Top 10 Tips About the Physician Quality Reporting System for Palliative Care Professionals

Abstract

The U.S. healthcare system is shifting from a fee-for-service (FFS) system to a valued-based reimbursement system focused on improving the quality of healthcare. The Centers for Medicare and Medicaid Services (CMS) implemented the Physician Quality Reporting System (PQRS) as an important component of this transition. All clinicians, including physicians, nurse practitioners, or physician assistants who bill to Medicare Part B FFS, should submit quality data to the PQRS in 2015 or they will receive up to a 4% negative reimbursement penalty in 2017. As implementing and reporting PQRS measures can be a daunting task, especially for palliative care professionals, this article provides high priority tips identified by the authors for PQRS reporting in the palliative care field.

Introduction

The Physician Quality Reporting System (PQRS) encourages healthcare professionals to report clinical quality data for covered physician fee-for-service (FFS) care provided to Medicare Part B beneficiaries. Almost a decade ago, the Centers for Medicare and Medicaid Services (CMS) implemented the Physician Quality Reporting Initiative (PQRI), now called PQRS, as part of the Tax Relief and Health Care Act of 2006 (TRHCA). This program, built on prior demonstration projects, previewed a shift toward measuring and reporting clinical quality data as part of healthcare reform. At the start of the program, a 2.0% bonus incentive was given for successful participation, irrespective of performance, based on the estimated total Medicare Part B charges during the reporting period. Based on early success, in 2008, the Medicare Improvement for Patients and Providers Act (MIPPA) transitioned PQRI into a permanent program termed PQRS. This transition in 2008 began a new era of accountability for clinicians as MIPPA required CMS to identify the names of eligible professionals (EPs; physicians, nurse practitioners, physician assistants) and group practices that have satisfactorily reported under the PQRS program. These data were made available to the public by the Medicare Physician Compare website,¹ which allows patients, caregivers, payers, and policymakers to use the information on PQRS participation to assess the quality of care delivered by individual clinicians.

In 2010, the Patient Protection and Affordable Care Act (ACA) enacted several important program changes to PQRS. Most importantly, while the program is still considered voluntary, negative payment adjustments or penalties will be issued to healthcare professionals who do not satisfactorily report PQRS quality data. Incentives for simple participation were phased out and individuals or organizations who fail to satisfactorily report PQRS data in 2015 will be penalized during 2017 payments (Table 1). Failure to report the required PQRS measures will result in a 2% negative payment adjustment penalty based on the total Medicare Part B allowed charges during the reporting period. Beginning in January 2015, a separate adjustment was required by the ACA known as the Value Based Payment Modifier (VBM).² The VBM is determined by using both PQRS measures and cost data and is therefore intended to pay physicians differentially based on the quality and cost of care provided. Failure to report PQRS measures results in an additional 2% negative payment adjustment for the VBM, resulting in a total penalty of 4% (Table 1).

Table 1.

Physician Quality Reporting System Reporting Deadlines and Negative Payment Adjustments

Reporting	Reporting year	Year of negative payment adjustment	Payment adjustment for PQRS	Payment adjustment for VBM
Satisfy PQRS reporting requirements	2015	2017	No adjustment	No adjustment or −2% if do not meet VBM
Fail to satisfy PQRS reporting requirements	2015	2017	−2%	−2%

PQRS, Physician Quality Reporting System; VBM, Value Based Payment Modifier.

To avoid the negative PQRS payment adjustment, CMS require participation in PQRS by any physician, practitioner, or therapist providing Medicare Part B FFS covered services. Healthcare professionals can report quality data as individual EPs or as a group practice. PQRS quality measures can be reported through Medicare Part B claims, a qualified PQRS registry, direct electronic health records (EHRs) using certified EHR technology (CEHRT), CEHRT via a data submission vendor, or group practice reporting option (GPRO) web interface, depending on whether reporting as an individual EP or as a group practice.³ In 2014, the American Taxpayer Relief Act (ATRA) required the development of an additional PQRS reporting option, which allows physicians to submit data to CMS through a qualified clinical data registry (QCDR).³ A QCDR is a CMS-approved entity that can complete the collection and submission of PQRS quality measures data on behalf of individual EPs.

As implementing and reporting PQRS measures can be a daunting task, especially for palliative care professionals, this article will provide high priority tips identified by the authors for PQRS reporting in the palliative care field.

Tip 1: Palliative Care Providers Are Not Exempt From Reporting

All clinicians, including physicians, nurse practitioners, or physician assistants who bill to Medicare Part B Physician FFS, should submit quality data to PQRS. The exception is when physicians are part of an Accountable Care Organization (ACO) because the ACO reports for them. Physicians and other practitioners who fail to do so will receive up to a 4% negative reimbursement penalty in 2017 (2% for PQRS and 2% for VBM, Table 1). Nurse practitioners and physician assistants are required to report PQRS data, but will not be additionally penalized for the VBM until 2017. The challenge for palliative care providers is that there are no specific PQRS measures designed for palliative care services. The National Quality Forum (NQF) has endorsed 14 specific quality measures for palliative care,⁴ few of which are incorporated into PQRS. The Measuring What Matters work group recently identified 10 quality measures of importance to the palliative care field.⁵ Similar to the NQF measures set, few of these measures have been adopted into PQRS. Although current PQRS measures do not align with the identified measures considered high quality for palliative care, penalties will be assessed to nonreporting providers. Tip 3 contains suggestions and advice for palliative care providers for confronting the difficult task of choosing appropriate PQRS measures for palliative care.

Tip 2: Decide Whether to Report as an Individual or as a Group Practice and How to Report

First, organizations/clinicians must consider the best way to report PQRS quality data, either as an individual EP or as a group GPRO. Individual EPs are identified by a distinct Tax Identification Number (TIN) and a distinct National Provider Identifier (NPI). To report as a GPRO, PQRS requires a group practice to have a single TIN with ≥2 individual EPs that are identified by separate NPIs.³ Group practices must register to participate in PQRS GPRO by June 30th of that reporting period. Both individual and group practices can report PQRS measures using a qualified PQRS registry, through a certified EHR using CEHRT, or through a vendor using CEHRT. However, only individual EPs can report through Medicare Part B claims or a QCDR. In addition to the above, group practices of at least 25 participating EPs may report PQRS data via a GPRO web interface. Therefore, the three options of PQRS reporting are via claims (individual only), a registry, or a GPRO web interface (group only). See Table 2 for available PQRS reporting mechanisms for individual EPs and PQRS group practices.

Table 2.

Physician Quality Reporting System Reporting Mechanisms Available for Individual Eligible Professionals and Group Practice Reporting Options

Reporting mechanism	Who can report	Required reporting measures	Additional reporting measures information
EHR that is CEHRT	Individual EPs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. One measure must be cross cutting.	If CEHRT system does not contain these data → must report all the measures for which there are Medicare patient data. Must report ≥1 measure for Medicare patient data.
	GPROs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. One measure must be cross cutting.
Qualified PQRS registry	Individual EPs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. One measure must be cross cutting.	Or can report ≥1 measures group on 20-patient sample, a majority of which must be Medicare Part B FFS patients.
	GPROs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. One measure must be cross cutting.
Medicare Part B claims	Individual EPs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. One measure must be cross cutting.
QCDR	Individual EPs	Report ≥9 measures covering ≥3 NQS domains for 50% applicable Medicare FSS patients for each measure. Of nine measures, ≥2 must be outcome measures.
GPRO web interface	GPROs	Groups of ≥25 report on all measures included in GPRO interface and populate data fields for first 248 consecutively ranked and assigned beneficiaries for each measure. Must report on at least one measure for which there is Medicare patient data.	If eligible assigned beneficiaries are less than 248, then report on 100% assigned beneficiaries
CAHPS for PQRS-CMS-Certified Survey Vendor (patient experience surveys)	GPROs	Groups of ≥100 EPs must participate (in addition to reporting via EHR, qualified registry, or GPRO)	Groups of 2–24 EPs have option to participate (in addition to reporting via EHR or qualified registry), groups 25–99 have option (in addition to EHR, qualified registry, or GPRO)

CEHRT, certified EHR technology; CMS, Centers for Medicare and Medicaid Services; EP, eligible professional; FFS, fee-for-service; EHR, electronic health record; GPRO, group practice reporting option; NQS, National Quality Strategy; QCDR, qualified clinical data registry.

Reporting PQRS measures as a group is advantageous to clinicians who struggle to meet reporting requirements for individual EPs because one set of quality data can be reported on behalf of all EPs in the group. In addition, if PQRS measures are reported as a group practice, not every EP in the group has to meet the required PQRS reporting, instead the combination of PQRS reporting EPs in the group has to equal at least 50% of applicable Medicare FFS patients to meet the reporting criteria. Group reporting can be attractive to large palliative care programs that span multiple care settings. For example, if an organization reports PQRS measures for a group of providers that span different care settings, measures can be chosen that apply to a particular care setting or diagnosis. Certain criteria need to be met to satisfy the requirement, but it may be possible to report on measures that are driven by a few providers and eliminate the need for all to report.

Tip 3: Decide Which PQRS Measures to Report

The challenge for palliative care providers is choosing which PQRS measures to report because as described in Tip 1, there are no specific PQRS measures designed for palliative care. PQRS measures address different aspects of the quality of care, and are reported as either individual measures or a measures group. Individual EPs may report using either of these while GPROs can only report using the individual measures. To report using individual measures, providers must choose nine measures across three National Quality Strategy (NQS) domains and report on at least 50% of the patients who meet the measure criteria.³ The six NQS domains include patient and family engagement, patient safety, care coordination and communication, population and public health, efficient use of healthcare resources, clinical processes, and effectiveness measures. The following factors are important to consider when choosing which individual measures to select from: common clinical diagnosis in the practice, type of care provided (acute vs. chronic), setting where care is delivered (hospital, clinic, home, long-term care facility), and quality improvement goals.³ Also, note that as discussed in Tip 8, not all measures are appropriate for palliative care. A list of individual PQRS measures that could potentially be used by palliative care providers can be found in Table 3.

Table 3.

Individual Physician Quality Reporting System Measures

Measure No.	Title	Domain	Reporting method	Hospital	SNF/NF	Home	ALF
1	Diabetes: Hemoglobin A1c Poor Control	Effective Clinical Care	Claims, Registry	Yes	Yes	Yes	Yes
33	Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for AF at Discharge	Effective Clinical Care	Registry only	Yes	Yes	Yes	Yes
47	Care Plan	Communication and Care Coordination	Claims, Registry	Yes	Yes	Yes	Yes
117	Diabetes: Eye Examination	Effective Clinical Care	Claims, Registry	Yes	Yes	Yes	Yes
119	Diabetes: Medical Attention for Nephropathy	Effective Clinical Care	Claims, Registry	Yes	Yes	Yes	Yes
163	Diabetes: Foot Examination	Effective Clinical Care	Claims, Registry	Yes	Yes	Yes	Yes
383	Adherence to Antipsychotic Medications for Individuals with Schizophrenia	Patient Safety	Registry only	Yes	Yes	Yes	Yes
130	Documentation of Current Medications in the Medical Record	Patient Safety	Claims, Registry	Yes	No	Yes	Yes
32	Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy	Effective Clinical Care	Claims, Registry	Yes	No	No	No
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Effective Clinical Care	Registry only	Yes	No	No	No
391	Follow-up after Hospitalization for Mental Illness	Communication and Care Coordination	Registry only	Yes	No	No	No
5	HF: ACE Inhibitor or ARB Therapy for LVSD	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
6	CAD: Antiplatelet therapy	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
7	CAD: Beta-Blocker Therapy—Prior MI or LVSD (LVEF <40%)	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
8	HF: Beta-Blocker Therapy for LVSD	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
118	CAD: ACE Inhibitor or ARB Therapy—Diabetes or LVSD (LVEF <40%)	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
122	Adult Kidney Disease: Blood Pressure Management	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
154	Falls: Risk Assessment	Patient Safety	Claims, Registry	No	Yes	Yes	Yes
155	Falls: Plan of Care	Communication and Care Coordination	Claims, Registry	No	Yes	Yes	Yes
181	Elder Maltreatment Screen and Follow-up Plan	Patient Safety	Claims, Registry	No	Yes	Yes	Yes
242	CAD: Symptom Management	Effective Clinical Care	Registry only	No	Yes	Yes	Yes
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Effective Clinical Care	Claims, Registry	No	Yes	Yes	Yes
331	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use)	Efficiency and Cost Reduction	Registry only	No	Yes	Yes	Yes
333	Adult Sinusitis: CT for Acute Sinusitis (Overuse)	Efficiency and Cost Reduction	Registry only	No	Yes	Yes	Yes
334	Adult Sinusitis: More than One CT Scan Within 90 Days for Chronic Sinusitis (Overuse)	Efficiency and Cost Reduction	Registry only	No	Yes	Yes	Yes
400	Hepatitis C: One-Time Screening for HCV for Patients at Risk	Community/Population Health	Registry only	No	Yes	Yes	Yes
12	POAG: Optic Nerve Evaluation	Effective Clinical Care	Claims, Registry	No	Yes	No	Yes
19	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	Effective Clinical Care	Claims, Registry	No	Yes	No	Yes
91	AOE: Topical Therapy	Effective Clinical Care	Claims, Registry	No	Yes	No	Yes
110	Preventive Care and Screening: Influenza Immunization	Community/Population Health	Claims, Registry	No	Yes	No	Yes
113	Colorectal Cancer Screening	Effective Clinical Care	Claims, Registry	No	Yes	No	Yes
386	ALS Patient Care Preferences	Person- and Caregiver-Centered Experience and Outcomes	Registry only	No	Yes	No	Yes
268	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy	Effective Clinical Care	Claims, Registry	No	Yes	No	No

ACE, angiotensin-converting enzyme; AF, atrial fibrillation; ALF, assisted living facility; ALS, amyotrophic lateral sclerosis; AOE, acute otitis externa; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CT, computed tomography; HCV, hepatitis C virus; HF, heart failure; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; MI, myocardial infarction; NF, nursing facility; POAG, primary open-angle glaucoma; SNF, skilled nursing facility.

Each measure consists of three components: a denominator (eligible patient population), a numerator (clinical action), and exclusive definitions. These components are used to calculate the reporting rate and performance rate and are specified by codes designated in CMS PQRS measures specification documents. The denominator describes the eligible patient population for that measure using ICD-10 codes, current procedural terminology (CPT) codes, patient demographics, other disease-specific factors, and place of service,³ therefore, some of the measures apply only in certain settings and are defined by a specific diagnosis code. This may pose difficulties for palliative care providers because they often use symptom codes when submitting a claim. As PQRS data are often pulled by disease diagnosis, palliative care providers must have relevant ICD-10 diagnosis codes on their submitted bills and registry when reporting.

Instead of reporting under individual measures, individual EPs can choose to report under measures groups. A measures group is a series of four to nine measures that have a common theme, for example, diabetes or oncology. There are 22 measures groups and each group contains 4–10 different measures, all of which need to be reported if choosing this option. One advantage of reporting PQRS data with measures group is that to qualify for the measures group, a clinician only needs to report PQRS data on 20 patients, with the majority of these patients being Medicare Part B FFS beneficiaries. The measures groups were designed to be used by specialty groups, however, they may be an option for some palliative care programs such as those embedded in specialty clinics like oncology or cardiac specialty clinics. Furthermore, in the outpatient setting, a palliative care provider could use the dementia measures group and would only be required to report on ≥20 patients. All measures within the measures group must be reported on, and it is important to know the requirements for each group. Regardless of which measures are chosen, it is imperative that documentation supports the required measure.

Tip 4: Understand and Report at Least One Cross Cutting Measure

To satisfactorily meet PQRS reporting requirements, at least one of the nine measures must be a cross-cutting measure. A cross cutting measure is a measure that is broad and therefore applicable across many specialties and clinical settings.³ There are 19 cross cutting measures and many of these are relevant to palliative care (Table 4). The majority of cross cutting measures do not have an associated ICD-10 code. Therefore, these measures may be easier for palliative care providers to use because, as stated earlier, palliative care providers often do not submit disease-specific diagnostic codes on their billing claims. Furthermore, during a claims audit, CMS may feel these measures are applicable to the palliative care specialty. See Table 5 for examples of two palliative care programs reporting PQRS quality data. Some cross-cutting measures are only applicable to the office or clinic setting (e.g., #128), and therefore, palliative care programs that do not have a clinic cannot use these measures. In addition, for those palliative care programs that are operating within a hospital setting, there are a limited number of relevant PQRS measures as noted in Tables 2 and 5.

Table 4.

Cross-Cutting Measures List

PQRS No.	NQS domain	Measure title: description
001	Effective Clinical Care	Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18–75 years of age with diabetes who had hemoglobin A1c >9.0% during the measurement period.
046	Communication and Care Coordination	Medication Reconciliation: Percentage of patients aged ≥18 years discharged from any inpatient facility and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.
047	Communication and Care Coordination	Care Plan: Percentage of patients aged ≥65 years who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
110	Community/Population Health	Preventive Care and Screening: Influenza Immunization: Percentage of patients aged six months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
111	Community/Population Health	Pneumonia Vaccination Status for Older Adults: Percentage of patients ≥65 years who have ever received a pneumococcal vaccine.
128	Community/Population Health	Preventive Care and Screening: BMI Screening and Follow-up Plan: Percentage of patients aged ≥18 years with a BMI documented during the current encounter or during the previous six months and with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.
130	Patient Safety	Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged ≥18 years for which the EP attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medications' name, dosage, frequency, and route of administration.
131	Community/Population Health	Pain Assessment and Follow-up: Percentage of visits for patients aged ≥18 years with documentation of a pain assessment using a standardized tool(s) on each visit and documentation of a follow-up plan when pain is present.
134	Community/Population Health	Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan: Percentage of patients aged ≥12 years screened for clinical depression on the date of the encounter using an age-appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of the positive screen.
226	Community/Population Health	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged ≥18 years who were screened for tobacco use one or more times within 24 months and who received cessation counseling intervention if identified as a tobacco user.
236	Effective Clinical Care	Controlling High Blood Pressure: Percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.
240	Community/Population Health	Childhood Immunization Status: Percentage of children two years of age who had four DTaP; three polio (IPV), one MMR; three HiB; three Hep B; one chicken pox (VZV); four PCV; one Hep A; two or three RV; and two influenza (flu) vaccines by their second birthday.
317	Community/Population Health	Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented: Percentage of patients aged ≥18 years seen during the reporting period who were screened for high blood pressure and a recommended follow-up plan is documented based on the current blood pressure reading as indicated.
318	Patient Safety	Falls: Screening for Fall Risk: Percentage of patients ≥65 years of age who were screened for future fall risk at least once during the measurement period.
321	Person and Caregiver—Centered Experience and Outcomes	CAHPS for PQRS Clinician/Group Survey:
		• Getting timely care, appointments, and information;
		• How well providers communicate;
		• Patient's rating of provider;
		• Access to specialists;
		• Health promotion and education;
		• Shared decision making;
		• Health status/functional status;
		• Courteous and helpful office staff;
		• Care coordination;
		• Between-visit communication;
		• Helping you to take medication as directed; and
		• Stewardship of patient resources.
374	Communication and Care Coordination	Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
400	Effective Clinical Care	Hepatitis C: One-Time Screening for HCV for Patients at Risk: Percentage of patients aged ≥18 years with one or more of the following: a history of injection drug use, receipt of a blood transfusion before 1992, receiving maintenance hemodialysis or birth date in the years 1945–1965, who received a one-time screening for HCV infection.
402	Community/Population Health	Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12–20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.

BMI, body mass index; DTaP, diphtheria, tetanus, and acellular pertussis; Hep A, hepatitis A; Hep B, hepatitis B; HiB, H influenza type B; MMR, measles, mumps, and rubella; PCV, pneumococcal conjugate vaccine; RV, rotavirus; VZV, varicella-zoster virus.

Table 5.

Example of Two Palliative Care Programs Reporting Physician Quality Reporting System Data

	PC program A	PC program B
No. of providers	Six MDs, five NPs	Six MDs, five NPs
Care setting served	Nursing home, Home, Clinic, Hospital	Nursing home, Home, Clinic, Hospital
Reporting as EP or GPRO	Individual EPs	GPRO
How reporting measures	Registry	Registry
Measures chosen	Group measures	Individual measures
Measures requirements	20 patients (11 of those must be Medicare FFS Part B)	50% applicable Medicare FSS Part B patients
Specific measures chosen	Inpatient: Diabetes measures group outpatient: Dementia measures group ^*must report on all measures in group	#46 Med Reconciliation [Clinic, SNF/NF, Home, ALF]^* #47 Care Plan [Clinic, H, SNF/NF, Home, ALF]^* #110 Influenza Immunization [Clinic, Home, SNF/NF, ALF]^* #111 Pneumonia Vaccination [Clinic, Home, ALF]^* #128 Body Mass Index (BMI) Screening [Clinic]^* #131 Pain Assessment and Follow-up [Clinic]^* #154 Falls: Risk Assessment [Clinic, SNF/NF, Home, ALF] #155 Falls: Plan of Care [Clinic, SNF/NF, Home, ALF] #386 ALS Patient Preferences [Clinic, SNF/NF, ALF]

Cross cutting.

H, hospital; MD, doctor of medicine; NP, nurse practioner; PC, palliative care.

Tip 5: Individuals or Groups Who Fail to Satisfactorily Report PQRS Data Will Be Subject to a Measure Applicability Validation

Individual EPs or group practices who report but fail to report PQRS data on at least nine measures covering at least three NQS domains for 50% of applicable Medicare Part B FFS patients will be subjected to a measure applicability validation (MAV).⁶ The objective of the registry-based MAV is to determine if there were additional measures or domains that could have been applied by the individual or group practice to meet the PQRS requirements. CMS perform an MAV by executing a “clinical/domain test” during a claims audit.⁶ Basically, they are reviewing the claims and comparing closely related measures to determine if others could have been included. If it is established there were no other potential measures that could have been applied, then the MAV is passed and the individual or group is not subjected to the negative adjustment penalty. For example, if a clinician did not have patients who qualified for reporting on all of the nine measures/three domains, then that clinician is exempt from the penalty. On the contrary, if the MAV identifies additional measures or domains that are relevant (perhaps based on ICD-10 codes submitted on claims), then the individual EP or group practice would be subjected to the negative payment adjustment penalty.

Tip 6: Understand Clusters and How They Are Used for MAV

Related PQRS measures are clustered into groups, which means they are relevant to one another and should be reported on together. There are 39 cluster groupings and these clusters can be used to identify measures that could possibly have been reported by those individuals or groups that report less than nine measures.⁶ For example, fall risk and fall plan of care are in a cluster (PQRS measure #154, 155). If a clinician reports PQRS data on fall risk only and they do not satisfactorily report data on at least nine measures, they will likely be subjected to the negative adjustment penalty. This is because CMS would likely determine that the clinician could have also reported on fall plan of care since it is in a cluster with fall risk. Another example of a cluster relevant to palliative care is urinary incontinence assessment and plan of care (PQRS measures #48, 49).

Tip 7: Know the Frequency and Setting of Each Measure

PQRS measures vary in the frequency in which they are required to be reported. For example, reporting for the influenza screening measure (PQRS measure #110) is required once for patients seen between January and March 2015, and once for patients seen between October and December 2015. There is no diagnostic code associated with this measure, and relevant CPT codes include clinic, home, nursing home, and assisted living facility. Another example, the medication reconciliation (PQRS measure #46) measure requires reporting on all patients seen within 30 days of discharge from an inpatient facility. In addition, there are two reporting requirements for this measure, one for patients between 18 and 64 years old, and another for those 65 years and older. There is no diagnostic code required for this measure and relevant CPT codes include clinic, facility, and home settings. Along with providers, nurses and pharmacists are also eligible to document the medication reconciliation measure. A third example extremely relevant to palliative care is the care plan measure (PQRS measure #47). This measure requires reporting data on patients who are ≥65 years old, who have an advance directive or surrogate decision maker. The reporting frequency for this measure is only once per reporting period, and CPT codes in the denominator are relevant for both inpatient and outpatient settings.

Tip 8: Not all Measures Are Appropriate for Palliative Care

The PQRS measure functional outcome assessment (#182) may seem appropriate for palliative care as many palliative care clinicians are using the Palliative Performance Scale as a validated tool to measure functional status. However, the CPT codes in this measure's denominator are only designed for physical therapists and chiropractors, and so, it is not appropriate for reporting by palliative care providers. When choosing PQRS measures, it is important to align the specialties and practice settings appropriately. For instance, PQRS measure #181, elder maltreatment screen and follow-up plan, is for patients ≥65 with a documented elder maltreatment screen and a documented follow-up plan. It is only applicable in the skilled nursing facility, assisted living facility, and home setting and reportable both by claims and registry methods (Table 3).

Tip 9: Don't Assume Your Employer Is Reporting for You

Some employers determine which PQRS measures to report and will also report for their employees. This is especially true in the hospital setting or hospital-based clinics. However, one should not assume their employer is reporting PQRS data for them. It is critical to understand what measures need to be collected and how these results will be reported. Furthermore, if the employing hospital/healthcare system participates in an ACO or a Medicare Shared Savings Program, the reported PQRS data are published on the Physician Compare website. The PQRS reporting data are now being made available to the public as CMS allow patients, caregivers, payers, and policymakers to use the information on PQRS participation to assess the quality of care delivered by individual clinicians. Providers may want to contact their billing services, as an outside billing company that is aware of PQRS and its importance on reimbursement could proactively provide guidance. Some large multispecialty groups have coding and billing specialists that could assist palliative care providers in proper PQRS reporting. In addition, it is possible to consult with companies for assistance with PQRS quality reporting.

Tip 10: Stay Up to Date

As PQRS regulations are continually changing, it is essential to stay up to date. Never assume that measures reported on in one year will be valid in a subsequent year. Subscribers to a CMS PRQS listserve will periodically receive e-mail updates about the program.⁷ There is also a QualityNet Help Desk that is available to answer questions Monday to Friday 12 hours/day.⁸ Importantly, make note of specific deadlines for collection and reporting PQRS data. Collection for the year always follows a calendar year. If reporting individual measures by the claims reporting option, the 2015 reporting deadline occurred on February 26, 2016, however, if utilizing a registry to report, the 2015 reporting deadline is March 31, 2016.¹

Conclusion

While there remains much discussion around the inappropriateness of PQRS measures for the specialty of palliative care, palliative care providers must still report PQRS data on their Medicare Part B FFS patients to avoid the negative payment adjustment. It will be important to develop more specific PQRS measures relevant to the palliative care specialty; the authors are currently working on the development of a QDCR relevant to our field. In an era with slim financial margins and consistent growth in the need for our services, remaining aligned with the incentives associated with our largest payers while staying cognizant of penalties is required for sustainability of our practices.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

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