ED Coding and Reimbursement Alert

The penalties are getting bigger and some familiar performance measures may disappear

CMS has finalized new requirements for the 2015 Physician Quality Reporting System (PQRS)incentive and the 2017 payment adjustments, as well as the PQRS measures themselves. To make sure you’re up to date on how to comply, read on.

The big picture: The gradual shift from pay for reporting and pay for performance has reached the state where there are no longer incentive payments, only penalties for failure to satisfy the reporting requirements.

No Carrot, Just An Increasingly Larger Stick

In the 2015 rule, the incentives for satisfying the traditional PQRS requirement (formerly 0.5 percent) and the PQRS maintenance of certification (MOC) incentive (formerly 0.5 percent) that had totaled a 1 percent potential bonus are now gone, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford. MA.

The penalty for failure to satisfy the PQRS reporting requirements is -2percent. But don’t forget that there is an additional Value-Based Modifier penalty for failure to adequately report PQRS, which has increased from -2% to -4%. The combination of the PQRS failure to report penalty and the Value based modifier failure to report penalty now totals -6 percent. Remember the reporting year, 2015, is used to determine the payment adjustment in a 2017, Granovsky explains.

Be Aware of These Three National Quality Strategy Domains

In order to earn the PQRS incentives, you have to report nine measures across three National Quality Strategy (NQS) domains, which must also include at least one “cross-cutting” measure, CMS indicates in the in the 2015 Final Rule as a requirement for eligible professionals. For 2015, the available national quality strategy domains are:

1. Person and Caregiver-Centered Experience
2. Patient Safety
3. Communication and Care Coordination
4. Community and Population health
5. Efficiency and Cost Reduction
6. Effective Clinical Care

There is also an emergency care cross-cutting measure, 317 (Community-Population Health) that includes preventive care and screening for high blood pressure and that follow up is documented.

You Can Forget These Key Emergency Care Measures

Last year, many ED groups met the reporting requirements utilizinga menu of seven typical ED Care measures. Unfortunately, in 2015 CMS has retired four out of those seven measures that were important components of ED PQRS reporting. CMS cleaned house and ultimately retired 50 measures for 2015.

These ED measures were retired because they were “topped out” by being successfully reported the vast majority of the time, Granovsky explains.

FrequentED-reported performance measures no longer available include:

• #28: Aspirin at Arrival for Acute Myocardial Infarction (AMI)
• #55: Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope
• #56: Emergency Medicine: Community- Acquired Bacterial Pneumonia (CAP): Vital Signs
• #59: Emergency Medicine: Community- Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic

See the “Potential Measures” table to review measures which may potentially be available for emergency physicians to assist towards satisfying the PQRS reporting requirements, says Granovsky.

Don’t Overlook Value-Based Modifier (VBM)

As required under statute, CMS has finalized the application of the VBM to groups of two or more providers,as well as to solo-practitioners in 2017.

Important: The 2017 payments will be determinedbasedon actions/reporting during the 2015 calendar year. The final rule allows groups with 50 percent of their eligible professionals meeting the individual criteria for satisfactory PQRS reporting in 2015 to avoid the -4 percent 2017 value based modifier penalty.These groups who satisfy the 50% PQRS satisfaction threshold will then be “quality-tiered” based on a quality and cost compositescore. The quality tiering is based on a providers score related to efficiency and cost as measured by the CMS Quality and Resource Use Reports (QRUR) introduced as part of the ACA, says Granovsky.

Groups would be quality-,tiered based on whether they were scored as high cost, average cost or low cost and, additionally, whether they were scored as high quality, average quality, orlow quality. Groups of 10 or more eligible professionals could be adjusted up as much as 4 percent if they were scored ashigh quality and low cost or down 4 percent if they were determined to be low quality and high cost.

Groups of 2 to9 eligible professionals and solo practitioners would have no downside and be able to potentially earn a bonus up to 2 percent, Granovsky explains.

CMS published the following VBM payment charts in the final rule: