIS v3b3
PQRS – Physician Quality Reporting System http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS
Applicable for Eligible Professionals Report on quality of care to Medicare
patients Avoid a negative payment adjustment
of 2% applied 2 years following the reporting period
Incentives ended with 2014 program year
No registration or sign-up required Claims-based reporting only
methodology supported in PrognoCIS PQRS is not the same as MU
Eligibility for Medical Professionals https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2016_PQRS_List_of_EPs.pdf
Differs from MU Eligibility criteria Medicare physicians, practitioners,
and therapists Must qualify for measure
denominators Billing methodologies apply
2015 Timeline http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2015-17_CMS_PQRS_Timeline.pdf
Last day of 2015 reporting period for DOS 12/1 – 12/31.
2016 Timeline http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2015-17_CMS_PQRS_Timeline.pdf
2015 claims must be billed to
Medicare
Claims-based Reporting Requirements http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Downloads/2015PQRS_Claims_Made_Simple.pdf
9 measures across 3 domains At least 50% of all Medicare
patients seen by the EP 1 cross-cutting measure Measures with 0% performance
are not applicable
1 – 8 measures, or 9+ measures for < 3 domains At least 50% of all Medicare
patients seen by the EP 1 cross-cutting measures Subject to MAV Measures with 0% performance
are not applicable
PQRS Measures http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
CMS Web Tool for Measures https://pqrs.cms.gov/#/home
Cross-Cutting Measures https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/downloads/2016_PQRS-Crosscutting.pdf?agree=yes&next=Accept
Applies to Face-to-face encounters
At least 1 Cross-cutting Measure* applicable on at least 15 denominator-eligble claims
*Measures that are broadly applicable across multiple providers & specialties
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments /PQRS/AnalysisandPayment.html
MAV – Measure Applicability Validation
Many measures are broad across all specialties while some are specialty-specific
MAV applies for EP who cannot report successfully on 9 measures across 3 domains, or reports
between 1 and 8 measures across less than 3 domains
MAV is analytically complex & does not guarantee EP will avoid payment adjustment
Based on Measure Clusters, which groups individual measures relevant to your practice
MAV review is a 2-step process which validates claims against these clusters
MAV – Measure Applicability Validation (cont’d) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments /PQRS/Downloads/2016_PQRS_MAV_ProcessforClaimsBasedReporting_111715.pdf
MAV User Process Guide
w/Case Studies
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_sampleCMS1500claim_12-19-2012.pdf
Claims-based Reporting (cont’d)
Reporting period covers entire calendar year Dates of Service Claims must be submitted to Medicare by end of February the following calendar year.
QDC must be reported on all applicable line-items w/only 1 ICD
All PQRS data is posted to the Assessment screen within EHR
Service provider (EP) is identified by his/her individual NPI/TIN
Automated cross-over to PM side within PrognoCIS
PQRS Report available for external PM/Billing Service users
Claims that are denied are not considered for PQRS credit (unless correctly rebilled/reprocessed)
Claims may not be resubmitted solely for the sake of reporting QDC that were originally missing
PQRS Measures Master – Measures Setup
Inactive measures will not be applied at encounter level.
Settings Configuration Codes/Drugs PQRS Measures
All current measures (by calendar year) for which PrognoCIS is certified with CMS
Only Active measures will be validated on each Medicare encounter per the Categories (PQRS
Domain) assigned to the Attending Provider’s user profile.
Category is the PQRS Domain which is assigned to the EP.
PQRS Measures Master – Measures Info The Info button displays the measure’s details (e.g.: Denominator, Numerator, Age, Gender, etc.)
Info button is also available at the encounter level.
Attending Provider User Profile Setup The PQRS Category defines the domains that the Attending Provider will be reporting, which will
pull applicable measures that are defined as Active within PQRS Measures master
Each provider may select different domains
Settings Configuration Medics Provider
User/Role Permissions Each provider should have appropriate security permissions for documenting PQRS
Patient Encounter PQRS allows you to document under the PQRS screen from encounter TOC
PQRS PQRS Measures allows you to assign measures as Active/Inactive under Configuration
Settings Configuration Admin Role
Only EMR Admin or EP requires these
rights.
EP & applicable clinical staff requires
these rights.
PQRS Encounters are identified by Insurance Type = Medicare under Patient Insurance
Note: This field is otherwise not used on the Patient Insurance screen.
Patient Insurance
Patient Register Patient Insurance ( )
Insurance Type
PQRS option will display on TOC for all encounters but will be disabled when not applicable*
All Active measures for the Attending Provider will display with status as of that encounter
PQRS Encounter
The option will be grayed-out when the Insurance Type is not Medicare.
Status reflects the Assessment screen
Info Button Same as we saw in the PQRS Measures master, the Info button displays the measure’s details (e.g.:
Denominator, Numerator, Age, Gender, etc.) at the encounter level
Assign ICD Button Displays all valid ICD codes as defined within the Denominator for the selected measure
Button only works when status = FAIL and the encounter is Missing ICD
Bi-directional with Assessment ICD tab
Click the ICD10 hyperlink and select appropriate
ICD
Assign CPT/HCPC Button Displays all valid CPT/HCPC codes as defined within the Denominator for the selected measure
Button only works when status = FAIL and the encounter is Missing CPT/HCPC
Bi-directional with Assessment CPT/HCPC tab
Note that the CPT/HCPC may be missing
even when there is an ICD present or
both may be missing for the same
measure
G-Code Icon ( )
Bi-directional with Assessment CPT/HCPC tab
Note: The physician will have to manually associate the applicable ICD code to the CPT/HCPC & QDC
combination in order for it to cross over to the billing side/report correctly.
If using PrognoCIS PM, it will populate on the CMS-1500 as a non-charge line item as required
The QDC along with an appropriate ICD & CPT/HCPC from the Denominator is what is required on the
claim in order to be considered successfully reported
Displays all valid QDC (Quality Data Code)* as defined within the Numerator for the selected measure
Button only works when status = PASS (Missing G-Code)
Note: An error will display if a CPT/HCPC has not yet been assigned; as the QDC must be associated to
a valid HCPC within the numerator. Note that the QDC is not always a “G” code
Workflow on the PQRS Screen Local preference decides if you prefer completing the Assessment first or use PQRS as a tool to do so
Select Encounter TOC PQRS Identify the measures applicable for
the current encounter Click to Assign ICD Click to Assign CPT/HCPC Each modified line will display in pale
yellow background until updated Click save to apply assignment of ICD
and CPT/HCPC Click and select QDC that is most
appropriate for the encounter Click OK Click save Status should = PASS Update Assessment screen (i.e.: map 1
valid ICD per each QDC code)
PQRS Data on the Assessment
Encounter TOC Assessment CPT/HCPC Source
Local preference decides if you prefer completing the Assessment first or use PQRS as a tool to do so
When data is chosen from PQRS screen the Source reflects that. Only 1 ICD
should be assigned to each QDC.
PQRS Report By provider, measures group, and date range
Share with external Billing Service when not using PrognoCIS PM/Billing module
Reports PQRS Report
Can specify individual or multiple providers for 1 or all
patients within period.
Charge Code = QDC (or G-Code)
Ensure all 9 measures you want to report are Active in PQRS Measures master Note: You must include at least 1 cost-cutting measure within these 9. MAV may apply for those who cannot report 9 measures/3 domains. Associate at least 3 PQRS Categories (Domains) to each eligible provider Remind Patient Registration to assign Ins Type = Medicare to patient insurance Document all clinical codes (ICD, CPT/HCPC, etc.) to the Assessment or assign them from the PQRS screen (they are bi-directional) Assign appropriate QDC (G-code) to each applicable measure Assign only 1 valid ICD to each QDC under Assessment CPT/HCPC tab Reporting period is the entire calendar year for Medicare B claims only Submit claims before Feb. 28 of the following year
Remember: Payment Adjustments will be applied 2 years
following the reporting period, i.e.: 2015 DOS will be adjusted in 2017 2016 DOS will be adjusted in 2018
24/7 technical support via Live Chat or (408) 873-3032 / (800) 552-3301
OK! Let’s Summarize….
Questions & Answers
Review Time!!!