Neurosurgery Coding Alert

Watch for providers in your group and changes in physician’s quality reporting program.

Your practice may be participating in the Physician Quality Reporting System (PQRS) wherein you may be reporting on a minimum of 3 individual measures on a particular group of patients which can help you to earn a bonus payment of 0.5% on Medicare billing for 2013 and avoid a 1.5% penalty which would be applied in 2015.

The final rule also finalizes changes to several of the quality reporting initiatives that are associated with PFS payments – the PQRS, as well as changes to the Physician Compare tool on the Medicare.gov website.

The rule also continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, that will affect payments to certain physician groups based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA.

Decide on Individual vs. Group Reporting

Eligible providers have an option to report as either an individual or a group to earn their PQRS incentive.

As an individual, your PQRS quality measures are reported using your national provider number (NPI). However, the incentive payment is provided to the TIN reporting entity. An individual may report using traditional claims using the appropriate quality data codes on the claim form as part of the billing process. Beginning last year, you may also report through a qualified registry if you have access to one. “More and more professional medical associations have begun developing registries over the past few years, both in response to offering members more relevant reporting activities as well as to develop and collect outcome measures to facilitate our understanding of the impact of treatments rendered,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Third option: Of note, there is a third option of reporting via an electronic health record, but this option is not available to some providers at this time.

As a group, CMS again redefined the Group Practice Reporting Option (GPRO) and changed the definition of a group practice to start at two or more eligible professionals practicing under the same TIN. There is now distinction for small, medium and large in the GPRO and the reporting requirements are different for each of the three GPROs.

Group practices with 99 or fewer eligible professionals must decide if they want to continue to report as individuals using one of the multiple reporting options for individuals described above, or if they would like to participate as a group. Group participation is referred to as the Group Practice Reporting Option.

Beginning with the 2013 reporting year, group practices of 100 or more eligible professionals will be subject to a separate Value-Based Modifier in 2015. Such groups must self-nominate to report quality data as a GPRO and then groups would typically elect to be reviewed using the administrative claims options

These quality initiatives of the CMS will empower you to improve overall delivery and coordination of care. You will find more financial resources to support improved quality of care.

Review the Group Reporting Options

If you’re reporting your quality data using the group designation, you should get familiar with three reporting options you might use. Watch out for what is most appropriate for you.

GPRO Web Interface: The GPRO Web Interface is only available to group practices of 25 or more eligible professionals. Groups electing this option will report on a set of 18 primary care and prevention measures.

Note that this option is not recommended for emergency department only or hospital-based TINs and will not meet the criteria for the incentive for hospital-based group practices, Beck says.

GPRO Qualified Registry: CMS will offer group practices consisting of two or more eligible professionals the option to report PQRS measures through qualified registries. This is a new reporting option for group practices and actually the only option that smaller group practices (2-24 professionals) can use to qualify as a group for the PQRS incentive.

GPRO Administrative Claims Option: The new administrative claims option provides groups with an additional opportunity to avoid the 2015 PQRS and VBM penalties. Under this option, CMS will analyze a group’s Medicare claims for a set of 17 measures for assigned beneficiaries, and specific quality data codes do not have to be submitted to CMS. CMS has agreed that for groups who elect this option, even if they have a denominator of zero for all measures, they can still avoid the 2015 PQRS penalty for this option only.

Although participation in the new administrative claims option does not earn a PQRS incentive, if a group practice elects to use the administrative claims option, the individual eligible professionals may still use the traditional claims or registry reporting mechanisms to qualify for the PQRS incentive for this option only.

Bottom line: You need to figure out where your practice falls in the guidelines, based on the number of providers you have reporting together as a group.

Size Does Matter on Payment for Data Collection

Chief among the changes is a proposed expansion in 2014 of PQRS’s quality measures and collection of data from all practices — regardless of size — and ACOs that are in the Medicare Shared Savings Program. Also, for data reported in 2014, the agency proposes adding patient-derived data collected via the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey to the site. The measures designed around the survey focus on providers’ performance based on patient responses. While CMS wants to encourage all practices to report the provider performance measures, it will pay only for the collection of such data from PQRS GPRO practices with 100 or more eligible providers. You would have to have at least 20 participating patients to report the seven measures, warns Granovsky.

Check out These Changes to CMS’s Quality Reporting Programs

1. CMS: Hospital Outpatient Quality Reporting (OQR) Program.

The rule finalizes several new measures for the OQR program affecting the CY 2016 payment determination and subsequent years, with data collection beginning in CY 2014. One new measure in particular will impact EDs and their healthcare staff, says Granovsky.

New measure finalized: Influenza Vaccination Coverage among Healthcare Personnel (OP-27) (NQF #0431). This measure was adopted previously for the Hospital Inpatient Quality Reporting (IQR) Program for the FY 2015 payment determination and subsequent years.

Each year, CMS reevaluates its list of outpatient quality measures, and for 2014 elected to remove one particular ED relevant measure due to a concern regarding the ability to technically implement the measures within the parameters raised by stake holders. Additionally, the measure was thought to be potentially overly burdensome, Granovsky adds.

Measure removed: Transition record: Transition Record with Specified Elements Received by Discharged ED Patients (OP-19) (NQF# 0649), because this measure cannot be implemented with the degree of specificity needed to fully address stakeholders’ concerns without being overly burdensome to both hospitals and CMS.

2. CMS: Hospital Value-Based Purchasing (VBP) Program.

The rule sets performance and baseline periods for the catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and surgical site infection (SSI) measures for the FY 2016 Hospital VBP Program. “Surgeons for the most part have been limited to reporting timeliness of perioperative antibiotics in their PQRS, which may have an impact on SSI. For hospitals, the focus has been on SSI and CAUTI for surgical procedures,” says Przybylski.

The final performance period is Jan. 1, 2014 through Dec. 31, 2014, and the final baseline period is Jan. 1, 2012 through Dec. 31, 2012. The rule also creates a second level independent CMS review process for hospitals that are dissatisfied with the result of their existing administrative appeal, Granovsky explains.

CMS Announces Meaningful Use Revised Timeline

The agency recently announced a revised timeline for Meaningful Use Stage 2 and 3.

Under the revised timeline, Stage 2 will be extended through 2016, and Stage 3 will begin in 2017 for those providers that have completed at least two years in Stage 2. The stated goal of this change is two-fold: (1) to allow CMS and the Office of the National Coordinator for Health Information Technology (ONC) to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and (2) to utilize data from Stage 2 participation to inform policy decisions for Stage 3.

Benefit: The phased approach to program participation should help providers move from creating information in Stage 1, to exchanging health information in Stage 2, to focusing on improved outcomes in Stage 3.

Eligible providers who have already completed at least two years of Stage 2 would now begin Stage 3 in 2017, says Granovsky.