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As March 31st looms on the horizon, we've been hard at work shepherding our PQRS Registry participants towards successful quality reporting. That means we spend a lot of time analyzing data, reviewing measure selections, and answering basic questions about the PQRS program. One consistent pattern we’ve seen is confusion between 2016’s PQRS reporting program and 2017’s MIPS Quality reporting program. It’s understandable: in 2017 MIPS Quality will completely replace PQRS. To help alleviate the confusion, I’ve gathered together 8 main differences between PQRS and the MIPS Quality program.

1. Bonus and Penalty Structure:
PQRS is a stand-alone program. In 2016, failure to satisfactorily report PQRS results in an automatic 2% penalty to your 2018 Medicare billings. But, PQRS also overlaps with a variety of other CMS programs like MAV, VM, and MU. Most of these other programs also carry their own penalty or bonus, so figuring out exactly what’s at stake for one reporting period is complicated. For 2017, CMS has attempted to streamline these various programs. The 2017 MIPS Quality program is actually one part of the bigger MIPS program. So, participants in the MIPS Quality program will only have one overall MIPS penalty or bonus, rather than separate bonuses or penalties for each distinct program.

2. Who Is Required to Report Quality Measures:
For PQRS, everyone that had submitted a bill on a patient to Medicare Part B Fee For Service in 2016 needed to report quality measures if they wanted to avoid the automatic 2% penalty. For MIPS Quality reporting, not everyone that bills Medicare Part B Fee For Service will need to report. For example, the low threshold exception exempts participants who have less than $30,000 worth of Medicare Part B Fee For Service bills, or who have less than 100 Medicare Part B Fee For Service patients. Additionally, certain types of Advanced Payment Models are exempted from MIPS Quality reporting. Finally, participation in a certain other types of Advanced Payment Models means that participants can skip MIPS reporting - including MIPS Quality reporting - altogether.

3. Reporting Time Period:
To avoid an automatic penalty in PQRS, the program required that quality measures be reported for the full performance year, January 1st to December 31st. With MIPS - at least for 2017 - participants can avoid an automatic penalty as long as they report on something for some time period. Though, participants should keep in mind that this relaxed time frame for reporting period will change in 2018 and beyond, eventually once again requiring a full year's reporting.

4. Reporting Population:
PQRS requires that participants report on at least 50% of the Medicare Part B Fee For Service patients who qualify for the chosen quality measures. MIPS requires that participants report on at least 50% of all patients who qualify for the chosen quality measures, regardless of payer.

5. Number of Quality Measures Required to Report:
PQRS requires participants to report at least 9 quality measures. MIPS requires participants to report on 6 quality measures.

6. Structure of Required Quality Measures:
PQRS requires that the quality measures participants choose to report span across 3 domains, which are like categories of effective healthcare. MIPS only requires quality measures to be reported, they do not have to be chosen from any specific categories.

7. Cross-Cutting Measures vs. Outcomes Measures:
PQRS requires that the quality measures reported by participants include one cross-cutting measure, unless a special exception applies. MIPS does not require cross-cutting measures, but rather requests that the quality measures reported by participants include one outcomes measure.

8. Measure Groups:
PQRS allowed participants to utilize measure groups reporting as an alternative way to satisfactorily report quality measures; MIPS does not allow for measure groups reporting.

And, finally, one bonus difference plus similarity...

Still a Four Letter Word, Just a Different One:
PQRS means the “Physician Quality Reporting System” and MIPS is the “Merit-Based Incentive Payment System.” Thus far, despite efforts by CMS to ease the burden of quality reporting, both programs have caused frustration, anxiety and struggle for many of those involved.

“Unbelievable.” “Miraculous.” “Greatest catch of all time.” These are all words and phrases to describe one particular play from this past Super Bowl. If you were one of the 111 million people watching the football game, you definitely remember this one specific play by the New England Patriots. The end of the game was quickly approaching with only 2 minutes and 28 seconds left in the game, and the Patriots were down by 8 points. In that moment, Patriots’ receiver, Julian Edelman, made one of the most memorable catches in all of football history. The odds were not in his favor as it looked like time would expire on the Patriots before they would have a chance to come back against the Atlanta Falcons. However, Julian Edelman had different plans in mind when he made an incredible catch in the last few minutes of the game to help lead a push to victory for the New England Patriots in what looked like a lost cause only minutes earlier.

So how does this epic catch relate? As the reporting deadline for CMS’s PQRS program is rapidly approaching, I’ve been speaking with many physicians and practice administrators around the country. What I’m hearing is the same sense of desperation that the New England Patriots and fans must have been feeling during the Super Bowl as their team was facing an insurmountable deficit with very little time left.

The physicians and practice administrators feel as if they need a miraculous event to save them from a 2 - 6% negative adjustment to their Medicare reimbursement in 2018. Many of these practices have had unfortunate situations where a PQRS registry was full, they were unable to follow through on successful reporting, or they simply had poor communication and planning which led to a scramble late in the 4th quarter.

I hear sentiments of anxiety, frustration, exhaustion and feelings of giving up as physicians and practices know they are almost out of time. However, as the New England Patriots can attest, “almost out of time” and “out of time” are two very different things! If you’re in a situation where you have not submitted your PQRS data for 2016, there is still time to make that game-changing diving catch to finish strong. pMD is a CMS qualified PQRS registry, and we would be happy to see if we can help. We’re accepting customers through February 28, 2017 and there is still time to work with a member of our PQRS team for a consultation and be able to submit your data to CMS to avoid the looming negative adjustment in 2018. Don’t throw in the towel!

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As I've worked with several health systems on how they have been handling PQRS reporting and how they intend to report MIPS quality data to CMS, I've seen some things that I can't unsee: the thick binder overflowing with handwritten pages describing various quality measures; the room full of data entry personnel busily reading patient charts; the EHR screens packed with data fields for a physician group that turned on every single outpatient quality measure.

"We'll capture them all up front, then we'll figure out which ones to submit to CMS later," they said. But it turned out that they were having a hard time convincing physicians to go into that EHR screen at all because it was so heinous. Hence the room full of data entry folks.

MIPS is complicated to begin with; and for complicated health systems, it can get REALLY complicated. They have physicians reporting under multiple Tax ID Numbers (TINs), and often many completely different specialties that ended up sharing a single TIN. Assuming they're reporting as a group (GPRO), that means they often pick "lowest common denominator" measures centered around primary care. This burdens their already-overworked Primary Care Providers with additional data entry, and it effectively excludes many hospitalists, surgeons, and other specialists from quality reporting - certainly from any quality metrics that matter to them.

But with ever-increasing risk from mandatory bundled payments, Accountable Care Organizations and other advanced payment models, and the upcoming cost component of MIPS, I'm hearing from more and more of these enterprises that they can no longer afford to make quality something that only the Primary Care Providers and care coordinators worry about. It's something that involves the specialists too - for example, if a hospitalist fails to talk with a patient about their advance care planning, that patient could end up receiving a very costly and unpleasant intervention that perhaps they didn't want. Getting buy-in from the specialists, and giving them a way to measure their success on these metrics, is vital.

Thinking back to the room full of data entry specialists reading charts, I'm struck by the gap between the ostensible intention of these quality programs (improve the quality of care by rewarding physicians who follow evidence-based care) versus their result (the physicians are not engaged, and the hospital suffers additional costs to hire a room full of people to read their charts and enter data into a registry). There is a better way to engage specialists in quality programs and to actually improve outcomes in the process, but it has to meet them where they are - which is not necessarily sitting in front of a computer - and it has to offer them targeted measures that are relevant to their specialty, not just smoking cessation.

At pMD, we say: bring it on! We love working with specialists of all kinds, and we've developed some innovative tools that help with measure selection and targeted mobile data capture during hospital rounds and immediately after surgeries. There is no one-size-fits-all solution for MIPS, but the future is bright for organizations that embrace their own complexity and find a nuanced solution that will work for them and their physicians.

For many practices, PQRS is a four-letter word. PQRS, or Physician Quality Reporting System, is a federal program that requires the large majority of medical practitioners to submit data annually on their patient encounters. If they fail to do so, they get dinged on their Medicare reimbursements. The program is intended to standardize the quality of health care across the country, but it’s also causing many headaches and sleepless nights for medical practices along the way. PQRS isn't going away, either. In fact, it has more or less been renamed "Quality" measures under the MIPS program starting this year.

Practices who are eligible for PQRS reporting have a couple of options for reporting their data, depending on their Medicare volume and what kind of data they have (or haven’t) captured in 2016. And for practices that haven’t started yet, it’s not too late. Some PQRS registries will allow you to submit your data as late as February 28.

Measures Groups reporting allows practices to submit data on just 20 patients per provider, and not all of those patients have to be Medicare! You must select one of CMS’ approved groups, such as Diabetes, Heart Failure, Preventative Care, Oncology, and more. These groups include a specific set of applicable measures you will need to report on.

Individual Measures allows practices to choose 9 measures to report on, but they must report these measures for at least 50% of their qualifying Medicare patients in 2016. Practices who see a high volume of Medicare patients can expect to report on a much larger set of patients if they choose to report individual measures. GPRO practices will report on 50% of their group’s patients versus individually by provider.

If you have been capturing PQRS data throughout the year on your Medicare patients, then you’re doing well and the manual data entry at the end of the year should be minimal. And if you haven’t been thinking about PQRS until now for fear it may give you more gray hairs, then you’ve come to the right place. It’s important to work with a registry that will work collaboratively with you to choose the best reporting plan for your group. pMD allows you to upload your patient and billing data, view your progress in a user-friendly dashboard, and easily update or add any additional data. Contact us to learn more at 415-422-9578.
To run a health care practice, it’s crucial to have the right information to navigate through the many government changes. So I’ve put together a MIPS For Dummies, of sorts. My goal is to give you some insight into the quickly approaching government changes to the reimbursement process. The Centers for Medicare & Medicaid Services (CMS) has released some preliminary information and here is what we know.

Let’s start with the basics. What does MIPS stand for?
Monkey-Identified Petite Scoliosis. Just kidding! MIPS is the Merit-Based Incentive Payment System and it is a new value-based payment model. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the statute that created this new advancement of the value-based payment model.

What is MIPS?
MIPS is a new payment system outlining financial incentives (and penalties) based on the data submitted by practices, which judges the quality, outcomes, and efficiency of patient treatment. Imagine that the Value-Based Modifier Program, Physician Quality Reporting System (PQRS), and the Medicare Electronic Health Record (EHR) all met and joined forces under one larger, combined program.

Who is at the mercy of MIPS?
Perhaps you, if you’re reading this blog post. But really, MIPS reporting will be required for any clinician billing for professional services under Medicare Part B. This includes all physicians, dentists, chiropractors, physician assistants, physical or speech therapists, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based eligible providers. Providers who are in their first year of Medicare or are below the low-volume threshold may not be required to participate in MIPS.

When is MIPS currently scheduled to roll out?
January 1, 2017! This time I’m not kidding…

Finally, here are some fun facts about MIPS:
1. Centers for Medicare & Medicaid Services (CMS) is no longer accepting comments on the proposed rule - The cut off date was June 27, 2016. However, the final rule with comment period was issued on 11/4/16, and you can comment on that for only a few more days! Cut off for the comment period for this version of the rule is 12/19/16.

2. Qualifying Advanced Alternative Payment Model (APM) Participants are eligible clinicians who are exempt from the MIPS model. This includes Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models.

3. CMS released a fancy new (and surprisingly helpful!) website that guides practices through how to participate in each category of MIPS.

4. To participate in the ACI portion of MIPS you will need a 2014 or 2015 Edition Certified EHR before or on January 1, 2017.

5. If you're eligible for MIPS but decide not to participate in the program, you will receive an automatic negative 4% payment adjustment on your 2018 Medicare reimbursements. (This one is a not-so-fun fact).

Now, last but not least, pMD’s web portal can produce reports reflecting valuable quality data that can be leveraged for MIPS reporting, PQRS solutions and other government changes.

#MIPTASTIC #MIPSYALL #MIPSYEAH
Picture the first day of class for a group of first year medical students. The classroom brims with excitement as students anticipate learning the fundamentals of healing. The students’ overarching goal is incredibly noble: leverage their intellect to save lives. But years pass and the goal fuzzes as the reality of practicing medicine sets in. The once abundant enthusiasm for providing the best patient care possible is downtrodden by business realities such as reimbursement rates, security concerns, regulatory structures and political landmines. We at pMD hear over and over “this isn’t how medicine should be.” Truly, we agree.

Well, we have good news and bad news. The good news is that more and more stakeholders agree that quality of care needs to be prioritized over “the business of medicine.” The bad news is that no one yet understands exactly how to achieve this goal. With the aim of prioritizing patient quality of care, lawmakers have released convoluted and frustrating programs such as Meaningful Use, PQRS, Maintenance of Certification, and CAHPS. These programs have noble goals, but they often make little sense in the real world of practicing medicine. Luckily, these programs are not static, but continue to evolve and adapt each year, inching health care closer and closer to a system that is solely motivated by patient quality of care.

One program that continues to evolve is PQRS, or the Physician Quality Reporting Service. As my colleague Elise explained in an earlier blog, successful participation in PQRS involves reporting quality measures about patient treatment. There are a variety of ways to report these measures, and one of the newest is via a QCDR.

What is a QCDR?

A QCDR, or a Qualified Clinical Data Registry, is an entity that collects quality measures data and can report to CMS to satisfy PQRS requirements on behalf of its members. CMS, the federal agency that runs PQRS, sanctioned QCDRs as an official PQRS reporting method in 2014. The concept is similar to a PQRS registry, with a few notable exceptions - described below - that allow a QCDR to become a broader, more relevant quality database. QCDRs that report quality measures to CMS are required to be certified by CMS, and the list of 2015 CMS certified QCDRs can be found here.

What are the differences between a QCDR and a PQRS Registry?

A QCDR is essentially an evolved PQRS registry. Participants are able to satisfy the requirements for PQRS participation by using broader, more relevant and more accurate data. A few key differences allow a QCDR to be an easier mechanism for PQRS reporting, which makes the QCDR data set more useful for participants.

First, a QCDR can collect and report quality measures beyond just PQRS mandated measures. This allows providers much more flexibility in choosing quality measures to report, thus allowing providers to use measures that actually make sense for their patient population and/or specialty. The result is a more relevant and meaningful collection of quality data that providers feel actually conveys important information. Traditional PQRS registry reporting vs. QCDR reporting can be thought of like this:



Second, a QCDR collects and reports information about an entire population – not just Medicare patients. Collecting quality measures across an entire patient population again results in more accurate and relevant quality data.

Third and fourth, QCDRs do not have to include a cross-cutting measure, and they are not subject to MAV, or Measure-Applicability Validation. This makes it is easier for providers to successfully participate in PQRS because there is less red tape to trip over. Finally, the data reported via a QCDR can, in certain situations, be carried over to other CMS quality programs, such as Meaningful Use and Maintenance of Certification. This intentional overlap facilitates providers' participation in multiple quality based programs.

QCDRs certainly aren't a magic solution that will solve the systemic issues in health care, but they appear to be a step in the right direction. We at pMD carefully watch the evolution of these programs in order to provide powerful solutions for our customers as the seismic shift to quality-based medicine develops. For many of our current customers - charge capture, secure messaging, care coordination, and otherwise - we are a trusted partner in both implementing new ideas and navigating new regulations. If you have any thoughts on how pMD can better assist your practice in doing so, please let us know!
One thing that we can predict with certainty in the health care industry is new acronyms. And new acronyms can mean changes to CMS payment programs. It was approximately one year ago that my colleague Elise wrote a great article on the Physician Quality Reporting System (PQRS). PQRS was originally an incentive based program which, in 2006, included a 1.5% incentive payment based on total allowable charges to providers who reported quality information to CMS. In 2008, the Medicare Improvement for Patients and Providers Act (MIPPA) extended PQRS and increased the incentive to 2%.

This incentive continued until 2010 when the Affordable Care Act (ACA) introduced penalties for providers who did not submit PQRS data. The introduction of penalties forced providers to rethink how they were submitting PQRS data in order to ensure they wouldn't see their levels of reimbursement decline. Participating providers were forced to adopt additional software solutions, employ additional specialists, or join PQRS registries (like us!) in order to not be penalized.

Fast forward to 2016, and after 13 years and over $150 billion spent, the Sustainable Growth Rate (SGR) formula is being eliminated! The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law by the President on April 16, 2015 and completely revamps how CMS pays providers.

According to MACRA, we are now in a transition period whereby:

• Physicians will receive annual growth fee schedule rate increases of 0.5% starting on July 1st, 2015 through the end of 2018.
• There will be a 2% penalty for failure to report PQRS measures.
• There will be a 3% penalty for failure to meet meaningful use requirements.
• The rates in 2019 will be effective through 2025 and providers will have the opportunity to receive additional payments through the 'Merit-Based Incentive Payment System' (MIPS).

Compare the MIPS incentive payments to the SGR formula of a 21% cut in reimbursement, and you can see why the American College of Physicians is in complete support of MACRA and MIPS.

The most surprising provision in MACRA, however, is the fact that CMS is now required to replace not only the SGR, but also PQRS, the Electronic Medical Record Incentive Program (Meaningful Use), and the Value Based Modifier program by 2019 with MIPS.

The AMA and the ACP both agree that the MIPS program is a positive development for physicians as it allows them to effectively determine their eligibility for incentive payments beginning in 2019.

pMD is getting set to help our providers proactively set their performance goals and get credit where credit is due! Check back for part two on MIPS where I describe how pMD helps our providers in the four MIPS assessment categories which will be crucial to receiving positive MIPS adjustments in 2019.

Earlier this month, Centers for Medicare and Medicaid Services (CMS) made a surprising announcement that drew a sigh of relief for many medical practices across the country. It was not the total elimination of ICD-10 that some people had been (or perhaps still are) dreaming of, but the new ICD-10 grace period was a compromise of sorts intended to help ease the transition for physicians and help reduce disruptions in payor reimbursement.

CMS has granted a 1 year grace period for ICD-10 billing codes that are sent out on Medicare claims beginning on Oct. 1. During the grace period, claims will not be denied based solely on the specificity of ICD-10 diagnosis code submitted, as long as the code is from an appropriate family of codes. How do you know if the code is in the correct code family? CMS has released a document to help answer many questions about how to best submit ICD-10 codes on claims. The American Medical Association (AMA) was a driving force behind this new flexibility around ICD-10 code submission.

The new grace period doesn’t just stop at ICD-10 codes - it also affects the Physician Quality Reporting System (PQRS) as well. Health care professionals who are eligible to report on PQRS value-based modifiers will not be penalized during the 2015 reporting year for failure to select a specific enough modifier; the code just has to be from the appropriate family. CMS will still apply a negative payment adjustment to any eligible professionals who do not report the required number of PQRS measures this year.

Even with this grace period, the reality is that practices still do have to submit ICD-10 and PQRS codes and they should be submitting them accurately. Practices who have already implemented ICD-10 into their electronic charge capture system may not need that extra buffer, and it will be business as usual when the clock strikes Oct. 1.

As I mentioned in my December post, capturing data and reporting for the Physician Quality Reporting System (PQRS) is more important than ever in 2015. CMS will apply a negative payment adjustment to any Eligible Professionals not reporting PQRS data this year. The decision to move forward with PQRS reporting seems obvious, but with multiple reporting options and hundreds of quality measures to choose from, getting started can be a formidable task.

Some of the most common questions we receive from the charge capture practices that we work with are listed (and answered!) below.

How many measures do we need to choose?
CMS specifies that Eligible Professionals (EPs) need to report at least nine clinic quality measures across three National Quality Strategy (NQS) domains of care for at least 50% of the EP’s Medicare Part B patients. One of these measures must be a cross-cutting (or broadly applicable) measure. The NQS domains are Effective Clinical Care, Efficiency and Cost Reduction Use of Healthcare Resources, Community, Population and Public Health, Communication and Care Coordination, Patient Safety, and Person and Caregiver-Centered Experience Outcomes.

There are 254 total quality measures available for reporting in 2015, but some measures are only reportable through one or a subset of the possible reporting methods. Selecting a reporting method will decrease the number of measures from which to select; for example, there are 72 measures available for claims-based reporting.

How do we get PQRS data to CMS?
Providers can submit PQRS data to CMS via five different methods of reporting: claims-based, registry-based, qualified Electronic Health Record (EHR), Qualified Clinical Data Registry (QCDR), or as a group of providers via the Group Practice Reporting Option (GPRO).

What are the best measures to choose?
There are a wide variety of measures from which to select, and some are more suited toward certain medical specialties or provider types than others. Some factors to consider when choosing measures are clinical conditions treated, types of care (preventive, chronic, acute) provided, settings where care is usually delivered (office, hospital, emergency room), quality improvement goals for 2015, and any potential overlap with other reporting programs.

For example, Measure #164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation is applicable to cardiologists, while Measure #336: Maternity Care: Post-Partum Follow-Up and Care Coordination might be more relevant to an obstetrician or primary care provider.

Cross-cutting measures, such as Measure #46: Medication Reconciliation and Measure #128: Body Mass Index (BMI) Screening and Follow-Up Plan are intended to be applicable to a wider range of providers.

You can download a list of the 2015 measures and their individual specifications here: 2015 PQRS Individual Claims Registry Measure Specification Supporting Documents

Do I have to capture PQRS data for all nine measures for every patient I see?
No. PQRS only applies to patients with Medicare Part B insurance. Additionally, each individual measure has specific criteria to determine if a patient should be included in the denominator for that measure calculation. These criteria include diagnoses, previous or current patient encounters, gender, and age. In the example of Measure #46 above, only patients who were discharged from the hospital in the current reporting period would qualify for this measure. For measure #164, only patients who underwent a CABG procedure in the reporting year would be included.