PQRS Questions & Answers

Transcription

1 PQRS Questions & Answers Follow up from CAP s PQRS Webinar December 2011 GENERAL QUESTIONS Eligibility Q: Are these quality measures required if you do professional billing only? A: The measures only apply to Part B billing on the Physician Fee Schedule. Participation is voluntary, although penalties for non participation begin in 2015 (based on 2013 participation.) Q: Are pathologists who are employed by an independent laboratory eligible to participate in PQRS in 2012? A: At this time pathologists that work for an independent laboratory that bills using Place of Service 81 cannot participate in the PQRS. Q: Are physicians who report on 3 of the 5 measures eligible to get the bonus? A: Yes, participants only need to report on measures that apply to their practice but at least on 3 measures if 3 or more apply. Q: We are a sub specialized group in a tertiary care center. We each have an NPI number but are under one tax ID number as a group. Is participation based on individual practitioners or groups? A: CMS calculates the PQRS participation based on each unique NPI/TIN combination. Members of the group who are able to participate can do so. The bonuses under one TIN are combined and sent to recipients as one payment Q: If the pathology practice does not perform the services related to the five quality measures, is there any way to participate in the PQRS incentive program? A: At this time, only these 5 pathology measures are available for reporting in CAP has been actively working to get additional measures in the program and will inform membership of any additions in 2013 and beyond. 1

2 Q: For a lab performing only specialized testing (e.g. Her2, ER/PR; 88360) but does not perform the diagnostic part (88305), what is the recommendation for the participation in the program? A: A pathologist billing but not or could only report on the HER2 measure and not on the Breast Cancer Pathology reporting measure. Participants can report on only 1 measure if only 1 measure applies. Q: Hers/Neu sent to another lab for performance. I receive results and report results on surgical path report in an addendum. Am I eligible to report Her2 PQRS code?? No, You can only report on procedures or tests that you bill for. Coding Q: It is rare that we receive ICD9 codes with our surgical cases, making it very difficult to know when to use the PQRI codes in non obvious case types. Any insight? A: Physicians are responsible for including the correct ICD9 codes on their claims. We recommend that pathologists work with their billing and coding professionals to code their claims correctly. Q: The pathologist usually only enters CPT codes on signout. The billers confirm this code and then add the ICD9/10 code prior to submission to Medicare/insurance companies. Who would be responsible in the new reporting system for adding the new CPT Category II Code? A: Our understanding is that the physician is ultimately responsible for adding the correct code. The PQRS system does not change this which is why it is important to have a dialogue with your billing and coding professional to ensure this is done properly. Q: Which diagnosis is controlling when CPT coding a case? The submitting clinical diagnosis, which is usually WRONG, or the pathology diagnosis, which is hopefully always correct and may be different from the clinical diagnosis? A: There is a column on Form 1500 where you can indicate which ICD9 code corresponds to the CPT code. However, as PQRS could pick the claim for the denominator whenever the corresponding ICD9 and CPT code appear on the same claim, we recommend include the reporting codes whenever this occurs. The pathologist is responsible for placing the appropriate ICD 9 code on their claims. Q: In 2008 and 2009, of 14 pathologists participating in the PQRI program, only 2 were paid bonuses for their reporting. I believe some of the problem was related to pathologists not having CPT codes available. How can billing services be utilized to edit or input appropriate PQRI 2

3 codes? A: Specific questions about how CMS provided bonuses need to be resolved with CMS; CAP is unable to mediate these issues. Reporting Q: Do you have to notify CMS before starting with the program or will CMS automatically know once you report the first claim? A: You do not have to notify CMS if you want to participate. Simply including the reporting codes on your claims indicates your desire to participate. Q: My understanding is that we report our first cases for each measure, and that completes the reporting requirement, regardless of how many cases we have for the year. Is this correct? A: No. If using claims, PQRS participants must report on 50% of all of their eligible cases. The case rule applies to physicians using measure groups. Q: If we send out our HER2 IHC to an outside lab, do we still report #251 for the case or are we just considered a non participator for that measure? A: No, You can only report on procedures or tests that you bill for; in this case, the measure would not apply to you. Q: What if you order and report on ER/PR or HER2/FISH for your breast cancer patients but you don't actually perform them? Can you still report them? And can the facility that performed them for you but didn't have the actual breast case also do so? A: You can only report on procedures or tests that you bill for. Q: I perform professional services at more than one site. Can I be a PQRS participating physician at one site but not at the other, or is the reporting linked to whatever claims are submitted with my NPI / CMS number from any site?] A: Successful reporting is determined for every NPI/TIN combination. If you bill from two separate TINs, your PQRS success and bonus will be calculated independently for each one. The key is where you bill from not necessarily where your services are performed. Q: How and where do you document a medical reason for not reporting does it have to be 3

4 explicitly stated in the report itself or is it enough if the reasons are implicitly in the clinical history of the report? A: The medical reason for not reporting should be included on the pathology report or in the patient s medical records. Q: Is there a 30 case requirement for each measure? A: No there is not a minimum requirement for claims. However you are required to submit 50% of your Medicare Part B patients that meet the criteria for the measure. For example using the example of colon cancer reporting measure the number to be reported would be based on your number of patients. So if you have 200 patients then 100 would need to be reported on the measures. The 30 patient rule applies to measure groups. Q: Should a large group choose to report on all 5 measures, or restrict to 3, based on the practice of individual pathologists in the group? A: Since this is a program in which individual physicians participate, each individual pathologist should choose the 3 measures that are most applicable to their practice. In large practices, different members of the group may report on a different combination of measures. Q: We are an outpatient facility and most of our surgical pathology specimens are small biopsies. The only PQRS measure that applies to us is esophagus and Barrett's. Do we qualify to participate? A: If only one measure applies, you can quality for the bonus by reporting on a single measure. If two measures apply, you must report on both measures to eligible for the bonus. Please note that if fewer than three measures are reported, CMS applies the measure applicability validation to confirm. Please see the CMS website for more information on the measures applicabilityvalidation (MAV) process. Q: For claim based reporting, if I forget to report some cases, can I report them later? A: For claim based reporting, you must report the PQRS codes at the time of billing. PQRS cannot be reported retrospectively. Q: If I can report three measures including colon, breast, and HER2 of breast, I do not need to report for prostate or Barrett's esophagus. Is it correct? A: Yes, that is correct. You will only need to report on 3 measures to be eligible for the bonus for 2012 participation in the PQRS. Q: Should reports include a statement that stage/grade is not given due to no residual tumor, or 4

5 does the diagnosis "No residual tumor identified" alone meet the requirement for documenting the medical reason. A: We believe "No residual tumor identified" is adequate documentation for coder to indicate the 1P modifier. REPORTING REGISTRIES Q: Is there a fee for groups that use a registry for reporting? A: Fees will be registry dependent, as registries are private entities. When considering using a particular registry, participants may want to take fees into consideration. CMS does not charge a fee for registry participation. Q: How do you participate in a registry? is this different from a billing company? A: Registries are different than billing companies. Please refer to the CMS website for more information on Alternate Reporting Mechanisms. Q: What are our registry options on 1/1/2012? A: CMS should post qualified registries in the Summer/Fall of 2012 for the reporting year. Eligible professionals can choose to participate as late into the year as the registry is willing to accept clients. A: Please check the CMS website at that time for a list of participating registries. Physicians will have to check with the registry itself to see if the applicable measures are being reported by that registry. It is very important to make sure the registry is capable of reporting the specific measures that pertain to that physician. The CMS PQRS HELP Desk can also provide guidance. Q: When is the deadline for deciding whether to submit as registry? Can you decide in mid year. How do you make this election? A: Yes, you can decide mid year to participate by registry. Registries may summit data on physicians behalf sometime within the first quarter of the following year. For example, 2012 measure data would need to be submitted to CMS from a registry by March of Participants should identify potential registries through the CMS website then independently contact the registry to establish a relationship with that registry. Q: What Pathology registries exist? A: CMS should post qualified registries in the Summer/Fall of Eligible professionals can choose to participate as late into the year as the registry is willing to accept clients. Please check the CMS 5

6 website at that time for a list of participating registries. Physicians will have to check with the registry itself to see if the applicable measures are being reported by that registry. Q: Will the CAP develop a registry? A: Not at this time. However, CAP is exploring this option. PATHOLOGY MEASURES Colorectal Cancer Coding C Q: Can you confirm the new colorectal cancer reporting measure codes? A: The colon cancer reporting codes are G8722 and G8724 (not G2722 and G2724 as indicated on an early slide in our presentation) along with G8721 and G8723. Q: Does CMS allow PQRS reporting on liver metastasis in either pt with colorectal carcinoma or prostate these are coded A: No. Both measures are specific to Billing for does not trigger the denominator. Breast Cancer Reporting Measure Q: If you participate in the first breast measure of staging, must you also participate in the her2 testing measure? A: Depends! If you can report on 3 other measures, you do not need to report on the HER2 Measures. However, if these two measures are the only measures that apply, you must report on both. HER2 Coding HH Q: We send all our breast cancer cases for FISH by HER2. Will that satisfy the requirement? A: No. FISH cases are not coded in such a way to be included in the HER2 denominator. Q: We often report ER/PR on DCIS cases. These cases do not have a malignant breast ICD9 code. Does 3395F apply? A: If codes denoting the measure denominator do not appear on your claim form, the measure does 6

7 not apply. Q: Our Pathologists review quantitative ER/PR but send out for Her2 and once the results come back to our office we document it on the report with the ASCO/CAP guidelines. I understand that we will use 3395F for ER/PR but do we need to report 3394F even though we do not review the HER2 stain? A: You can only report on cases that you also bill. You can report on the ER/PR cases that you bill but not on the HER2 cases that you don t bill. Q: Does the HER2 measure apply to needle biopsies? FNA? Core biopsies? A: The HER2 measure applies whenever the combination of ICD 9 and CPT codes denoted in the denominator appear on a claim form. Q: Since we review the ER/PR stain and would bill x2 with each having a diagnosis of 174.9, would we need to enter 3395F x2? A: Multiple applicable procedure codes billed on one claim will only be counted once in the denominator for the measure. Therefore, only one quality data code will need to be reported on the claim. In the scenario above, the reporting of 3394F only would seem appropriate if that clinical action was performed. Q: For Breast, ER/PR/Her2 usually is reported separately from the main report. Is the 3394F and 3395F codes attached to the original report which includes the 3260F or only on the separate hormone receptor report. A: 3394F and 3395F are included on the claims not actually the pathology report. The code should be included on the same claim as the procedures were billed. Q: In your first case Study #1 from CAP s December 2011 webinar, in which the patient had HER2 testing by IHC using the CAP/ASCO guidelines (add 3394F), you indicated that the 3395F code is added if ER/PR were also performed. I thought you only added 3395F if ER/PR was performed and HER2 was NOT performed. Could you please clarify? A: Multiple applicable procedure codes billed on one claim will only be counted once in the denominator for the measure. Therefore, only one quality data code will need to be reported on the claim. In the scenario above, the reporting of 3394F only would seem appropriate if that clinical action was performed. Including 3395F on the same claim will not count against you. However, adding 3395F whenever ER/PR is performed and billed separately is important. 7

8 Q: For one report with Her2 ER and PR X3 how is this coded? F and F? A: Multiple applicable procedure codes billed on one claim will only be counted once in the denominator for the measure. Therefore, only one quality data code will need to be reported on the claim. In the scenario above, the reporting of 3394F only would seem appropriate if that clinical action was performed. Including 3395F on the same claim will not count against you. However, adding 3395F whenever ER/PR is performed and billed separately is important. Q: My understanding is the totally negative Her2, ER or PR results should be charged as 88342, not 88360/ If so I assume these negative Her2 results are not eligible for PQRS. Is that your understanding? A: Correct. Any procedure billed as is not included in the measure. Q: I read ER/PR IHC performed at another lab, and send HER2 neu to an outside lab to be performed and reported. The HER2 neu is later reported on the patient s lumpectomy or mastectomy specimen. Would I report both3394f and 3395 F and would 3395 be times one or two? A: Only on the case where the ICD 9 codes and the or CPT codes are reported on the claim form would the pathologist also report the Category II code of 3394F it would not be later coded on a lumpectomy case in which the or was not reported. These CPT II codes are only coded once per patient per each date of service. Barrett s Esophagus Coding Q: Do the words "Barrett's esophagus" need to be in the report or does "intestinal metaplasia" count as equivalent to "Barrett's esophagus"? A: The key to reporting is that whenever the measures denominator codes (ICD and CPT code 88305) appear on the claim form the measure applies. Providers should report whenever those two codes appear on the same claim form with the appropriate code. Q: If my diagnosis states Barrett's esophagus, negative for dysplasia. Should l use the modifier 8F or not? A: The measure calls for a statement about dysplasia. Negative for dysplasia counts as a statement; therefore report 3125F without a modifier. Q: In case of Barrett's, when a gastric biopsy also received, is coding 3125F AND G8797? 8

9 A: Since the Barrett s measure requires reporting only once per patient per date of service; inclusion of 3125F should fulfill reporting requirements. Q: Is the diagnosis of Barrett's Esophagus the point of endoscopic finding or presence of intestinal metaplasia of pathologic finding? A: The ICD 9 code for Barrett s with the CPT code is what identifies potentially eligible cases for PQRS, however, if Barrett s is not actually identified in the biopsy then the 3125F with the 1P modifier would be used as this would be a medical reason not to mention dysplasia in Barrett s. Q: What if the esophagus bx meets the ICD9 and CPT criteria but is negative for Barretts so neither Barrett s, metaplasia, or dysplasia is mentioned in the Dx? A: If the measure codes appear on the claim form, but the patient does not have Barrett then use the 1P modifier to CPT Code II 3125F. Q: Since Barrett requires both intestinal metaplasia and the presence of endoscopic involvement of the esophagus, we do not report "Barrett mucosa", but rather intestinal metaplasia, negative for dysplasia. Does this meet the requirement for Barrett reporting? A: The key to reporting is that whenever the measures denominator codes (ICD and CPT code 88305) appear on the claim form the measure applies. Providers should report whenever those two codes appear on the same claim form with the appropriate code. Q: Does the previous history of Barrett's esophagus require PQRS reporting automatically? A: Only if the ICD 9 code appears on the claim form with the CPT code Q: Does stating absence of dysplasia in a barrett's case count? A: Yes. The measure developers believe that stating the absence of dysplasia is important information for the patient, and does not leave the ordering physician wondering whether it was assessed. The key to reporting is that whenever the measures denominator codes (ICD and CPT code 88305) appear on the claim form the measure applies. Providers should report whenever those two codes appear on the same claim form with the appropriate code. The point of the measure is to report whether or not dysplasia is present when Barrett s is diagnosed. Q: For a patient with history of Barretts but only a stomach biopsy do we have to code the case as a G8797? A: If the ICD9 code appears on the claim for a stomach biopsy, then the G8797 is used to 9

10 report. Helpful Tools from AMA and CAP Q: When will the CAP website have updated "crib sheets" for reporting the 2012 PQRI measures? A: The AMA Physicians Consortium on Performance Improvement is developing toolkits that will be available in early The toolkit will include three documents for each measure: 1) description of the measure; 2) measure worksheet; 3) coding specification. PQRS in 2015 and Beyond Q: If you opt out of the PQRI system does the % penalty apply. Or is PQRI reporting required. A: You cannot opt out of the PQRS if you bill Medicare Fee for Service. There is no registration required, everyone is automatically included. The 1.5% penalty in 2015 will be based on participation in the 2013 PQRS, though CMS has not stated how it will handle eligible professionals who do not have measures. Q: Is the 1.5% penalty applied only to the claims that qualify, or is it applied to ALL claims reported? A: The 1.5% penalty applies to all claims billed to Medicare Fee for Service associated with the provider s TIN/NPI combination. Q: Someone mentioned that the system is "pay for reporting" not "pay for performance"...will this be changing in the future to "pay for performance" only? A: Most likely CMS already is working on a Value based modifier that will be applied to all physicians in