2016 PQRS Measures for use in LTPAC Medicine, Part 1

February 23rd, 2016 by Rod Baird

The article below is Rod Baird’s annual overview of CMS approved Individual Quality Measures for use by medical groups practicing in Nursing Facilities, Homecare, Assisted Living, and related places of service. It includes an exhaustive list of all measures based on CPT® codes – which are the only link to build a crosswalk to LTPAC settings.

2016 Individual PQRS Measures for use in LTPAC Medicine

Currently, there are no PQRS measures intentionally developed for use in Nursing Facilities, so groups electing to report via use of 9 Individual Measures should read each measure carefully.  Some measures that include the Nursing Home family of CPT Codes (i.e. 99304-99310) specify actions inconsistent with typical LTPAC goals of care.

Medical Groups working in the SNF/NF setting also should note that measures include (99304-99310), but exclude discharge measures (99315-99316) and the Annual H&P – 99318.  This seems to illustrate a significant lack of site specific knowledge.

For the first time, we include PQRS measures associated with Medicare’s Annual Wellness Visit (CPT G0438/G0439).  We are not offering an opinion on the appropriate use of this code in LTPAC settings, but noting that many medical groups are experimenting with its use as part of a Chronic Care Management program (99490).

For the benefit of behavioral health groups covering the various LTPAC settings, we also include the two codes for Psychiatric Diagnostic Evaluation – 90971 & 90972. Based on an analysis of CMS Published Part B data, individuals providing behavioral health services in LTPAC use a combination of those, and traditional E&M codes.

The information is extracted from multiple CMS lists and documents, and the pertinent elements are merged into a single document. The list includes the CPT families associated with the measure, the quality domain, and allowable reporting options.

For individuals and groups electing to use individual measures, there are several caveats:

1. There are 9 or more individual measures that apply to every LTPAC Place of Service code (based on CTP’s). You should plan to pick 9 measures that apply to at least one patient in your Medicare Part B Population or risk failing to satisfy PQRS reporting.  Some of the measures that apply can only be reported when a particular diagnosis and patient status are present (e.g. measure 387 –  Annual Hepatitis C Virus Screening for Patients who are Active Injection Drug Users).  Be thoughtful when selecting measures!

a. A note about the MAV (measures applicability verification) process. If you fail to report on 9 measures, CMS analyzes your universe of Part B claims for the year using a combination of patient demographics, CPT codes, and diagnoses you submitted on claims.  That analysis identifies all the PQRS measures that you, or your group, could potentially report.  If the number of measures is less than nine, you must report on all those measures; otherwise, report on 9 measures,  Failure to report on the required number of measures means you didn’t satisfy the PQRS reporting threshold.

2. Be certain to verify the measures you choose satisfy two additional criteria:

a. At least 1 measure is ‘cross cutting’, and
b. The chosen measures cover 3 or more ‘quality domains’

1. Patient and Family Engagement
2. Patient Safety
3. Care Coordination
4. Population/Public Health
5. Efficient Use of Healthcare Resources
6. Clinical Process/Effectiveness

3. If you elect to report using ‘claims’ – pay particular attention to the measures’ allowable reporting method. CMS is trying to discourage Claims Based PQRS reporting; many new measures cannot be reported by claims, and some older measures had updates that eliminated that reporting option.

A final thought – BENCHMARKS MATTER!  The only criteria for satisfying PQRS is successfully reporting.  But if you are successful, what happens with the data you reported?  That data is the foundation for measuring your Group’s performance under VBP (Value Based Purchasing).  The PQRS Measures results will also be posted on CMS’s Physician Compare Website.

One of the most frustrating aspects of CMS’s quality reporting strategy is the minimal guidance on benchmarks.  Physicians are ‘graded’ in comparison to the performance reported in the prior year, through PQRS, by other medical professionals.  That means the benchmarks for 2016 won’t be available until late fall of 2016 (when 2015 data is fully analyzed).  Scoring ‘high quality’ under VBP is very difficult, as discussed in earlier posts to this blog, achieving a high value score under VBP is quite a challenge.  Starting with Calendar Year 2017, PQRS and VBP transition into MIPS (merit based incentive payment system).  This scheme will rank medical providers against each other on a 0-100 scoring spectrum.  That means your reimbursement is directly tied to a performance score.  For 2017, you should consider selecting Quality Measures that yield a high probability of demonstrating above average performance.

In the absence of benchmarks for 2016, the best guide is to look at the Performance Year 2015 Prior Year Benchmarks which CMS published in December, 2015.  Also note that new PQRS measures will have no benchmark for the 1st year simply because no data was reported for the prior year.  This can have a negative impact if you are trying to achieve above average quality scores as part of your reporting strategy.

The next post in this series includes our recommendation for 2016 PQRS quality reporting strategies, including option for use of Measures Groups and GRPO.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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