Making Sense of PQRS for Mental & Behavioral Health
by Leigh-Ann Renz, 5/20/14
How does PQRS apply to mental / behavioral health?
There’s a lot of confusion about PQRS, in part because it’s so similar to the EHR Meaningful Use (MU), with overlapping terms and dates. While the goal-plan-hope is for PQRS reporting to be combined with MU in the future, for now the 2 programs are separate and need to be addressed individually.
Before we go further into PQRS, a few quick facts about Meaningful Use
Meaningful Use - or MU - is the term used to describe the federal program that awards incentive funds to eligible providers for demonstrating meaningful use of a certified EHR software. There are 2 available programs: one for Medicare and another for Medicaid (you can only participate in 1).
Currently, only providers who can prescribe are eligible for MU, which is why many mental / behavioral health care organizations don’t know or care about it: unless you have a psychiatrist, NP, or DO on staff, the providers (and therefore practices) don’t qualify for the program.
How much money is up for grabs? See MU Use It or Lose It for an overview, including fee schedules for both programs, as well as information about the penalties for providers / agencies who do qualify for the Medicare program but aren’t on a certified system.
What is PQRS and does it affect mental / behavioral health?
PQRS is the Physicians Quality Reporting System, and it does apply to mental/behavioral health: if you are seeing clients who meet the PQRS criteria, or measures, you must report on your treatment. In the past, the PQRS program was voluntary, and incentives were given to practices to encourage participation. Starting in 2013, the program is now mandatory, and 2014 is the last year to earn incentives.
In 2013, participation was easy: practices only had to report on 1 measure, and claims-based reporting was an easy way to ensure compliance to avoid the penalty. In 2014, the process is more complex, and further changes are expected in 2015. Check out PQRS Guide for Mental Health and Penalties & Bonuses: PQRS for Mental Health for more info, plus see details about the different reporting options below.
How do MU and PQRS overlap?
Both MU and PQRS require you to submit information to the government; both therefore have reporting deadlines; both have incentives (until 2015) for participating & penalties for non-participation; and both involve reporting on clinical quality measures (CQMs). The eClinicial quality measures are identical for both programs.
How are MU & PQRS different?
> MU involves attesting / reporting on how your practice is using an electronic health records (EHR) software to provide care; while PQRS involves reporting the actual treatments that were provided to clients / patients. MU is attesting that you have executed business practices in a certain way, but PQRS is providing data to the government about how certain diagnoses are being treated and addressed.
> For MU CQMs, there is often no numerator - ie, none of the patients will fall under that measure, but for PQRS, we do expect numerator: that at least 1 client will qualify for each measure. If you don’t have any clients that qualify for a measure, that’s fine; you simply don’t report. CMS will simply double check to make sure that you truly didn’t treat anyone falling into that specific category to report on.
> The MU incentives are much greater: while some practices have received a steady .5% incentive payment on all of their Medicare reimbursements, unless an organization processes a massive amount of claims, it can’t touch the $24,000 still available through the Medicare MU program or $63,750 available through the Medicaid option.
> The MU penalties are greater: for PQRS, a 1.5% penalty will be levied in 2015 for 2013 data, and a 2% penalty will be levied in 2016 for 2014 data. Penalties will apply to all Medicare charges by a provider. For MU, payment reduction starts at 1% and increases each year that an eligible professional does not demonstrate meaningful use, to a maximum of 5%. Providers that are eligible for both programs and fail to comply with participation may be subject to both penalties: ie, up to 7% of all Medicare reimbursements. See Do You Have to Use EHR and Are We Going to Jail?! for details about MU; continue reading for more about PQRS.
Providers can only participate in MU if they are medication prescribers, but the PQRS program does not have that limitation: compliance is required for all measures that are met for a qualifying provider.
What are the PQRS Reporting Rules?
The reporting rules differ according to the measures: for example, one measure may require that you report every time the client is seen – another may stipulate that you report only once. It also differs based on how you choose to report (claims-based, registry, EHR, GPRO).
The PQRS reporting period is for the entire year (2014) and the EHR reporting period is for 90 days (2014) and the frequency of reporting depends on the method:
• Claims – Upon submission of the encounter using the appropriate G-codes
• Registry – Annually
• EHR – Annually for PQRS and after 90 days for the 2014 EHR Incentive program
The best “short” answer to the reporting rules question is:
Reporting Criteria for Individual EPs
EPs can earn a 2014 PQRS incentive
by meeting one of the following criteria for satisfactory reporting:
1. Report on at least 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50% of the EP’s Medicare Part B FFS patients.
o EPs that submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures across less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure-Applicability Validation (MAV). (See http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html)
2. Report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients.
o For more information, see 2014 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups (click here – it will require you to accept a license use and then provide access to a zip file with several other documents)
EPs can avoid the 2016 PQRS payment adjustment
by meeting one of the following criteria:
1. Satisfactorily report and earn the 2014 PQRS incentive.
2. Report at least 3 measures covering one NQS domain for at least 50% of the EP’s Medicare Part B FFS patients.
o EPs that submit quality data for 1 or 2 PQRS measures for at least 50% of their patients or encounters eligible for each measure will be subject to MAV (a CMS double-checking database that confirms that the EP didn’t wasn’t able to submit data for other measures because they didn’t have qualifying clients / patients).
EPs opting to report via qualified registry are allowed to report on individual measures or measures groups
The 2014 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and the 2014 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual are to be used for this option of reporting and can be found on the Measures Codes page of the CMS PQRS website at http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
Reporting Criteria for Group Practices
A group practice must have registered to report via qualified registry under the GPRO for 2014 PQRS.
Group practices can earn a 2014 PQRS incentive
by meeting the following criteria for satisfactory reporting:
1. Report on at least 9 measures covering 3 NQS domains for at least 50% of the group’s Medicare Part B FFS patients.
o Group practices that submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures across less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to MAV.
Group practices can avoid the 2016 PQRS payment adjustment
by meeting one of the following criteria:
1. Satisfactorily report and earn the 2014 PQRS incentive.
2. Report at least 3 measures covering one NQS domain for at least 50% of the group’s Medicare Part B FFS patients.
o Group practices that submit quality data for 1 or 2 PQRS measures for at least 50% of their patients or encounters eligible for each measure will be subject to MAV.
What are the PQRS Reporting Options?
As you can see, PQRS can be very confusing, not only because of its overlapping similarities with MU and the differing reporting frequencies, but also because each of the reporting options have different deadlines and rules. For example, a practice can report via GPRO using certified EHR or registry. Here’s an overview:
For solo providers and small practices, the most likely method will be to report the measures using a designated G or F code (i.e., G8126 or 1040F), which is entered with the procedure (CPT) code when filing a Medicare claim, either on paper or electronically.
Those group practices electing to report via registry will use the 2014 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures. These specifications are located at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
> EHR (or Direct Reporting)
Practices can report via a certified EHR. This is another area where PQRS and MU overlap: EHR software that has been MU certified (meaning, it can be used to attest to MU) can also be used to report PQRS. In order to report for 2014 PQRS, you’ll need to use an EHR that is also 2014 Edition (“Stage 2”) certified. Click here for details.
> Group Practice Reporting Option (GPRO)
This can be 2 NPI numbers, or 100+, that are reporting under the same tax id number. GPRO can report via registry and/or EHR and can report on only a batch of 20 clients per measure, vs. 50%. See Group Practice Reporting Option for more info.
Confused Yet?? What Should You Do!?
It is the responsibility of each practice to ensure compliance with PQRS, Meaningful Use, HIPAA and all other mandates. It’s really up to you how to proceed with PQRS, but if you’d like some guidance, click here is an optional suggested action plan for mental & behavioral health care providers:
All of these acronyms crossing your wires? Click here for our handy-dandy Compliance & Acronym Guide.
Can you get “double dinged”?
Yes! If you are a MU Medicare EP and do not participate in the program (deadline is 7/1/14 for 1st year participants), you can expect a 1% penalty on all of your Medicare reimbursements (levied in 2015 for 1st year participants or levied in 2016) – and an additional 1% penalty for each year, up to 5%.
If you qualify for Medicare PQRS reporting and do not participate, you can expect a 1.5% penalty for not reporting for 2013 (levied in 2015) and a 2% penalty for not reporting for 2014 (levied in 2016).
This means that your Medicare reimbursements can be penalized by up to 7%!!
How is PIMSY handling PQRS?
PIMSY behavioral health EHR has built one of the most comprehensive PQRS claims-based reporting systems on the market. It’s just one of the many ways that we take care of our clients and put in weeks of development work to make it easy for them to avoid PQRS penalties (or get the incentives!). Click here for a 2 minute video too see how it works.
Ask us for details about how PIMSY practice management system can help you maintain compliance for PQRS, DSM, ICD, Meaningful Use, audits and more.
PQRS Resource Center
PQRS Reporting Once in 2014 Tool
CMS PQRS Claims Reporting Made Simple
How to Report Once for 2014
PQRS Guide for Mental Health
Penalties & Bonuses: PQRS for Mental Health
APA Practice Central PQRS Overview
(note: this article contains the 7/1/14 deadline for EPs participating in the Meaningful Use Medicare program for the first time. While it has been proposed that this deadline be extended, the rule is still open to comments for 60 days. Until this proposal has been finalized, we will use the deadline of 7/1/14).
(Disclaimer: Ultimately, it is the responsibility of each practice to ensure PQRS compliance. PIMSY EMR/SMIS has gathered information from various resources believed to be authorities in their field. However, neither PIMSY EMR/SMIS nor the authors warrant that the information is in every respect accurate and/or complete. PIMSY EMR/SMIS assumes no responsibility for use of the information provided. Neither PIMSY EMR/SMIS nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials. These materials are for informational purposes only. PIMSY EMR/SMIS does not provide medical, legal, financial or other professional advice and readers are encouraged to consult a professional advisor for such advice.)