ED Coding and Reimbursement Alert

Cluster 4 will significantly help emergency physicians successfully report to avoid penalties in 2017

As reported in the February issue of ED Coding and Reimbursement Alert (Vol. 18, No. 2), CMS has retired 50 measures from the PQRS program for 2015 including the following 4 out of the 7 measures from the 2014 Measure Applicability Validation (MAV) for emergency care (i.e., 2014 Cluster 5).  The retired 2014 measures include:

#28: Aspirin for AMI
#55: 12-Lead ECG for Syncope
#56: Community Acquired Pneumonia (CAP): Vital Signs
#59: Community Acquired Pneumonia (CAP): Empiric Antibiotic

Elimination of these measures would have made it nearly impossible for emergency physicians to meet the requirement of reporting on 9 measures across 3 domains with at least 1 cross cutting measure. However, the 2015 MAV criteria should provide an opportunity for successful reporting for emergency medicine, says Dennis M. Beck, MD, FACEP.

There is good news, Beck adds. On Jan.  19, 2015, CMS released the 2015 Measures Applicability Validation (MAV) process and they identified the following Claims-Based MAV for Emergency Care = Cluster 4 + 1 Cross-Cutting Measure:

Given the typical scope of care provided to Medicare patients, it would appear to be impossible to meet the claims based reporting requirement of 9 measures across 3 domains given the above list. However, reporting on the measures in Cluster 4, along with cross-cutting measure 317, will be an appropriate strategy for most emergency providers, says Beck. Measures 254 and 255 would only be counted in the MAV process if an emergency physician saw greater than 15 eligible patients, which is highly unlikely in the Medicare population, he explains. 

Check Out These Insider Tips For Successful Reporting

Beck offers these additional PQRS reminders:

• PQRS applies to physicians AND non-physician providers

• Successful claims- based reporting requires reporting on at least 50 percent of eligible Medicare patients seen by the provider (i.e. all patients that meet the denominator CPT and ICD descriptors for a given measure)  

• Reporting on measures outside of Cluster 4 may trigger additional MAV testing and the requirement to satisfy other clusters

• Failure of an eligible provider to successfully report PQRS in 2015 will result in a 2 percent reduction in 2017 Medicare payments to  that eligible provider

• Additionally, based on PQRS reporting, a Value Based Modifier (VBM) will be applied to the group practice at the TIN level. At least 50 percent of the group’s eligible provider’s (includes physicians and NPP’s) in a group (“TIN’ or Tax ID Number)  must successfully report PQRS in 2015 to avoid an  additional 4 percent VBM penalty that will be assessed in 2017 at the TIN level. As far as calculating the “50 percent of eligible providers requirement”, CMS considers any EP that submitted a claim in 2015 under a given TIN to be in the denominator.