PQRS – How 4 letters affect your Practice
Unless you are billing the right set of PQRS codes on 50% of your qualifying visits, then you will lose 2% of your allowed reimbursement. Learn about the changes that this reporting system brings to your practice. Understand how this reporting system affects your reimbursements plus know how and when to use these codes.
Read the transcript:
Jess: All right. Thank you everyone for joining us today for our webinar on PQRS. Today’s instructors are Kathleen Casbarro and David Alben [SP]. Kathleen is the head of our Billing SWAT department here at Vericle and she has 30 years of experience in this industry. And she is a certified coder. David Alben helps practices achieve and maintain a culture of compliance. He is alsot he also assists healthcare attorneys in defending their clients who have been audited or are subject to prepayment review. So he has his finger on Medicare’s expectations and when it comes to medical documentation. So welcome, Kathleen and David.
Kathleen: Thanks so much Jess [SP], really appreciate that. So welcome everybody. I was told about some of the people that registered, and I’ve seen some familiar names. So I’m really glad you’re able to spend a half an hour with us today. So our focus today is going to be on PQRS. We have a single learning objective for today and that is really understanding the PQRS requirements and, you know, Medicare’s rules and the cost of PQRS to your practice.
So there could be several of you on the phone that say to yourself, “Well, what is PQRS? What does it stand for? You know, why do I have to go ahead and report another set of claims to the insurance company? I mean, it just sounds like there’s a lot to juggle.” What we wanna talk to you about is, first off, is what is PQRS? So PQRS stands for the Physician Quality Reporting System. It was actually renamed from the Physician Quality of Reporting Initiative. So it used to be PQRI, if anybody familiar with that, and now it’s PQRS. They changed the acronym.
The reason why we have PQRS is CMS is wants to make sure that, you know, the patient is getting the right care, that you’re providing the quality of care to your patient. And they wanna make sure that the patients are getting the right care at the right time. That’s what this system is actually built. It was actually built for reporting outcomes. The other thing that they wanna do, too, and Dave is really here to talk about that, I brought Dave on really for the auditing part of this, is, you know, quantifying how they’re meeting the particular quality measure. And Dave, how do you suggest the practice does that?
David: So I think it’s important to, first up, really understand what Medicare is looking for, which we’re talking about today. And the other aspect of it is that you pretty much have to patrol your own house, keep it in order, auditing your own claims to make sure that you’re meeting the standards and the number of claims that you need to report on on a…at least a quarterly basis, maybe a little more frequently at the beginning and that everyone on your team understands the significance of this, and why it’s important to the practice.
Kathleen: Right, I agree. So the feedback that CMS is getting from this is they’re gonna compare your performance with other peers in your same specialty. And really, the overall goal here is to make changes to payment structures and implement new rules. So, you know, a lot of times you put things on the back burner but, you know, we’re gonna get into later on why really it’s not a good time to do that.
We talked about PQRS and what it is and really what it stands for. So, you know, what’s the problem? Why is PQRS a problem? Well, PQRS is a problem because what’s gonna happen is that right now for 2013, the requirements have actually changed. For 2013, you had to report on 20% of your eligible patients within the year and only report on three measures, okay? If you didn’t do that, you’re gonna be penalized by Medicare in 2015 and that’s based on your Medicare allowable. By the way, nobody knows on this call what the Medicare allowable is going to be in 2015. I wish I had a crystal ball for you but I don’t.
So for 2014, the rules have changed. So now we go from 20% of your eligible patients now having to report on 50% of your eligible patients. I know most of you out there are going, “Well, what’s an eligible patient? Is that all my Medicare patients?” And we’re gonna get into that, and, you know, nine reporting measures. “Well, what if I don’t have nine reporting measures? What if I only have three? Will I still be penalized?” And we’re gonna get into that as well.
But what I’m trying to show here is that you’re trying to juggle a lot of things right now and things are now changing in the industry. Fifty percent of your eligible patients, nine reporting measures, if you don’t report for PQRS in 2014, you’ll have a 2% reduction on your Medicare allowables for 2016, ’17, ’18, ’19, ’20, and so on until they stop. So just remember that. It’s 2016 onwards, not just 2016. So that’s why this is such a huge problem, because this is not going to affect one year.
We kinda then have to talk to why is the problem important? The problem is hugely important for a specific reason. Anytime CMS implements something, and they want you to be part of something because they want to make an effect in your industry. So I represented this by a fish bowl effect. On the left-hand side, we have a couple of fish just swimming around, not really sure what they’re gonna do. We have one little fish jumping over. We have now a little fish sitting in the fish bowl by himself. With PQRS, that one fish, he is going to be the one that determines the mandates in your fee schedules in 2015, ’16, and forward.
By not participating in PQRS, you’re not representing your practice and you’re leaving it up to one or two. Or the few that are doing PQRS reporting, you’re leaving it up to them to determine the changes in your industry. That’s not what we wanna do. We wanna make sure that we have a say, that we are reporting these PQRS codes showing Medicare the outcome can be different even with the same methodology that one clinician is using to another. Outcomes can be different. And that’s [inaudible 00:06:39]… You know, we’re talking age as well.
So, really, what I’m saying here is don’t let one person drive your industry. Be part of that change. And I’m gonna turn it over to Dave, too, because I can’t say this enough. Dave, I mean, what do you have to say about this?
David: Well, the bottom line is, and it comes through in all of the slides, everything we’re trying to say is, this is it ¦although Medicare hasn’t said, “You have to do this,” they really have to say, “You have to do this.” This isn’t going away if you combine this with the functional reporting that we’re doing with the G-codes and so forth. Medicare is just developing an enormous database and it’s really the first time they’re able to see not only what codes are we billing for and what procedures are we performing but what’s happening with the patients.
And with PQRS, it goes beyond… If you’re a chiropractor, or a physical therapist, or a mental health professional, it’s really asking you to take a look at other things outside of what might necessarily be your normal course of treatment so that things don’t fall through the cracks with patients. And we’ll talk about this some more when we go through the specifics, but at this point, the bottom line of this is it goes well beyond the money. It’s really we have to do this. We have to this as an industry and there’s really no choice.
Kathleen: Right. Now, absolutely. You know, really talking about cost here, say you have a $50 allowed. With PQRS, with reporting your PQRS in 2014, ’15, and, you know, ’til they make it go away at this point, you know, you’re gonna get $50. Without it, you’re gonna lose your 2% in 2016 going forward. So for $50, you’re gone at $49. But, again, here we’re just using round numbers and we’re basing it on, you know, 500 Medicare patients a month times 12 months. You can see the math. It’s $6,000.
The way healthcare is reimbursing these days, I don’t think anybody has the ability to lose $6,000. But we’re gonna get into why this problem is really so difficult to solve. So the chart here below two just really shows the qualifying incentive, because there’s a possibility you could qualify for a half percent incentive for this year. But just know, the 2%, even in this chart directly from CMS, ’16, ’17,’18, ’19, all right? And I don’t think that this is gonna go away anytime soon.
All right, so let’s go over to the next slide, Jeff. So then we have to talk why the problem is difficult to solve. And the reason why it’s difficult to solve is because there’s a delay in consequences. Really, what we do is we don’t know what’s urgent. Usually, when there’s a consequence, a consequence is immediate. It happens to us right now. So we feel it and then we have the need to make change. The problem is, is that the consequence, in this case, is delayed. For you not to report for 2014, you’re not gonna see really a consequence until 2016. In some That’s two years away.
So people say to themselves, “Well, you know, maybe I won’t participate in Medicare in 2016 and I won’t see it or maybe my Medicare account will go down by 2016, so I don’t have to worry about it.” CMS has been sending out notifications to practices over the past years saying, you know, “If you choose to participate with PQRS.” But, again, the message is, “Well, we’re really not gonna we’re not gonna penalize you until, you know, for two years from now.” But they don’t tell you that you have to do it that year in order to avoid that penalty in the future.
The other problem is is that, you know, you have different measures for a different specialty. So we have chiropractic offices that have physical therapists. I have mental health offices that have occupational therapists in their practice. So, you know, can we just all report on the same measure? Or do different specialties have different measures? Or can we both report on the same one, on the same patient, based on the treatment that we have? So that’s why this problem is so difficult to solve because we always wanna handle the immediate.
And we talk about the immediate because we have ICD-10 coming up. And, I’m gonna turn this over to Dave in a minute, we have ICD-10. We have functional G-codes. We throw in PQRS. Our CPT codes change. Our, you know, Hicks-Picks codes change. PQRS codes have changed. But, you know, getting the changes to your CPT code is now. I mean, so you wanna be able to focus on that so that you can get paid for the services that you supply now. That’s why this problem is difficult to solve because we have to find a way to prioritize, and we always prioritize to the present, not to the future. And I’m gonna turn it over to Dave to explain that a little bit further to us.
David: All right, thank you. If we take off our clinician hat for the moment to put on our business owners’ hat in its place, there’s an awful lot of balls in the air. You know, you add to this, all the challenges of running a business, staff issues, marketing, trying to track and keep your patients. And now we have five things in front of us on this slide that also put extra burden on managing your business, trying to grow your business. And Kathy and I were talking about this earlier, you really can’t leave any of this stuff to chance.
So we have tools to help us do this in a system and we have and we need to develop protocols in our own practices to keep this going because the last of the items listed there have documentation, and audits comes to play in all of this, is perhaps the biggest of all the consequences. And as Kathy said earlier, it’s not necessarily an immediate consequence, but it’s the consequence none of us really wanna have to deal with.
Kathleen: Right. I mean, let me ask you, Dave, with PQRS, does can Medicare still come audit those records even if you report PQRS?
David: Well, here’s the issue with this. They know exactly who everyone is. They know all of our provider numbers. They know who we are. They know the amount of volume we submit every month and every year. So there’s something called the Measure Applicability Validation. They call it MAV. And to simply state it, it’s if you did this or [SP] should have done this, and if you should have done this, if you should have filed these PQRS statistics, and you haven’t done it, they have the right to come in and ask you to submit documentation behind it. Once Medicare has your documentation, they can do whatever they want with it. So in de facto, it is an audit. And it’s not and that’s not
Kathleen: Right, but even if you…and even if you do report PQRS, they can still come in and audit like you said. Even if you did or you didn’t report, you know, they still wanna make sure when you’re reporting the PQRS code that your documentation matches.
Dave: Well, that’s well, we haven’t talked about that yet, but there are specific requirements. We’re gonna go over that in a few slides, by practice specialty, the outcomes measures they’re asking for. The important thing to remember is we have to incorporate that into our procedures so that your notes support what your PQRS reporting says. They have to match.
Kathleen: Right, and, you know, I love that, you know, policies and procedures manual. I think I reference it a lot. You know, make sure everybody in your practice is all on the same page. You know, we talked about why it’s difficult to solve and now we’re really gonna start touching these on the measures themselves. So for chiropractic measures, there are actually, there are three. So, as I mentioned, Medicare says you have to report on nine, but if you there are only three within your grouping, then you’ll only have to report on the three.
So in this particular case, we’re seeing three measures for chiropractors: pain assessment, functional outcome, and then preventative care and screening. If Jess could go to the next slide, we’re gonna talk about PQRS for PT, OT and speech language.
So for PT, I really what we’ve done here is we’ve actually charted it where PT and OT could do BMI. PT, OT and speech can do current medications. But if you’re seeing here in the speech column, they really only have one measure that they are able to report on. So going back to you may have nine, but for speech here, you only have one. As long as you report on the one, they are considering that you’ve completed all your measures and you reported effectively.
The next slide that we have represents mental health. And for mental health here, we have it broken down by both Psychiatrist and Psychologist. There are some that only psychiatrists can do and there are some that only psychologists can do. I’m gonna briefly say to you on these measures. I’m sure you’re asking yourselves. It’s great to show all the measures. I’m gonna repeat it again later, but when you’re emailed after this webinar, you will get a zip file with all the measures and the printout from CMS that explain how to report on these particular measures for your particular specialty.
The next thing that we’re gonna show here is the a claim example. And I’m actually just gonna turn this one over to Dave.
David: All right, so the important thing to take away from this is you can’t you cannot report your PQRS data to Medicare as a stand-alone event. It has to be coupled with a billable event. Sounds a little confusing. So the bottom line is, let’s say that each time we do an evaluation, and depending and we bill, you know, 97001 or 02 if you’re in therapy, or the 941 to the 43 codes, or the 99212 to the 215 codes, depending on your specialty, that’s the time to be reporting your PQRS data. And it just gets incorporated into the billing record and submitted to Medicare that way.
The interesting thing out of this though is it’s right. We were talking earlier about the fact that they’re gathering a ton of data on every patient. So here we have it in this situation, what we did on that date, who’s the patient, what’s the diagnosis code, what’s the procedure that we did. And as we move forward with ICD-10, those descriptors for what’s going on with the patient from a medical perspective get more and more detailed. So they really are getting a full snapshot of what the patient looked like, what we as clinicians did to that patient, provided service to that patient on that day. And now, we’re adding outcomes to it.
So that’s how this all ties together. And the real takeaway here is they see everything. They see it right there in the billing record.
Kathleen: They see it right there. Absolutely. So, really, you know, you’re saying to yourself, “Okay, what’s our approach?” And I see that, and I’m gonna revert back to this question now, there was a question, you know, “Why was Vericle EHR not implemented?â€ Vericle did have Vericle is CCHIP certified and Vericle did put out in 2013 an EHR-based reporting system. It was available to all practices that needed to use it and the PQRS codes were also available in Vericle as well as they are year-over-year.
What’s our approach? So the printable specialty specific PQRS measures actually will be emailed to you at the end of this webinar. All of the 2014 PQRS measures are also available to you in the system. And we have two processes in terms of workflow because, you know, we wanna make sure that you’re able to capture that patient. So the two things that we have is the schedule alerts. You can talk to the training team, and David is gonna get to that on the next slide, talk to the training team so they can help you set up a schedule alert so that you don’t miss a Medicare patient that’s coming in.
And the other validation that we have is that if you do have a Medicare patient and you we do turn on the validation to ensure that you have a PQRS code on your claim. If you do not have the PQRS code on the claim, that claim will invalidate to your workbench, letting you know that you missed it. You have the opportunity at that point to apply an applicable PQRS code or to go ahead and force the claim out the system.
So really, you know, then, you have to talk to yourself, “All right, what are your next steps? We have an approach and a solution, so what are the next steps that need to be taken by the practice itself?” I’m gonna turn this one back over to Dave as well.
David: Okay, so let’s just walk through this together. The first would be talking about the bonus or avoiding the penalty. So we have to get our house in order to make sure that we’re doing this. And there’s an immediate reward and a longer-term consequence that we talked about. Second thing would be for each of the measures that required documentation, that has to be in the chart. And as we’ve talked about in the past, if you didn’t write it, you didn’t do it. These are auditable items. So if you report that a patient has a Body Mass Index of X, your notes for that they need to show that the patient’s weight was such and such. The patient’s height was so and so.
If you’re measuring pain scale, there needs to be documentation to support whatever we say that’s there, keeping track of which claims specifically need this, for the system, as Kathy just explained, the system can help you with that. We can alert you to it, but you need to have a process in place within your practice to make sure that people do the work that’s required when it’s supposed to be. Unfortunately with this, there is no later. Once you bill out the billable event for that day, there’s really no practical way to go back and say, “Oops, I forgot to include the PQRS data.” It really has to be done right the first time and each time it’s required.
And how do we do that? Well, we do that by internal documentation audit. You can conduct that yourself. You can bring in outside contractors to help you with this. But the bottom line is it needs to be somebody’s job, somebody’s responsibility. What I always say is, “What is the name of the person in your organization that is responsible for this?” Accountability is not a bad thing at a time like this. It’s the only thing at a time like this. It would be very dangerous to assume that your that the clinicians on your staff understand this the way you do because you bear the consequences as the stakeholders in the practice.
And there is, as I said, there is no later. There is no mechanism to really go back and fix this if you get it wrong. It’s important to get it right the first time.
Kathleen: I agree completely. Gotta get it right the first time because if you submit the claim to Medicare and you don’t have the code and it’s already been accepted, you can’t go back and apply it after the fact. Actually, by the way, the same thing is also true for functional G-codes as well.
In order to prepare your practice, you do wanna talk to your practice success coach to make sure that they can set you up with the training department, talk about setting up the alert, and to talk about turning on the validation so those claims go to your workbench so that you have an opportunity to review them before they go out the door and put on any appropriate PQRS codes before that happens.
Just so you know, too, we will also be putting out some future webinars. So one is gonna be on workflow, and then we’re gonna be talking about ICD-10 documentation in March as well. We also will be sending to you…there’s helpful websites for each of your organizations. So we have the ACA, the American Chiropractic Association, that has information on their site about PQRS, CAPTA who also does, and the APA, that also has information on PQRS as well.
The other link that we’re gonna be providing to you is the Getting Started, The CMS Guide to PQRS. We’ll be providing you with that link as well in your Thank you email. And then, lastly, again, I’m just repeating myself, all this information will be forwarded to you in a zip file, all the measures, and that will actually answer some of the questions that we have here. Hey, Jess, you wanna finish up?
Jess: All right, yeah. It doesn’t sound like we have any others. So thank you everyone for joining us. If you do come up with any questions, you can go onto the blogs on our websites and post your questions there. And we will answer them there as well. Just wanted to bring up our extended hours, and thank you everyone for attending our PQRS meeting.
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