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© 2012 American Physical Therapy Association 1

Physical Therapy and PQRS in 2015:How to Report Successfully

Heather L. Smith, PT, MPH

©2014 American Physical Therapy Association. All rights reserved. All

reproduction or redistribution prohibited.1

Introduction

Heather Smith currently serves as the Program Director of Quality for APTA. In her current roll, Heather coordinates quality initiatives for the Association and develops and implements key member resources related to quality. Two areas of focus in her work include the Physician Quality Reporting System (PQRS) and Functional Limitation Reporting (FLR)requirements for therapy services under Medicare. Heather previously worked the Quality Divisions for both New York Presbyterian Hospital and the Hospital of the University of Pennsylvania. Previous to her role in quality improvement, she was a practicing clinician for over ten years with the majority of her focus on orthopedics in the outpatient setting.



Learning Objectives

1. Illustrate the purpose of the PQRS program and the relationship between reporting and payment.

2. Identify the quality measures for 2014 that apply to physical therapists in private practice settings.

3. Characterize the anatomy of a PQRS measure and the distinction between reporting the individual measures and measures groups.

4. Describe the successful reporting requirements for 2014 and identify common mistakes associated with unsuccessful reporting by physical therapists.

5. Determine the changes to practice operations you need to make in order to participate successfully in the PQRS program in 2014.

6. Understand the basics of the new value‐based modifier program for 2016.

©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.

3


PQRS OVERVIEW

4©2014 American Physical Therapy Association. All rights reserved. All

reproduction or redistribution prohibited.

POLL 1

What is your primary role (select one):

‐clinician in private practice

‐administrator in private practice

‐other



POLL 2

Is your practice currently participating in PQRS for the 2013 reporting year?

‐yes, reporting 3 measures

‐yes, reporting more than 3 measures

‐no




Current Quality Reporting Programs Under Medicare

Healthcare Setting Quality Program(s) Mandatory Reporting Payment Incentive/ Penalty

Inpatient(Acute Care Hospitals)

IQR, Readmissions & VBP

Yes Yes P4R & P4P in 2013

Long Term Care Hospitals (LTCH) Beginning in 2014 Yes Yes P4R Penalty 2%

Inpatient Rehabilitation Facilities (IRF)

Beginning in 2014 Yes Yes P4R Penalty 2%

Skilled Nursing Facilities (SNF) MDS 3.0 Yes No

Hospice Beginning in 2014 Yes YesP4R Penalty2%

Home Health OASIS, HH CAHPS Yes Yes P4R Penalty 2%

Outpatient PQRS No, payment adjustments for non‐participation beginning in 2015 (based on 2013 data)

Yes P4R Incentive0.5% through 2014, Penalty ‐2.0% 2016 and beyond

Value‐based Modifier (VM)

No‐ tied to participation in PQRS

Yes P4P+4.0x to ‐4.0%+2.0x to ‐2.0%

Functional LimitationReporting (FLR)

Yes Condition of payment7



PQRS in Evolution

2006

TRHCA

• 74 measures

• Claims‐based only

2007

MMSEA

•119 measures

•4 group measures

•Claims & registry

2008

MIPPA

•153 measures

•7 group measures

•Claims & registry

• EHR testing

•eRX

2010

ACA & HITECH

•170 individual measures

•14 group measures

•Claims, registry, & EHR

•eRx

•GPRO

8©2014 American Physical Therapy Association. All rights reserved. All reproduction or

redistribution prohibited.

Updates annually in the Physician Fee Schedule Rule

PQRS Eligible Providers

• In 2015, eligible providers who bill under the physician fee schedule must report successfully under PQRS to avoid a ‐2.0% reduction in their 2017 fee scheduled.

– Rehab agencies, outpatient hospitals, SNFs Part B unable to participate in PQRS; use UB‐92 (UB‐04) or 837I for billing to intermediary

– No place on claim form for individual NPI




Increasing PT/ OT Participation in PQRS


10

PT/ OT PQRS Data Submission Mechanism



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012

Claims Individual Claims Group Registry Individual Registry Group

Recent PPS Survey on PQRS

• Response: 540 members

• 85.0% participating in PQRS in 2014

– The top reason sited for non‐participation: practice does not have resources to manage the PQRS reporting burden; we are willing to take the 2.0% penalty to avoid the reporting burden (8.0%)

• 83.7% report via claims

• 76.5% have never accessed a feedback report

– Only 31.0% have received a bonus in past years


12


2014 Top Reported Measures for PTs

# Measure Description Reporting %

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow‐up

34.1%

130 Documentation and Verification of Current Medications in the Medical Record

45.7%

131 Pain Assessment Prior to Initiation of Patient Treatment 65.7%

154 Falls: Risk Assessment 48.5%

155 Falls: Plan of Care 42.4%

182 Functional Outcome Assessment 55.7%


Based on PPS survey results

13

PQRS Participation 2015(Reporting Period January 1‐ December 31)

Individual Professional

Data analyzed at the NPI level/TIN level

No registration required

Reporting mechanism: claims or registry

GPRO

(Group Practice Reporting Option)

Data analyzed at the practice TIN level (Includes all NPIs in group)

Registration required by June 30, 2015

Reporting must be done via registry


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Medicare Quality Reporting and Payment

Calendar/ Current Year (Data Year)

Year Penalty/ Payment Applied

PQRS Penalty*(calculated by

NPI/TIN)

VM Incentive/ Penalty**

(calculated by TIN)

Cumulative PQRS & VM Penalty

2013 2015 ‐1.5% N/A ‐1.5%

2014 2016 ‐2.0% N/A ‐2.0%

2015 2017 ‐2.0% N/A ‐2.0%

2016 2018 ‐2.0% Up to ‐4.0% Up to ‐6.0%



* The PQRS penalty will apply to eligible PT’s who do not report OR who fail to meet the successful reporting requirements for PQRS in a given calendar year**The VM full VM penalty will apply to eligible PT’s who do not report OR who fail to meet the successful reporting requirements for PQRS in a given calendar year


2015 PQRS Payment Adjustment

• What if I did not participate in PQRS in 2013 or I failed to meet the reporting requirements for PQRS in 2013 – Successfully reports 3 measures on 50% or more of eligible Medicare

patients OR

– Reported at least one measure on one patient

• Providers will receive 98.5% of Medicare Part B PFS allowed charges amount (or 1.5% less reimbursement) for all charges with dates of service from January 1 – December 31,2015


16

The Financial Impact of PQRS


17

Calendar/ Current Year (Data Year)

Year Penalty/ Payment Applied

PQRS Penalty(calculated by

NPI/TIN)

Estimated Loses per Therapist*

2013 2015 ‐1.5% $485.10

2014 2016 ‐2.0% $646.80

2015 2017 ‐2.0% $646.80

*Penalty dollar amounts based on the median total Medicare payment amount for physical therapists in 2012 $32,340.10

PQRS: Public Reporting & Future

• Providers who report successfully in the program will have their names listed on the CMS website

• CMS is planning to make:

– 2015 PQRS GPRO data to be available Physician Compare Website in CY2016 for all groups of 2 or more Eligible Professionals (EPs).

– 2015 individual EP PQRS data to be available Physician Compare Website in late CY2016 if technically feasible.



http://www.medicare.gov/physiciancompare/search.html


PQRS REPORTING: GETTING STARTED



POLL 3

How are you submitting your PQRS data to Medicare:

‐via claims

‐via registry



Physician Fee Schedule: PQRS Changes in 2015

Program Detail Changes

Successful reporting requirements

• Reporting of 9 measures (or 1‐8 as applicable) on 50% of eligible patients will be needed to avoid the ‐2.0% penalty

• Requires reporting of 1 cross cutting measures

Available measures • Elimination of 245 Chronic Wound Care measure• Elimination of 148‐151 Back Pain Measures Group• New category of measure – cross cutting

Specific measure changes • TBD (awaiting release of measure specification manuals)

Future changes • Strongly encouraging providers to move away from claims‐based reporting

New Programs • Value‐Based Modifier in CY2016 (penalty year 2018)




PQRS Participation 2015


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Should I participate in

PQRS in 2015 ?

I want to avoid the ‐2.0% penalty in 2017

Report via claims

Report all available individual measures

(128, 130, 131, 154, 155, 182)

Report via registry Select 9 individual measures (or if less

available 1‐8)

Successful Reporting in PQRS 2015Individual Measures

Claims‐Based OR Traditional Registry Reporting12 Month Reporting Period (Jan 1‐ Dec 31, 2015)

Report at least 9 measures covering at least 3 NQS domains, OR, if less than 9 measures covering at least 3 NQS domains apply to the eligible professional, report 1—8 measures covering 1—3 NQSdomains*, AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted. Of the measures reported, if the eligible professional sees at least 1 Medicare patient in a face‐to‐face encounter the eligible professional would report on at least 1 measure contained in the proposed crosscutting measure set.**

* For an eligible professional who reports fewer than 9 measures covering 3 NQS domains via the claims‐based reporting mechanism, the eligible professional will be subject to the MAV process, which would allow us to determine whether an eligible professional should have reported quality data codes for additional measures and/or covering additional NQSdomains.**For those reporting via registry the successful reporting requirements are the same reporting as an individual professional or GPRO


23

Successful Reporting in PQRS 2015Individual Measures

Qualified Clinical Data Registry12 Month Reporting Period (Jan 1‐ Dec 31, 2015)

Report at least 9 measures covering at least 3 NQS domains AND report each measure for at least 50 percent of the eligible professional’s applicable patients seen during the reporting period towhich the measure applies. Measures with a 0 percent performance rate would not be counted.Of the measures reported via a qualified clinical data registry, the eligible professional must report on at least 1 outcome measure. Of these measures, the eligible professional would report on at least 2 outcome measures, OR, if 2 outcomes measures are not available, report on at least 1 outcome measures and at least 1 of the following types of measures – resource use, patient experience of care, or efficiency/appropriate use.


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Measures Care Coordination

Population Health

Safety Effective Care

Cross Cutting

#126‐127 Diabetes Foot Care

X

#128 BMI Screening X X

#130 Medication Documentation

X X

#131 Pain Assessment X X

#154 Falls Screening X

#155 Falls Plan of Care X

#182 Functional Assessment

X X

#217‐223 FOTO Measures X

Successful reporting requirements

9 measures in 3+ domains(if less 1‐8 then 1‐3 domains*)

1 required

Totals


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*Subject to the MAV process

How Do I Choose a Reporting Method?Claims Registry

Cost None Variable

QDC Selection Each practitioner is responsible for choosing and submitting the QDC’s

Each practitioner is responsible for entering data into the registry

Updating Annual measure updates must be monitored by the facility

Registry monitors and incorporates annual measure updates

ReportingRequirements

Data must be submitted on +50% of all eligible Medicare patients

Data must be submitted on +50% of all eligible Medicare patients

Timing of DataSubmission

Done on the initial submission of claim form

Done throughout the year; ability to retrospectively submit data

Auditing Providers must obtain feedback reports from QualityNet and/or establish internal auditing process

Registry provides participants with feedback reports throughout the year



http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/PQRS/Registry‐Reporting.html

CMS Remarks on the Future of PQRS Claims‐based Reporting

“We understand that the claims‐based reporting mechanism remains the most popular reporting mechanism. However, to streamline the PQRS

reporting options, as well as to encourage reporting options where eligible professionals are found to be more successful in reporting, it is our intention to eliminate the claims‐based reporting mechanism

in future rulemaking. During this time, we encourage eligible professionals to use alternative

reporting methods to become familiar with reporting mechanisms other than the claims‐based

reporting mechanism.”


27


Physical Therapy Outcome Registry Timeline

2014

Testing and pilot launch

2015

Continued pilot testing and

preparation for full launch in 2016

2016 & Beyond

Continued PTOR growth

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For further information please visit www.apta.org/Registry

Or email us at [email protected]©2014 American Physical Therapy Association. All rights reserved. All reproduction or


PQRS MEASURES SPECIFICATIONS AND DETAILS



POLL 4

Which of the following individual measures do you currently report (select all that apply):‐BMI screening (#128)‐Medications (#130)‐Pain assessment (#131)‐Falls measures (#154 & 155)‐Functional assessment (#182)




POLL 5

Which of the following individual measures do you currently report (select all that apply):

‐Diabetes measures (#126 & 127)

‐Wound Care measures (#245)

‐FOTO measures (#217‐223)



POLL 6

Do you report the back pain measures group?

‐yes

‐no



2015 Individual Measures for PTs

# Measure Description Claims Registry

126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation

X

127 Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear

X

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow‐up

X X

130 Documentation and Verification of Current Medications in the Medical Record

X X

131 Pain Assessment Prior to Initiation of Patient Treatment X X

154 Falls: Risk Assessment X X

155 Falls: Plan of Care X X

182 Functional Outcome Assessment X X




2015 Individual Measures for PT’s# Measure Description Claims Registry

217 Change in Risk‐Adjusted Functional Status for Patients with Knee Impairments

X

218 Change in Risk‐Adjusted Functional Status for Patients with Hip Impairments

X

219 Change in Risk‐Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments

X

220 Change in Risk‐Adjusted Functional Status for Patients with Lumbar Spine Impairments

X

221 Change in Risk‐Adjusted Functional Status for Patients with Shoulder Impairments

X

222 Change in Risk‐Adjusted Functional Status for Patients with Elbow, Wrist, or Hand Impairments

X

223 Change in Risk‐Adjusted Functional Status for Patients with a Functional Deficit of the Neck, Cranium, Mandible, Thoracic Spine, Ribs, or other General Orthopedic Impairment

X



PT Measures and National Quality Strategy Domains

•Falls plan of care (#155)

• Functional assessment (#182)

•FOTO measures (#217‐223)

Communication and care coordination

•BMI screening (#128)

•Pain assessment (#131)

Community / population health

•N/AEfficiency and cost reduction

•Medication verification (#130)

•Falls risk (#154)Safety

•Diabetes measures (#126 &127)Effective clinical care

• N/A

Person‐ and caregiver‐centered experience and

outcomes


35

Bolded measures are cross cutting measures

Measure‐Applicability Validation (MAV) Process

• Used when a clinician reports less than 9 measures

• Measures are grouped in clusters and if one measures is reported in the cluster all applicable measures in that cluster must be reported

• MAV is based on data submission (MAV process for claims and registry)

• Updated annually


36


MAV Process Example


37

http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/PQRS/AnalysisAndPayment.html

PQRS Measure Specifications

• Published and updated annually

• Critically important to success

• Tells you everything you need to know about a measure

• Information Provided in the Specification:

– Measure description

– Instructions

– Denominator

– Numerator

– Rationale and Clinical recommendation statements


38

Who, When, What, and How of Reporting

Reporting Question

Clinical Importance Information Needed from Measure Specification

Who “Who counts?” Denominator (patient age, eligible CPT codes*, ICD9 requirements if applicable)

When “When do I report?”

Instructions (reporting frequency)+ denominator information

What “What do I need to include in my documentation?”

Instructions (describe the relevant clinical actions that must be taken‐may need to refer to numerator definitions)

How “Which code do I report”

Numerator (all available QDC’s outlined in detail, including definitions for “not eligible” and reporting exceptions if applicable)

* Most measures for PT’s require reporting with the submission of CPT codes 97001 and 97002; see the measure specifications for details




Who, When, What and How Measure #130 Medication Documentation (2014)

Reporting Question

Clinical Importance Information Needed form Measure Specification

Who “Who counts?”

When “When do I report?”

What “What do I need to include in my documentation?”

How “Which code do I report”

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18 years and olderCPT codes: 97001, 97002, 97110, 97140, 97532ICD9: N/A

“Each visit” where any of the CPT codes are billed (97001, 97002, 97110, 97140 OR 97532)

This measure is intended to determine whether or not documentationof a current medication list occurred for all patients aged 18 years and older. See Numerator for details.

G8427‐ complete informationG8430‐ not documented/ incomplete infoG8428‐ not eligible


Measure

Number

Measure Description Eligible CPT

Codes for

Reporting

Frequency of

ReportingAvailable Quality Data Codes

128 Preventive Care and Screening: Body

Mass Index (BMI) Screening and

Follow‐up

97001 Once per

reporting

period

G8417, G8418, G8419, G8420,

G8421, G8422, G8938

130 Documentation and Verification of

Current Medications in the Medical

Record

97001, 97002,

97110, 97140,

97532

Each visit* G8427, G8428, G8430

131 Pain Assessment Prior to Initiation of

Patient Treatment

97001, 97002,

97532

Each visit* G8730, G8731, G8732, G8442,

G8509, G8939

154 Falls: Risk Assessment 97001, 97002, Once per

reporting

period

3288F & 1100F, 3288F‐1P &

1100F, 3288F‐8P & 1100F,

1101F, 1101F‐8P

155 Falls: Plan of Care 1100F AND

97001, 97002,

Once per

reporting

period

0518F,

0518F‐1P, 0518F‐8P

182 Functional Outcome Assessment 97001, 97002 Each visit* G8539, G8540, G8541, G8542,

G8543, G8942, G9227

41

Reporting Details for Individual Claims Measures (2014)

* Note that “each visit” is only reportable with the listed eligible CPT codes.


PQRS Quality Data Codes (QDC)

• QDC information is:

– Specific to each measure

– Updated annually (with measure review and revision)

– Specific to the clinical action taken by the provider




PQRS Quality Data Codes & Modifiers

• Do not use GP or KX modifier with the QDC’s

• CPT II Modifiers are allowed for the use in specific cases with the falls measures (154‐155)

– Exclusion Modifiers• 1P: exclusion modifier due to medical reasons (e.g. not indicated due to absence of limb or already performed)

– Reporting modifier • 8P: action not performed, reason not otherwise specified

• Credit for “reporting”, but no credit for “performance”

• Use judiciously!



PQRS FEEDBACK REPORTS



Annual Feedback Report Timeline for 2015 Reporting Year

February 28, 2015

Close of 2014 reporting

period, last day to submit claims

Summer 2015

Q1 2015 interim dashboard released

September/ October 2015

Release of 2014 annual feedback reports and bonuses

Fall 2015


Winter 2015




Spring/ Summer 2014 data analysis of


How Do I Know if I am Successful?Therapist Measure # 97001

Billed 97002Billed

97110 Billed

97140 Billed

97532 Billed

Total Eligible Visits

Total QDC’s

Submitted

Reporting Rate

Reporting Success

Ann 128 BMI92 2 1656 1401 0 92 88 96%

Yes

130 Medication 92 2 1656 1401 0 1196 1103 92%

131 Pain92 2 1656 1401 0 94 89 95%

Bob 128 BMI80 1 1602 1396 0 80 78 98%

NO

130 Medication 80 1 1602 1396 0 883 79 9%

131 Pain80 1 1602 1396 0 81 79 98%

BMI: once per reporting period when billing 97001 OR 97002Medication: every visit when billing 97001, 97002, 97110, 97140 OR 97532Pain: every visit when billing 97001 AND 97002



QualityNet Online Report Access



https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

• Typically released 9 months after the close of the reporting period

• Annual provider feedback reports contain the following information:

– Roll up of the facilities performance (TIN level)

– Individual reports for each eligible provider in the practice (NPI level)

• Summary of reporting by measure

• Detailed report of measure errors

Annual Feedback Report




• Interim dashboard reports contain the following information:

– Roll up of the facilities performance (TIN level)

– Individual reports for each eligible provider in the practice (NPI level)

– Raw data only

Interim Dashboard Report

49


How Do I Utilize this Information

Report Type and Frequency

Information Provided Importance to Success

TIN level report•Annual •Interim

Overall success of the clinic and the individual practitioners

Managers can use this information to determine overall success of the clinic and the variation in reporting rates of the therapists

NPI level report•Annual •Interim

Details the individual measures reported by a therapist and the reporting rates of those measures

Managers can use this information to determine the variation in reporting rates for each measure reported by a therapist

NPI level error report•Annual

Details the individual reportingerrors for each measure submitted by a therapist

Managers can use this information to determine the errors in data submission for each measure reported by a therapist



Performance Improvement and Feedback

Performance Improvement Feedback

• Feedback on performance should be shared regularly with all staff involved in the process to increase your success– Managers

– Clinicians

– Administrative staff

• Data transparency has been shown to increase performance

•Audit your process, and your reporting performance

•Audit your process, and your reporting performance

•Make changes to your process as needed

•Make changes to your process as needed

•Implement the PQRS process in your clinic

•Implement the PQRS process in your clinic

•Choose measures, select a reporting method, and educate staff

•Choose measures, select a reporting method, and educate staff

Plan Do

CheckAdjust




PQRS REPORTING: CASE EXAMPLE CLAIMS REPORTING



PQRS Process: Claims Reporting


53

Source: CMS

Final 2014 Feedback Report‐(released fall 2015)

Interim Quarterly Dashboard Reports for 2015

PQRS Step by Step: Individual Measures

Select the measure

• #131 Pain Assessment

Review measurespecifications

• Age 18+ years

Determine when the measures should be reported

• Every visit

• CPT codes 97001 OR 97002

Perform and document all clinical actions

• Pain assessed throughpatient interview and astandardized tool

• Documentation of a follow‐up plan if painpresent

Determine the appropriate Quality Data Code (QDC)

• G8730 or other defined numerator

Submit the selected QDC

• Submit via claims or registry




PQRS: Example 1500 Claim Form


55

Functional limitation data with therapy modifier and severity

modifier (GP & CK/CI)

PQRS Quality Data Codes (QDC’s)

Functional limitation G‐codes are submitted with a $0.01 charge; CMS recommends that PQRS G‐codes are submitted with a $0.01 charge

Both functional limitation and PQRS G‐codes are submitted with “1” unit attached

PQRS: RARC & CARC

Remittance Advice Remark Code (RARC) for QDCs with $0.00

• The new RARC code N620 is your indication that the PQRS codes were received into the CMS National Claims History (NCH) database.

– EPs who bill with $0.00 charge on a QDC line item will see N620 instead of N365.

– N620 reads: This procedure code is for quality reporting/informational purposes only.

– EPs who bill with a $0.00 charge on a QDC line item will receive an N620 code on the EOB and may or may not receive any Group Code or CARC.

Claim Adjustment Reason Code (CARC) for QDCs with $0.01

• The new CARC 246 with Group Code CO or PR and with RARC N572 indicates that this procedure is not payable unless non‐payable reporting codes and appropriate modifiers are submitted.

– In addition to N572, the remittance advice will show Claim Adjustment Reason Code (CARC) CO or PR 246 (This non‐payable code is for required reporting only).

– CARC 246 reads: This non‐payable code is for required reporting only. EPs who bill with a charge of $0.01 on a QDC item will receive CO 246 N572 on the EOB



VALUE‐BASED MODIFIER (VM) PROGRAM: AN INTRODUCTION




POLL 6

Prior to this call, have you heard about the value‐based modifier program?

‐yes

‐no



What is the Value‐Based Modifier (VM) Program?

• VM was mandated by Section 3007 of the Affordable Care Act, to begin by 2015. This program is separate from PQRS.

– The VM is determined by using both cost and quality data to calculate payments.

– CMS will begin applying VM under the Medicare Physician Fee Schedule (MPFS) in CY2015 (using CY2013 data), beginning with physician groups over 100 providers.


59

Timeline for the VM Program

2015

(using 2013 data) VM program begins with MD groups

over 100

2016

(using 2014 data) VM program

expands to MD groups 10‐99

2017


expands to include all MDs

2018


expands to include all nonphysiciansincluding PTs


60


The Value‐Based Modifier (VM) and PTs

• CMS has finalized the inclusion of PTs in the VM program in CY2018, however this would be based on the PTs performance in CY2016.

• The VM program has a quality tiering methodology that takes into account both quality and cost.– The quality portion of the methodology is based largely on PQRS performance.

– The cost portion of the methodology would not typically apply to PTs and PTs would be given an average rating on this section based on CMS guidelines.


61

VM Program ExpansionParticipants Data

YearVM Year

Payment Adjustments

Physician groups over 100 providers*

2013 2015 ‐1.0% to +2.0x

Physician groups over 10‐99 providers

2014 2016 ‐2.0% to +2.0x

Physicians in groups 2‐9 AND solo providers

2015 2017 ‐4.0% to +4.0x (MD groups 10+)

‐2% to +2x (MD groups up to 9 and solo providers)

Non‐physician Eligible Professionals (EPs) in groups 2‐9 AND solo providers

2016 2018 TBD: up to ‐4.0%


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*Group size determined by number of total eligible professionals who have reassigned payment to the practice in the calendar (reporting)year.

Estimated Impact of PQRS & VM for PTs in 2018 Based on 2016 Data

Reporting Scenario PQRS Penalty

VM Incentive/Penalty*

Total Impact in 2018*

PT practice successfully reportsin PQRS

0% 0% to +2.0x to 4.0x based on group size(high quality

performers may earn incentives )

0% to +2.0x to 4.0x based on group size

PT practice does not report successfully

‐2% Additional penalty (‐2% to ‐4%)

Combined penalty up to

‐6%PT practice chooses not to participate

63

* Penalty estimates based on 2017 VM penalties. CMS will set 2018 VM penalties in the CY2016 rulemaking



Estimated Financial Impact of PQRS & VM in 2018


64

CY2016 Reporting Year Penalties PQRS

(‐2%)

VM

(up to ‐4%)

Total

(up to ‐6%)

Estimated Loses per Therapist in CY2018* $646.80 $1293.60 $1940.40

*Penalty dollar amounts based on the median total Medicare payment amount for physical therapists in 2012 $32,340.10

KEYS TO SUCCESS FOR TODAY AND TOMORROW



Keys to PQRS Success

Decide on your reporting mechanism and your measures

• Individuals reporting via claims or registry

• GPRO reporting via registry

Access and review your feedback reports

• Review feedback throughout the year

• Make practice changes as needed to improve your reporting performance


66


Keys to PQRS Success: Claims‐based Reporting

Preparing for the 2015 reporting year

• Ensure that you have a reporting process in place

• Review the measure specification changes (check back for new APTA resources in December)

• Check your EOBs for RARCs/ CARCs and perform audits as needed throughout the year


67

Keys to Preparing for VM Program in CY2016

Preparing for the VM program in 2016

Actively participate and be successful in PQRS reporting in CY2015

Become knowledgeable in the basics of the VM program

Check for VM updates with the release of the CY2016 Physician Fee Schedule rule


68

PQRS Resources

• APTA: Quality Resources

http://www.apta.org/PQRS

• CMS‐ PQRS page

https://www.cms.gov/PQRS/

• Quality Net (general questions or feedback reports)

https://www.qualitynet.org/

866 288 8912 (option #1, then #7)




VM Resources

• APTA: Quality Resources

Coming soon

• CMS‐ VM Program page

http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html


70

QUESTIONS



If you have additional questions on PQRS or VM please feel free to contact us at

800 999 2782 ext 8511 OR [email protected]

If you are interested in participating in the Physical Therapy Outcomes Registry please

email us at [email protected]

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