2016 Physician Quality Reporting System (PQRS)

Transcription

1 2016 Physician Quality Reporting System (PQRS) Virtual Office Hour Session Measure-Applicability Validation (MAV) 301 Sophia Autrey, MPH, CHES Research Analyst Center for Clinical Standards and Quality, CMS May 24, 2016

2 Disclaimer This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. 2

3 2016 PQRS Presenter: Sophia Autrey, CMS INTRODUCTION 3

4 Virtual Office Hours: Measures Series 101: PQRS Measures Overview Process of choosing the right measures Introduction to Quality Measures 201: Using online tools and documents to assist in choosing measures 301: Meeting measure requirements without having the prerequisite number of measures 4

5 2016 PQRS Presenter: Jamie Welch, CMS Contractor MEASURE-APPLICABILITY VALIDATION (MAV) 5

6 What is the Objective of MAV? MAV is an automatic process applied as part of the PQRS program to assist individual eligible professionals (EPs) or group practices that report less than 9 measures, or less than 3 National Quality Strategy (NQS) domains. The objective of MAV is to validate that there were no other measures that should have been reported. CMS applies the MAV process to determine the 2018 PQRS payment adjustment for individual EPs and group practices. 6

7 MAV-Related Terms and Concepts Term or Concept Claims-Based MAV Minimum Threshold Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS; CAHPS for PQRS): Cluster Cross-Cutting Measures Face-to-Face Encounters Definition The 15-minimum patient or encounter threshold is only related to the Centers for Medicare & Medicaid Services (CMS) determination pertaining to claims if the other measure(s) within the clinical cluster should have been reported by the individual EP. Registry-based MAV does not contain a Minimum Threshold. MAV will apply to group practices that choose the reporting of CG-CAHPS and less 6 registry measures or less than 2 NQS domains. A Group Practice Reporting Option (GPRO) that is greater than 100 eligible professionals is required to report CG-CAHPS. A GPRO that is less than 100 eligible professionals is not required to report CG-CAHPS. If CG-CAHPS is chosen to report, than it would be considered a cross-cutting measure for PQRS. Measures related to a particular clinical topic or individual EP service that is applicable to a specific, individual EP or group practice. Measures that are applicable across multiple providers and specialties; measures that are broadly applicable; for example, PQRS measure #46 (NQF 0097): Medication Reconciliation. An instance in which the individual EP billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). 7

8 Requirements for Initiating MAV Individual EPs or group practices who satisfactorily report quality data codes (QDCs) for less than 9 measures or less than 3 domains Criteria for Satisfactorily Reporting: Individual EPs and group practices must satisfactorily report on at least 50% of their eligible patients or encounters for each measure reported or submitted There must be at least 1 Performance Met numerator outcome in order to be counted as satisfactorily reported. For measures that move towards 100% to indicate higher quality outcome, the rate must be greater than 0%. For inverse measures where higher quality moves the rate towards 0% the rate must be less than 100% At least 1 crossing-cutting measure for individual EP s or group practices with face-to-face encounters MAV is initiated automatically when individual EPs and group practices meet the criteria for satisfactorily reporting. MAV is not a separate reporting mechanism. 8

9 Satisfactorily Report Individual EPs or group practices who satisfactorily report quality data codes (QDCs) for less than nine measures and/or measures covering less than three NQS domains. All PQRS measures attempted to be reported must be satisfactorily reported If an individual EP or group practice reports or submits nine measures covering three NQS domains, but does not satisfactorily report on one of those measures, then they would be subject to the 2018 PQRS payment adjustment and CMS would not initiate MAV. EPs and group practices should report the measures that are applicable to decrease the likelihood of not satisfactorily reporting. EPs and group practices should not try to determine the cross-cutting measure eligibility threshold prior to submitting measures. 9

10 Criteria for Satisfactorily Reporting Individual eligible professionals must satisfactorily report on at least 50% of their eligible patients or encounters for each measure reported or submitted. There must be at least one Performance Met numerator outcome in order to be counted as satisfactorily reported. For measures that move towards 100% to indicate higher quality outcome, the rate must be greater than 0%. For inverse measures where higher quality moves the rate towards 0% the rate must be less than 100%. At least one crossing-cutting measure for individual EP s or group practices with face-to-face encounters. 10

11 MAV and Face-to-Face Encounters EPs or group practices with face-to-face encounters must satisfactorily report: A cross cutting measure. Individual EPs or group practices with face-to-face encounters that satisfactorily report at least one cross-cutting measures and satisfactorily report quality data codes (QDCs) for less than nine measures or measures covering less than three NQS domains will automatically go through the MAV process. EPs must satisfactorily report on at least 50% of their eligible patients or encounters for each measure they do report For those individual EPs or group practice with no face-to-face encounters, MAV will be utilized for those that report less than nine measures and/or measures covering less than three NQS domains. 11

12 MAV and Cross-Cutting Measures At least 1 cross-cutting measure must be satisfactorily reported for those individual EPs or group practices with face-to-face encounters. CMS will analyze claims data to determine if at least 15 cross-cutting measure denominator eligible patients or encounters can be associated with the individual EP or group practice. If it is determined that at least 1 cross-cutting measure was not reported, the individual EP or group practice with face-to-face encounters will be automatically subject to the 2018 PQRS payment adjustment and MAV will not be utilized for that individual EP or group practice. Review the Frequently Asked Question for Cross-Cutting Measures at this link for more information: 12

13 Presenter: Jocelyn Meyer, CMS Contractor CLAIMS AND REGISTRY-BASED MAV 13

14 Claims- and Registry-Based MAV Step 1: Clinical Relation/Domain Test The clinical relation/domain test will be applied to those who are subject to MAV for reported measures OR domains. The test is based on both of the following: If an individual EP or group practice reports data for a PQRS measure, then that measure applies to that practice. If the measure is found within a cluster, then the other closely related measures within the particular cluster would be considered applicable. 14

15 Step 2: Claims-Based MAV Minimum Threshold Test The second step in the process ensures that there are enough patient encounters represented by claims to have measures reported. CMS will evaluate the claims data to determine that there were 15 or more eligible encounters to report. If CMS determines there were 15 or more encounters, then CMS would anticipate that the measure was applicable for reporting. The Minimum Threshold Test is not analyzed for registry-based MAV. 15

16 Claims-Based MAV Example Scenario: An ENT specialist satisfactorily reports 3 measures (#91 and #93), including Measure #130. Within claims-based MAV, Measure #130 is found in the Claims-based MAV Lung Care Cluster. Question: Is she required to report Measures: #51 and #52, since #130 is found within the Claims-based MAV Lung Care Cluster? Answer: As long as the EP has less than 15 denominator eligible patients or encounters for any of the other measures within the cluster, she should pass MAV and avoid the 2018 PQRS payment adjustment. 16

17 Registry-Based MAV Example Scenario: A nephrologist satisfactorily submits his specialty-specific measures along with 1 cross-cutting measure: #130. Question: Is he required to submit the other two measures, #5 and #8, within the Heart Failure Cluster? Answer: As indicated within the note, when submitting Measure #130, it is not subject to MAV and potentially he could pass MAV and avoid the 2018 PQRS payment adjustment. However, if Measures #5 or #8 are reported, it is anticipated all measures within the cluster should be reported. 17

18 MAV Cluster Notes Notes are found in both claims- and registry-based MAV clusters. Notes impact satisfactorily reporting or submitting measures. 18

19 2016 PQRS MAV Training Course The 2016 Measure-Applicability Validation (MAV) self-paced online training course is designed for individual EPs reporting measures via claims or an individual EP or group practice reporting measures via a registry vendor and presents a high-level overview of the MAV process and how the MAV process will apply for 2016 Physician Quality Reporting System (PQRS) reporting purposes. The course includes: Four modules Learning checks Real-world MAV scenarios Helpful information on how to avoid the 2018 PQRS payment adjustment PQRS MAV Self-Paced Online Training Course Link: 19

20 2016 PQRS MAV Resources This is the hyperlink for 2016 PQRS claims-based MAV documents: Assessment- Instruments/PQRS/Downloads/2016_PQRS_MAV_Processfor ClaimsBasedReporting_ pdf This is the hyperlink for 2016 PQRS registry-based MAV documents: Assessment- Instruments/PQRS/Downloads/2016_PQRS_MAV_Processfor RegistryBasedReporting_ pdf 20

21 CMS Initiatives Resources & Where to Call for Help 21

22 Quality Net Help Desk Please contact the QualityNet help desk should you have any additional questions: Telephone: (TTY ) Hours of operation: 7 a.m. 7 p.m. CST, Monday - Friday 22

23 Time for Questions & Answers 23