Transcription
Understanding CMS PQRS New PathologyMeasures: How CAP Members Can ParticipateJonathan L. Myles, MD, FCAPChair, CAP Economic Affairs CommitteePathology Advisor, AMA RUCEmily E. Volk, MD, FCAPChair, Public Health Policy CommitteeKimberly SchwartzNurse Consultant, CMS PQRS ProgramManagercap.orgWebinar Broadcast Date: December 7, 20111
College of American Pathologists:Physician Quality Reporting System(Physician Quality Reporting)Kimberly Schwartz, Nurse ConsultantQuality Measurement and Health Assessment Group,Office of Clinical Standards and QualityDecember 7, 20112
DisclaimersThis presentation was current at the time it was published or uploaded onto the web. Medicare policychanges frequently so links to the source documents have been provided within the document for yourreference.This presentation was prepared as a tool to assist providers and is not intended to grant rights orimpose obligations. Although every reasonable effort has been made to assure the accuracy of theinformation within these pages, the ultimate responsibility for the correct submission of claims andresponse to any remittance advice lies with the provider of services. The Centers for Medicare &Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, orguarantee that this compilation of Medicare information is error-free and will bear no responsibility orliability for the results or consequences of the use of this guide. This publication is a general summarythat explains certain aspects of the Medicare Program, but is not a legal document. The officialMedicare Program provisions are contained in the relevant laws, regulations, and rulings.CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registeredtrademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply toGovernment Use. Fee schedules, relative value units, conversion factors and/or related componentsare not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. TheAMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumesno liability for data contained or not contained herein.3
Agenda Overview of Physician Quality Reporting System Tips for Successful Participation/Reporting Identifying Applicable Measures for Reporting Questions & Answers4
Overview ofPHYSICIAN QUALITYREPORTING SYSTEM5
Physician Quality Reporting:Incentives & Adjustments Established in 2007, the Physician Quality Reporting System is a pay-forreporting program that provides a combination of incentives and paymentadjustments to eligible professionals and group practices who satisfactorilyreport data on Physician Quality Reporting System quality measures The applicable incentive amounts are as follows:2012: 0.5 percent2013: 0.5 percent2014: 0.5 percent The applicable payment adjustment amounts are as follows:2015: 1.5 percent2016 and each subsequent year: 2.0 percent The Physician Quality Reporting System will be the basis for the Value-BasedModifier This final rule sets forth our requirements for the 2012 Physician QualityReporting System Website: http://www.cms.gov/PQRS/6
Moving Toward ValueBased Purchasing200720082009 74measures 119measures 153measures Claimsbased only Claims Claims 4MeasuresGroups 7MeasuresGroups Registry Registry EHRtesting eRx2010 175individualmeasures Claims 13MeasuresGroups20112012 ACA, HITECHFinal in the CY 2012 PFS NPRM: 194individualmeasures 211 measures total Claims Registry 14MeasuresGroups EHRs Registry eRx EHRs GPRO eRx GPRO I GPRO II 79 new individual measures Claims 8 new Measures Groups Registry EHRs EHR data submission vendor eRx GPRO (25 or more NPIs) EHR incentive program pilot7
2012 Decision Tree:12-Month Reporting Options8
Reporting Measures withClaims9
Registry Submission What is a registry? Captures and stores clinically related data submitted by the eligibleprofessional (or group practice) Registry submits information on Physician Quality Reporting Systemindividual measures or measures groups (or eRx measure) to CMS onbehalf of eligible professionals (or group practice) Registries provide CMS with calculated reporting and performancerates at the end of the reporting period Data must be submitted to CMS via defined .xml specifications CMS qualifies registries annually Current list of Qualified Registries for 2011 Reporting is available at:http://www.cms.gov/PQRS/Downloads/2011Qualified Registries Posting 10-04-2011.pdf 100 registries and 27 EHRs10
Examples ofTIPS FOR SUCCESSFULPARTICIPATION/REPORTING11
Participation:Tips for Success If reporting using claims: Ensure billing software and clearinghouse can capture allthe codes, zero charges (or a nominal amount), andassociated modifiers used in Physician Quality Reportingfor the measures selected Discuss with vendors if applicable Review reporting principles and specifications for eachmeasure or measures group selected CMS website is the official source of measures documentation,with materials updated yearly Be sure to use current program year materials for the reportingmethod chosen!12
Participation:Tips for Success (cont.) If reporting using claims: (cont.) Establish internal processes to identify and report allapplicable patients and codes Begin reporting on appropriate Medicare Part B FFSpatients via CMS-1500 form or electronically Use rendering National Provider Identifier (NPI) under theTaxpayer Identification Number (TIN) Check Remittance Advice for N365 remark code (confirmsreceipt of quality-data codes but not necessarily accuracy) Consider reporting more than required (i.e., report 35 applicable patients for 30 patient sample measuresgroup)13
Participation:Tips for Success (cont.) If submitting through a qualified registry orqualified EHR: Work with selected vendor Follow their specific instructions for datacollection/submission and timeframes Use rendering NPI/TIN Contact the vendor with questions14
Tips onIDENTIFYING APPLICABLEMEASURES FOR REPORTING15
2011 Quality Measures Eligible professionals can choose whether to report individualquality measures or a group of related measures (aka“measures groups”) 194 individual measures, including 44 registry-only measures,20 measures for EHR-based reporting, and 20 new measures 14 measures groups: Diabetes Mellitus, CKD, PreventiveCare, CABG, Rheumatoid Arthritis, Perioperative Care, BackPain, CAD, HF, IVD, Hepatitis C, HIV/AIDS, CAP, and Asthma(new) Registry-only includes: CABG, CAD, HF, & HIV/AIDS Back Pain measures are reportable as a measures group only16
Identifying Applicable Measures Review the Physician Quality Reporting SystemMeasures List, and determine which measures apply toyour practice To help select measures, search for frequently billedcodes: Single Source Master Code Table (claims/registry for individualmeasures) Measures Specifications Manual (claims/registry for individualmeasures) Measures Groups Specifications (for measures groups) Downloadable Resource Table (EHRs)17
2012 Quality Measures Eligible professionals can choose whether to report individualquality measures or a group of related measures (aka“measures groups”) 211 individual measures, including 28 new measures 20 measures groups: Diabetes Mellitus, CKD, PreventiveCare, CABG, Rheumatoid Arthritis, Perioperative Care, BackPain, CAD, HF, IVD, Hepatitis C, HIV/AIDS, CAP, Asthma,COPD, IBD, Sleep Apnea, Dementia, Parkinson’s,Hypertension, Cardiovascular Prevention, and Cataracts18
Physician Quality ReportingRESOURCES19
Resources CMS Physician Quality Reporting websitehttp://www.cms.gov/PQRS CMS eRx Incentive Program websitehttp://www.cms.gov/ERxIncentive 2011 eRx Final /2011-22629.pdf 2012 PFS Final Rulehttp://ofr.gov/OFRUpload/OFRData/2011-28597 PI.pdf Frequently Asked Questions Medicare and Medicaid EHR Incentive Programshttp://www.cms.gov/EHRIncentivePrograms Physician der-search.aspx20
Where to Call for Help QualityNet Help Desk: Portal password issuesPQRS/eRx feedback report availability and accessIACS registration questionsIACS login issuesPQRS and eRx Program and measure-specific questions866-288-8912 (TTY 877-715-6222)7:00 a.m.–7:00 p.m. CST M-F or [email protected] will be asked to provide basic information such asname, practice, address, phone, and e-mail Provider Contact Center: Questions on status of 2010 eRx/PQRI incentive payment (during distributiontimeframe) See Contact Center Directory terTollNumDirectory.zip EHR-ARRA Information Center:888-734-6433 (TTY 888-734-6563)21
Thanks!QUESTIONS & ANSWERS22
Pathology MeasuresPQRS 2012Jonathan L. Myles, MD FCAPChair, CAP Economic AffairsCommitteePathology Advisor, AMA RUCEmily E. Volk, MD FCAPChair, Public Health PolicyCommitteeDecember 7, 2011cap.org23
Pathology Measure Specifications Pathology measures in the 2012 PQRS 2012 PQRS Reporting 2012 Measure Specifications Case studies Q&A 2011 College of American Pathologists. All rights reserved.24
Pathology measures in the 2012 PQRS Breast Cancer Resection Pathology Reporting Colorectal Cancer Resection Pathology Reporting Barrett’s Esophagus* Radical Prostatectomy Pathology Reporting* Immunohistochemical (IHC) Evaluation of HumanEpidermal Growth Factor 2 Testing (HER2) for BreastCancer Patients**New in 2012 2011 College of American Pathologists. All rights reserved.25
2012 PQRS ReportingCMS requires eligible professionals (EP) to report onat least three measures to be eligible for the 0.5%bonus in for reporting in 2012. EPs with fewer than three applicable measuresmust report on all measures that apply and will besubject to measure-applicability validation process(MAV) by CMS EPs must report on 80% of eligible cases ifreporting via registry EPs must report on 50% of eligible cases ifreporting via claims 2011 College of American Pathologists. All rights reserved.26
Measure Specifications#99 Breast Cancer Resection Pathology ReportingNumerator: Reports that include the pT category, the pNcategory and the histologic gradeDenominator (Eligible Population): All breast cancerresection pathology reports (excluding needle biopsies)ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4,174.5, 174.6, 174.7, 174.8, 174.9, 175.0, 175.9ANDCPT service codes: 88307, 88309 2011 College of American Pathologists. All rights reserved.27
Measure SpecificationsReporting on Breast Cancer MeasureUse CPT Category II Codes:3260F Modify with (-1P) if medical reason documented fornot reporting required elements Modify with (-8P) if required elements not includedon report3250F-Specimen site other than anatomic location ofprimary tumor 2011 College of American Pathologists. All rights reserved.28
Measure Specifications#100 Colorectal Cancer Resection Pathology ReportingNumerator: Reports that include the pT category, the pNcategory and the histologic gradeDenominator (Eligible Population): All colon and rectumcancer resection pathology reports (excluding biopsies)ICD-9 diagnosis codes: 153.0, 153.1, 153.2, 153.3, 153.4,153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.8AND CPT service codes: 88309 2011 College of American Pathologists. All rights reserved.29
Measure SpecificationsReporting on Colorectal Cancer Measure (NEW)(NEW) Use G Codes:G8721 - if all required elements are included in the report Use G8722 if medical reason documented for notreporting required elements Use G8724 if required elements not included onreportG8723-Specimen site other than anatomic location ofprimary tumor 2011 College of American Pathologists. All rights reserved.30
Measure Specifications#249 Barrett’s EsophagusNumerator: Esophageal biopsy reports that documentthe presence of Barrett’s mucosa and includes astatement about dysplasiaDenominator (Eligible Population): All esophagealbiopsy reports that document the presence of Barrett’smucosaICD-9 diagnosis codes: 530.85ANDCPT service codes: 88305 2011 College of American Pathologists. All rights reserved.31
Measure SpecificationsReporting on Barrett’s Esophagus MeasureUse CPT Category II and G Codes:3125F – (once per patient per each date of service) Modify with (-1P) if medical reason documented fornot reporting the finding of Barrett’s mucosa (e.g.malignant neoplasm, absence of intestinal dysplasia) Modify with (-8P) if required element is not includedon reportG8797-Specimen site other than anatomic location ofesophagus 2011 College of American Pathologists. All rights reserved.32
Measure Specifications#250 Radical Prostatectomy Pathology ReportingNumerator: Reports that include the pT category, the pNcategory, Gleason score and statement about marginstatusDenominator (Eligible Population): Patients with radicalprostatectomy pathology reportsICD-9 diagnosis codes: 185ANDCPT service codes: 88309 2011 College of American Pathologists. All rights reserved.33
Measure SpecificationsReporting on Radical Prostatectomy MeasureUse CPT Category II and G Codes:3267F Modify with (-1P) if medical reason documentedfor not reporting required elements Modify with (-8P) if required elements not includedon reportG8798-Specimen site other than anatomic location ofprostate 2011 College of American Pathologists. All rights reserved.34
Measure Specifications#251 IHC Evaluation of Human Epidermal Growth Factor2 Testing (HER2) for Breast Cancer patientsNumerator: Quantitative HER2 by IHC evaluationconsistent with scoring system defined in the ASCO/CAPguidelinesDenominator (Eligible Population): All breast cancerpatients with quantitative breast tumor evaluation byHER2 IHCICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4,174.5, 174.6, 174.8, 174.9, 175.0, 175.9AND CPT service codes: 88360, 88361 2011 College of American Pathologists. All rights reserved.35
Measure SpecificationsReporting on HER2 measureUse CPT Category II Codes:3394F - Quantitative HER2 by IHC evaluation utilizingscoring system defined in the ASCO/CAP guidelines Modify with (-8P) if evaluation on HER2 was notperformed using the recommended scoringsystem3395F-Quantitative non-HER2 IHC evaluation (e.g.quantitative evaluation of estrogen or progesteronereceptors by IHC) 2011 College of American Pathologists. All rights reserved.36
Case Study 1 A 65-year-old woman developed a 3cm breast massand a subsequent needle biopsy specimen revealedinfiltrating ductal carcinoma. After consultation withher surgeon, oncologist and radiation therapist, thepatient elected to undergo a modified radicalmastectomy with axillary lymph node dissection. Thesurgical pathology report from the resection includespT, pN, and tumor grade. The specimen is sent forHER2 IHC testing and ER/PR IHC testing. Thepathologist has been participating in the PQRS forbreast cancer specimens. 2011 College of American Pathologists. All rights reserved.37
Case Study 1Two measures apply in this case Breast Cancer Resection Pathology Reporting Immunohistochemical (IHC) Evaluation of HumanEpidermal Growth Factor 2 Testing (HER2) for BreastCancer patients 2011 College of American Pathologists. All rights reserved.38
Case Study 1 The PQRS code 3260F is entered into field 24D of theCMS-1500 hard copy form. If the pathologist was participating in PQRS and hadnot included pTpN in the surgical pathology report,the case would be coded with the (-8P) modifier. In both cases, the pathologist would be consideredas meeting the PQRS requirement for reporting. 2011 College of American Pathologists. All rights reserved.39
Case Study 1The pathologist would also report on the HER2measure: The PQRS code 3394F is entered into field 24D of theCMS-1500 hard copy form if the measure is met. If the pathologist was participating in PQRS and hadnot used the ASCO/CAP scoring system, the casewould be coded with the (-8P) modifier. In both cases, the pathologist would be considered asmeeting the PQRS requirement for reporting 2011 College of American Pathologists. All rights reserved.40
Case Study 1 If ER/PR was also done at the same time and billedon the same claim, 3395F would also be added tothe CMS-1500 hard copy form If ER/PR was also done but on billed on a separateclaim, 3395F would be added to the CMS-1500 hardcopy form on which the ER/PR evaluation wasbilled. 2011 College of American Pathologists. All rights reserved.41
Case Study 2A 68 year old man with a history of Barrett's mucosaunderwent endoscopic evaluation of the esophagus.During the procedure, multiple endoscopic biopsieswere obtained and placed in a total of 6 specimencontainers representing different sites within theesophagus. Five of the six specimens demonstratedBarrett's mucosa. Two of those five specimensdemonstrated high grade dysplasia, while dysplasiawas not identified in the other three specimens. TheCMS 1500 form indicated 530.85 as a primary ICD9code in the case. The pathologist is participating inPQRS. What is the correct way to code this case forPQRS? 2011 College of American Pathologists. All rights reserved.42
Case Study 2Answer:A pathologist choosing to report on the Barrett’sEsophagus measures would enter CPT Category II(PQRS) code 3125F into field 24D once on the CMS1500 hard copy form if a statement about dysplasiawas included.For this measure, the PQRS code is entered once perpatient per each date of service. 2011 College of American Pathologists. All rights reserved.43
Case Study 2If the pathologist was participating in PQRS and hadnot included a statement on dysplasia, the case wouldbe coded with the (-8P) modifier appended to the 3125FCPT II code.For biopsies at other sites in Barrett’s patients use:G8797-Specimen site other than anatomic location ofesophagus 2011 College of American Pathologists. All rights reserved.44
Case Study 3A 73 year old man presents to his physician with anelevated serum Prostate Specific Antigen. Subsequentprostate biopsies are performed and reveal invasiveadenocarcinoma in 3 of 6 core biopsies (Gleason score4 3 7). The urologist later performs a radicalprostatectomy. The prostatectomy specimen is sent tothe hospital pathologist who wishes to participate inPQRS. The pathologist includes pT and pN, the Gleasonscore and the margin status in the final surgicalpathology report.What is the correct way to code this case? 2011 College of American Pathologists. All rights reserved.45
Case Study 3Answer:The CMS 1500 form indicated 185 as a primary ICD-9 code in thecase for malignant neoplasm of prostate.CPT code 88309 (level VI surg path, gross and microscopicexam) was listed in field 24D of the CMS-1500 hard copy form.For a pathologist choosing to report on the RadicalProstatectomy measure one enters CPT Category II (PQRS)code 3267F into field 24D once on the CMS-1500 hard copyform if all four required elements were included on the report. 2011 College of American Pathologists. All rights reserved.46
Measure Specifications Available at:https://www.cms.gov/PQRS/15 MeasuresCodes.asp 2011 College of American Pathologists. All rights reserved.47
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Case Study 4A 75-year-old man came to his primary care physician for a routineannual visit. History revealed symptoms of fatigue. Physicalexamination was essentially unremarkable, but fecal occult bloodtesting was positive, and laboratory examination revealed amicrocytic, hypochromic anemia. The patient was referred to agastroenterologist. Outpatient sigmoidoscopic examination revealeda friable mass in the sigmoid colon. The mass was biopsied, and thespecimen was sent to the hospital pathology laboratory, where it wasexamined and reported as showing infiltrating moderatelydifferentiated adenocarcinoma. The patient was then referred to asurgeon, who performed a sigmoid resection and regional lymph nodedissection at the same hospital. This specimen was sent to the samehospital pathology laboratory as the biopsy specimen. The surgicalpathology report from the resection includes pT, pN, and tumor grade.The pathologist wishes to participate in the PQRS program. 2011 College of American Pathologists. All rights reserved.49
Case Study 4 The PQRS code G8721 is entered into field 24D ofthe CMS-1500 hard copy form for the resectionspecimen. The biopsy specimen is not covered by themeasure, no CPT II code would be added for thebiopsy specimen. 2011 College of American Pathologists. All rights reserved.50
Case Study 4For specimens at other sites in this patientuse:G8723 - Specimen site other than anatomiclocation of colon 2011 College of American Pathologists. All rights reserved.51
Case Study 5The patient with breast cancer in Case #1 developedelevated liver enzymes one year later. CT scandemonstrated a 2 cm mass in the liver. A needlebiopsy of the liver demonstrated metastaticadenocarcinoma. The pathologist wishes to participatein the PQRS program.When coding the case, a secondary ICD9 code wasentered which qualified the case for PQRS. 2011 College of American Pathologists. All rights reserved.52
Case Study 5 The correct CPT code for this case would be 88307 The correct code to enter in field 24D on CMS form1500 would be 3250F. The pathologist would be considered as having metthe PQRS reporting requirement. 2011 College of American Pathologists. All rights reserved.53
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individual measures or measures groups (or eRx measure) to CMS on behalf of eligible professionals (or group practice) Registries provide CMS with calculated reporting and performance rates at the end of the reporting period Data must be submitted to CMS via defined .xml specific
