Who am I? Presented by Jeff Grant, President HCMA, Inc.

Presented by Jeff Grant, President HCMA, Inc. Who am I? Over 20 years Practice Management, Operations, Revenue Cycle Management & HIT Consulting with nearly 1,000 practices Provides Revenue Cycle Management Services to numerous practices Speaker at AAO, ASCRS, Hawaiian Eye, SECO, AOA, Vision Expo, & State Associations Articles in Administrative Eyecare, Ophthalmology Management, Optometric Management, Ophthalmic Professional, Ophthalmology Times, Premier Surgeon, Ophthalmology Business, & Advanced Ocular Care Assisted dozens of practices with EHR selection/implementation & MU 1

Legislative Update PQRS Overview Preventing Future PQRS Penalties PQRS Reporting Options ecqm s& PQRS Agenda PQRS Flowcharts for Each Reporting Option VM Overview Resources Legislative Update Law passed to end SGR Sunsets PQRS, VM, & current EHR programs after 2018 Replaced by MIPS (Merit-based Incentive Payment System) 4 Criteria, including EHR & quality PQRS & VM in 2015-2015, HCMA, Inc. 2

PQRS Overview No sign-up necessary No more PQRS incentives PQRS Overview 1.5% penalty in 2015 if you didn t submit at least 1 measure for 1 patient in 2013 (yes, just 1 measure for 1 patient would prevent the 2015 penalty) 2% penalty in 2016 if you didn t submit at least 3 measures 50% of the time 2014 3

PQRS Overview Future penalties if you aren t a successful PQRS submitter in 2015 and all future years. PQRS & VM penalties apply to Medicare Part B, MSP, & Railroad Medicare allowables, less durable medical equipment and injectable drugs. Preventing Future PQRS Penalties 4

Preventing Future PQRS Penalties PQRS reporting options require an EP or group practice to report 9 or more measures covering at least 3 National Quality Strategy (NQS) domainsfor at least 50% of the EP s Medicare Part B FFS patients. If the EP sees at least 1 Medicare patient in a face-to-face encounter, at least one measure must be a Cross Cutting measure. These primary care measures are meant to represent core competencies that apply to multiple specialties. Measures with 0% performance rate will not be counted. Preventing Future PQRS Penalties The domains associated with the measures are as follows: Patient Safety Person and Caregiver-Centered Experience and Outcomes Communication and Care Coordination Effective Clinical Care Community/Population Health Efficiency and Cost Reduction 5

Preventing Future PQRS Penalties Cross-Cutting Measures Requirement In order for eligible professionals (EPs) to satisfactorily report Physician Quality Reporting System (PQRS) measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. Eligible professionals or group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter. Preventing Future PQRS Penalties Cross Cutting measure examples: PQRS 110 Preventive Care & Screening: Influenza Immunization (claims or registry/iris) (Community/Pop. Health) PQRS 111 Pneumonia Vaccination Status for Older Adults (claims or registry/iris) (Effective Clinical Care) PQRS 130 Documentation of Current Medications (claims or registry/iris) (Patient Safety) PQRS 226 Preventive Care & Screening: Tobacco Use: Screening & Cessation Counseling (claims or registry/iris) (Community/Pop. Health) PQRS 236 Controlling High Blood Pressure (claims or registry/iris) (Effective Clinical Care) PQRS 238 High-risk Medications in the Elderly (claims or registry/iris) (Effective Clinical Care) PQRS 317 -Preventive Care & Screening: Screening for High Blood Pressure and Follow-up Documented (claims or registry) (Community/Pop. Health) PQRS 402 Tobacco Use and Helping with Quitting Among Adolescents (registry only/iris) (Community/Pop. Health) 6

Preventing Future PQRS Penalties Potential Ophthalmic Codes to use: PQRS 12 POAG: Optic Nerve Evaluation (claims or registry) (Effective Clinical Care) PQRS 14 AMD: Documentation of Macular Thickening & Level of Severity of AMD (claims or registry) (Effective Clinical Care) PQRS 19 Diabetic Retinopathy: Communication with Physician Managing Ongoing Diabetic Care (claims or registry) (Effective Clinical Care) PQRS 117 Diabetic Eye Exam (claims or registry)(effective Clinical Care) PQRS 140 AMD: Counseling on Anti-oxidant Supplements (claims or registry) (Effective Clinical Care) PQRS 141 POAG: 15% or Greater Reduction of IOP (claims or registry) (Communication and Care Coordination) Preventing Future PQRS Penalties Potential Ophthalmic Codes to use (surgeons only) (new for 2015): PQRS 384 -Adult Primary Rhegmatogenous Retinal Detachment Repair Success Rate: Percentage of surgeries for primary rhegmatogenous retinal detachment where the retina remains attached after only one surgery (registry only) (Effective Clinical Care) PQRS 385 -Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate: Percentage of retinal detachment cases achieving flat retinas six months post-surgery (registry only) (Effective Clinical Care) PQRS 388 -Cataract Surgery with Intra-Operative Complications: Rupture of Posterior Capsule Requiring Unplanned Vitrectomy (registry or Cataract Measures Group only) (Patient Safety) PQRS 389 -Cataract Surgery: Difference Between Planned and Final Refraction (registry or Cataract Measures Group only) (Effective Clinical Care) 7

Preventing Future PQRS Penalties What if an EP reports fewer than 9 measures? This can be done, but the EP will be subjected to Measure Applicability Validation (MAV) This process determines if the EP could/should have reported more measures. If so, the EP fails. If there are measures not reported which are related to a reported measure, MAV would determine that the EP should have reported additional measures. Preventing Future PQRS Penalties Measure Group Reporting instead of individual measures Example: Cataracts Measures Group Report on 20 patients via registry At least 11 out of the 20 patients (more than 50%) must be Medicare Part B FFS patients. 191, 192, 130, 226, 303, 304, 388, 389 8

Reporting Options Reporting Options Individual EP Reporting Options To satisfactorily report or to satisfactorily participate in the 2015 PQRS program, individual EPs may choose to report quality data via: 1. EHR Direct Product that is Certified Electronic Health Record Technology (CEHRT) 2. EHR data submission vendor that is CEHRT 3. A qualified PQRS registry* 4. Participation through a Qualified Clinical Data Registry (QCDR) 5. Medicare Part B claims submitted to CMS* Note that some measures can no longer be reported via claims. 9

Reporting Options Claims-based Reporting Least desirable due to time, confusion, chance of errors Must include modifiers when the measure was not performed Can still submit with $0.00 but CMS does seem to prefer having $0.01 Remittance Advice Codes are different depending on whether you submit with $0.00 or $0.01 Reporting Options Registry Reporting There are dozens of registries No need for marking PQRS codes in EHR or PM No need to send codes via claims Submission isn t due until after the end of the year; registries have until 3/31/16 to submit data for 2015 IRIS Registry (by AAO) for ophthalmology and OD s who work in an ophthalmology practice AOA MORE registry (optometry) will be able to submit for 2017 10

Reporting Options Registry Reporting IRIS Registry IRIS maps data from each EHR The IRIS Registry is certified to support three different PQRS submission methods at this time: EHR Data Submission - through interfaces with database systems Cataract Measure Group - through our manual data entry web portal Individual Measures Reporting -through our manual data entry web portal (for those w/o EHR) IRIS can be used as a Qualified Clinical Data Registry(QCDR). QCDR might be better for some sub-specialists who struggle to report 9 PQRS measures, but the reporting requirements for QCDR are different. Registry Reporting IRIS Registry Reporting Options Submission counts for PQRS/VBM & MU/CQM Meets the Stage 2 Menu Set measure for Specialized Registry 11

Reporting Options Registry Reporting AOA s MORE Registry (Measures and Outcomes Registry for Eyecare) Working now on integration with the 3 or 4 most-used EHR vendors AOA's MORE will launch at Optometry's Meeting 2015in Seattle, Washington, June 24-28. Attendees also can participate in continuing education discussing the optometric registry Course No. 1100, titled, "Quality in Patient Care Know it, Use it, Prove it, Oh my!" presented by Dr. Michaels and Andy Archila, O.D. from 1 to 2 p.m., June 25. Won t be able to help you until the 2017 reporting year! Reporting Options Group Practice Reporting Option (GPRO) Don t confuse this with Measure Group reporting option GPRO was introduced in 2010 as a reporting method for group practices to qualify to earn a PQRS incentive. PQRS defines a group practice as a single Tax Identification Number (TIN) with 2 or more individual EPs (as identified by Individual National Provider Identifier [NPI]) that have reassigned their billing rights to the TIN. Group practices may choose to report PQRS quality data via: 1. GPRO Web Interface (for groups of 25 or more EP s only) 2. Qualified PQRS Registry 3. EHR Direct Product that is CEHRT 4. EHR data submission vendor that is CERT Group practices reporting via GPRO must register for this reporting method. For more information about reporting PQRS measures as a group, visit the Group Practice Reporting Option webpage at http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/group_practice_reporting_option.html. 12

How often is each measure reported? Measure Reporting Frequency Each measure specification includes a reporting frequency (also referred to as a measure tag) for each denominator-eligible patient seen during the reporting period. The reporting frequency described in the instructions applies to each individual EP and group practice submitting individual PQRS measures. PQRS uses the reporting frequency to analyze each measure for determination of satisfactory reporting, according to the reporting frequency in the Instructions section of the measure: Patient-Process: Report a minimum of once per reporting periodper individual eligible professional (NPI). Patient-Intermediate: Report a minimum of once per reporting periodper individual eligible professional (NPI). Patient-Periodic: Report once per timeframe specifiedin the measure for each individual eligible professional (NPI) during the reporting period. Episode:Report once for each occurrenceof a particular illness/condition by each individual eligible professional (NPI) during the reporting period. Procedure:Report each time a procedure is performedby the individual eligible professional (NPI) during the reporting period. Visit:Report each time the patient is seenby the individual eligible professional (NPI) during the reporting period. ecqms with PQRS? 13

ecqms with PQRS? Beginning in 2014, the ecqm specifications will be used for multiple programs, including the EHR-based reporting option for the PQRS as well as the Medicare EHR Incentive Program to reduce the burden on providers reporting quality measures. Report via 1. EHR Direct Product that is Certified Electronic Health Record Technology (CEHRT) 2. EHR data submission vendor that is CEHRT 3. A qualified PQRS registry 4. Participation through a Qualified Clinical Data Registry (QCDR) ecqms with PQRS? By satisfactorily reporting ecqms using Direct EHR or EHR Data Submission Vendor Products, an EP or group practice will satisfy the 2015 PQRS requirements and avoid the 2017 PQRS payment adjustment. 14

ecqms with PQRS? If an eligible professional's or group practice s CEHRT system does not contain patient data for at least 9 measures covering at least 3 domains, then the EP or group practice must report the measures for which there is Medicare patient data. An EP or group practice must report on at least 1 measure for which there is Medicare patient data. Additionally, EPs and group practices may meet the Clinical Quality Measure (ecqm) component for the Medicare EHR Incentive Program if they participate via the PQRS EHR-based reporting method. ecqms with PQRS? Registry submission of PQRS & ecqm data 15

PQRS Flowcharts for Each Reporting Option From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 1. Claims-based reporting of less than 9 individual measures across 3 or more NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients and at least 1 crosscutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter (12 months) Note: This reporting option is subject to Claims Measure- Applicability Validation (MAV) 2. Claims-based reporting of at least 9 individual measures across 1-2 NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter(12 months) Note: This reporting option is subject to Registry Measure- Applicability Validation (MAV) 3. Claims-based reporting of at least 9 individual measures across at least 3 NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients (12 months) 16

From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 4. Qualified registry-based reporting of less than 9 individual measures across 3 or more NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter(12 months) Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV) 5. Qualified registry-based reporting of at least 9 individual measures across at 1-2 NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter(12 months) Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV) 6. Qualified registry-based reporting of at least 9 individual measures across at least 3 NQS domains for 50% or more of an EP s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter(12 months) 7. Qualified registry-based reporting of at least one measures group for 20 or more patients, the majority (11) of which must be Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a faceto-face encounter(12 months) From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 8. Direct CEHRT EHR-based reporting of at least 9 individual measures across at least 3 NQS domains (12 months) 9. CEHRT EHR Data Submission Vendor reporting of at least 9 individual measures across at least 3 NQS domains (12 months) 17

From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 10. GPRO-based reporting (2+ eligible professionals) of 1-8 individual measures across 3 NQS domains via registry for 50% or more of a group s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter (12 months) Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV) 11. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures across 1-2 NQS domains via registry for 50% or more of the group s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a face-to-face encounter(12 months) Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV) 12. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures across at least 3 NQS domains via registry for 50% or more of the group s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if the EP sees at least 1 Medicare patient in a faceto-face encounter (12 months) 13. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures across at least 3 NQS domains via Direct CEHRT EHR-based reporting (12 months) 14. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures across at least 3 NQS domains via EHR Data Submission Vendor that is CEHRT (12 months) From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 15. GPRO-based reporting (25-99 eligible professionals) of all applicable measures included in the submission Web Interface provided by CMS for consecutive, confirmed, and completed patients for each disease module and preventive care measures (12 months) 16. GPRO-based reporting (100+ eligible professionals) of all applicable measures included in the submission Web Interface provided by CMS for consecutive, confirmed, and completed patients for each disease module and preventive care measures AND report all CG CAHPS summary survey modules via CMS-certified survey vendor (12 months) 18

From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 17. Qualified clinical data registry-based reporting of at least 9 measures across at least 3 NQS domains for 50% or more of the EP s applicable Medicare Part B FFS patients AND report at least 2 outcome measures and at least 1 additional outcome measure or resource use, patient experience of care, or efficient/appropriate use measure (all payers) (12 months) From CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide 19

VM Overview VM Overview VM is Value-based Modifier or Value-based Payment Modifier VM assesses quality of care furnished compared to the cost of that care during the specific performance period. VM is tied to PQRS success / failure PQRS Failure: Additional automatic penalty on top PQRS penalty: -2% for groups of 2 9 EP s and solo practitioners -4% for groups of 10+ EP s PQRS Success: Mandatory Quality Tiering = potential for incentive, penalty, or neutral Penalty applied to both PAR and NON-PAR providers 20

VM Overview Reporting Quality Data at the Individual Level -50% Threshold Option If a group does not seek to report quality measures as a group, CMS will calculate a group quality score if at least 50 percent of the eligible professionals within the group report measures individually. At least 50% of EPs must successfully avoid the 2017 PQRS payment adjustment EPs may report on measures available to individual EPs via the following reporting mechanisms: Claims CMS Qualified Registries EHR Clinical Data Registries (new for CY 2014) VM Overview Applied to ALL EP s in 2017, based on 2015 performance Successful PQRS reporting in 2015 avoids the automatic -2% or -4% penalty(depending on group size) in 2017 and makes the EP subject to Quality-Tiering (the process of evaluating performance on cost and quality). Groups with 2 9 EP s and solo practitioners receive only upward or neutral VM adjustment. Groups with 10+ EP s can receive upward, neutral, or downward VM adjustment. 21

VM Overview Applied to ALL EP s in 2018, based on 2016 performance Successful PQRS reporting in 2016 avoids the automatic -2% or -4% penalty(depending on group size) in 2018 and makes the EP subject to Quality-Tiering (the process of evaluating performance on cost and quality). All groups and solo practitioners can receive upward, neutral, or downward VM adjustment. 22

VM Overview What Cost Measures will be used for Quality-tiering? Total per capita costs measures (Parts A & B) Total per capita costs for beneficiaries with 4 chronic conditions: Chronic Obstructive Pulmonary Disease (COPD) Heart Failure Coronary Artery Disease Diabetes Medicare Spending Per Beneficiary measure (3 days prior and 30 days after an inpatient hospitalization) attributed to the group providing the plurality of Part B services during the hospitalization All cost measures are payment standardized and risk adjusted. Each group s cost adjusted for specialty mix of the EPs in the group. 23

Cost Measure Attribution 5 Total Per Capita Cost Measures VM Overview Identify all beneficiaries who have had at least one primary care service rendered by a physician in the group. Followed by a two-step assignment process First, assign beneficiaries who have had a plurality of primary care services (allowed charges) rendered by primary care physicians. Second, for beneficiaries that remain unassigned, assign beneficiaries who have received a plurality of primary care services (allowed charges) rendered by any eligible professional MSPB measure attribute the hospitalization to the group of physicians providing the plurality of Part B services during the inpatient hospitalization. VM Overview Use domains to combine each quality measure into a quality composite and each cost measure into a cost composite: 24

VM Overview CY 2017 VM Payment Adjustment Amounts for Groups with Two-Nine Eligible Professionals and Solo Practitioners Low Cost Average Cost High Cost Low Quality Average Quality High Quality 0.0% +1.0x* +2.0x* 0.0% 0.0% +1.0x* 0.0% 0.0% 0.0% Notes: "x refers to a payment adjustment factor yet to be determined * higher performing groups serving high-risk beneficiaries (based on average risk scores) are eligible for an additional adjustment of +1.0x% VM Overview CY 2017 VM Payment Adjustment Amounts for Groups with Ten or More Eligible Professionals Low Cost Average Cost High Cost Low Quality Average Quality High Quality 0.0% +2.0x* +4.0x* -2.0% 0.0% +2.0x* -4.0% -2.0% 0.0% Notes: "x refers to a payment adjustment factor yet to be determined * higher performing groups serving high-risk beneficiaries (based on average risk scores) are eligible for an additional adjustment of +1.0x% 25

VM Overview Quality Resource and Use Reports (QRURs) The QRURs will preview information about a groups quality and cost performance rates for the VM starting with the 2012 QRURs. The QRURs contain quality of care and cost performance rates on measures that will be used to compute the value based payment modifier. The QRUR s also show how a group s payments would be affected if the group elected the quality tiering option. On September 30 th, 2014, CMS released the 2013 QRURs based on care provided in 2013 to all groups and solo practitioners (except those who participated in the MSSP). For group practices of 100 or more EPs that elected quality tiering, the 2013 QRUR display the group s 2015 value modifier payment adjustment. VM Overview Quality Resource and Use Reports (QRURs) Access the QRUR s via https://portal.cms.gov using an IACS account For questions about information contained in your QRUR or to provide feedback to CMS, please contact the Physician Value Help Desk: Monday Friday: 8:00 am 8:00 pm EST 1-888-734-6433 (press option 3) For more info, Google QRUR Quick-Reference-Guide-for-Accessing- 2013 data 26

Resources 2015 PQRS Info on CMS http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/measurescodes.html 2015 PQRS Measures List http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/pqrs_2015_measure-list_111014.zip CMS "2015 Physician Quality Reporting System (PQRS): Implementation Guide http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2015_pqrs_implementationguide.pdf 2015 PQRS Cross-cutting Measures List http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2015_pqrs_crosscuttingmeasures_12172014.pdf 2015 PQRS List of Face-to-Face Encounter Codes http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2015-pqrs-list-of-face-to-face-encounter-codes-.zip Thank You! Jeff Grant, President HCMA, Inc. www.hcma-consulting.com jeff@hcma-consulting.com 27