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AOTA Guide to PQRS

Reporting

Only eligible professionals (EPs) are subject reporting requirements under the Physician Quality Reporting System (PQRS). The list of EPs, as defined in statute, includes physicians and non-physicians. Occupational therapists who (1) are independent practitioners or who work in private practice, and (2) bill Medicare using an individual-level National Provider Identifier (NPI) are EPs for purposes of PQRS. 

For 2014, PQRS will contain a total of 287 measures and 25 measures groups. Of these, 110 individual quality measures are eligible for claims-based reporting. OTs are not eligible to report on all measures via all reporting mechanisms, however.

EPs may report on quality measures using the following methods: claims-based, registry-based, qualified Electronic Health Record (EHR), Qualified Clinical  Data Registry (QCDR) or the Group Practice Reporting Option (GPRO).

Claims: To report via Part B (paper) claims, an eligible OT should report at least 9 measures over 3 National Quality Strategy (NQS) domains for at least 50% of applicable Medicare Part B patients to avoid a penalty. There are a total of 6 NQS domains: clinical care, care coordination, population health, cost reduction, safety, and person/caregiver experiences, and outcomes. The reporting requirement of 9 measures is an increase from 3 in prior years. If fewer than 9 measures are reported (as will often be the case for many EPs), CMS will apply a measure-applicability validation (MAV) process to the claims data. This means that CMS will check whether the provider could have reported on more measures. If it would have been impossible for the provider to have done so given the patient mix, measure eligibility, etc., then the provider will be determined to have successfully satisfied PQRS requirements and will not face a negative payment adjustment.  Note that quality measures data reported on claims denied for payment are not included in PQRS analysis. For additional guidance, refer to the 2014 Physician Quality Reporting System Implementation Guide (pp. 14-18; see also Appendix E for a flow diagram of the PQRS claims-based process). In addition to PQRS measure data, the claim form will contain the usual applicable CPT codes, G-codes, and code modifiers. Meeting the functional data reporting requirements (G-codes) under Medicare Part B is a separate matter and does not mean an occupational therapist has satisfied PQRS reporting requirements. See an example of a CMS-1500 Claim Form for PQRS 2014.

Registry: Individual EPs and groups may report quality measures data to a qualified participating registry. Reporting requirements are 9 measures across 3 NQS domains for at least 50% of eligible instances. This is an increase from the previous 3 measures and, like claims-based submission, if fewer than 9 measures are reported, the MAV process for registry data will apply. If it would have been impossible for the provider to have reported 9 measures, then the provider will be determined to have successfully satisfied PQRS requirements and will not face a negative payment adjustment. EPs reporting via registry should work directly with the vendor for detailed information on how to submit data on the selected measures or measures group. The 2014 PQRS data submission window will be in the first quarter of 2015. For more information about registry-based reporting, see CMS: PQRS Registry Reporting

EHR: EPs may submit PQRS quality measure data to CMS directly from their EHR system.  The quality measure data may also be extracted from the EHR and sent to a qualified EHR Data Submission Vendor, who would then submit the data to CMS in a CMS-specified format on the OT’s behalf. EPs may also use the PQRS-Medicare EHR Incentive Program Pilot (Participation Guide (June 2013); Quick-Reference Guide (April 2013)). For more information about EHR-based reporting see CMS: EHR Incentive Program Reporting

QCDR: This reporting mechanism is brand new for CY 2014. A QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. The requirements for QCDRs are stricter than those for a traditional registry (i.e., transparency, feedback) and, uniquely, QCDRs can accept information on quality measures not limited to PQRS (e.g., Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) , National Quality Forum (NQF)-endorsed measures, measures used by boards or specialty societies, and measures used in regional quality collaborations). For additional information on reporting criteria, see CMS: QCDR Reporting

GPRO: For purposes of determining whether a group practice participating in GPRO satisfactorily submits PQRS quality measures data for 2014, each group practice will be required to report 17 quality measures (22 individual measures, when accounting for the two composite measures). More information on this method of reporting, and the 22 measures, may be reviewed on the CMS: GPRO page or the CMS: GPRO Web Interface page.

To select reporting mechanisms and establish reporting protocols, occupational therapists are advised to confer and partner with their EHR or registry vendors and/or personnel within their private practice settings who are responsible for coding and Medicare billing.  

Reporting Period 

The CY 2014 reporting period is the full calendar year: January 1, 2014 – December 31, 2014. Individuals reporting on measure groups via qualified registries are excepted and have a 6-month reporting option (July 1, 2014-December 31, 2014) available to them. 

Measures 

Occupational therapists are eligible to report quality data on measures with occupational therapy CPT service codes. For example, CPT codes 97003 (OT evaluation), 97004 (OT reevaluation), and 97535 (self-care/home management) are some of the CPT codes linked to measures reportable by occupational therapists. Not all measures are reportable via all reporting mechanisms, however. 

For 2014, occupational therapists may report the following measures: 

INDIVIDUAL MEASURES 

128 - Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (domain: community/population health; reporting options: claims, registry, EHR, GPRO) 

130 - Documentation of Current Medications in the Medical Record (domain: patient safety; reporting options: claims, registry, EHR) 

131 - Pain Assessment Prior to Initiation of Therapy and Follow-Up (domain: community/population health; reporting options: claims, registry) 

134 - Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan (domain: community/population health; reporting options: claims, registry, EHR, GPRO) 

154 - Falls: Risk Assessment (domain: patient safety; reporting options: claims, registry) 

155 - Falls: Plan of Care (domain: communication and care coordination; reporting option: claims, registry) 

173 - Preventative Care and Screening: Unhealthy Alcohol Use – Screening (domain: community/population health; reporting options: registry) 

181 - Elder Maltreatment Screen and Follow-Up Plan (domain: patient safety; reporting options: claims, registry) 

182 - Functional Outcome Assessment* (domain: communication and care coordination; reporting options: claims, registry) 

217 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments (domain: communication and care coordination; reporting option: registry) 

218 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments (domain: communication and care coordination; reporting option: registry) 

219 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments (domain: communication and care coordination: reporting option: registry) 

220 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments (domain: communication and care coordination; reporting option: registry)  

221 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments (domain: communication and care coordination; reporting option: registry)  

222 - Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments (domain: communication and care coordination; reporting option: registry) 

223 - Functional Deficit: 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 (domain: communication and care coordination; reporting option: registry)  

226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (domain: community/population health; reporting options: claims, registry, EHR, GPRO) 

* NEW for occupational therapy. 

For detailed measure specifications see: CMS: 2014 PQRS Individual Measures Specifications Manual.  

DEMENTIA MEASURES GROUP 

280 – Dementia: Staging of Dementia

281 – Dementia: Cognitive Assessment

282 – Dementia: Functional Status Assessment

285 – Dementia: Screening for Depressive Symptoms

286 – Dementia: Counseling Regarding Safety Concerns

287 – Dementia: Counseling Regarding Risks of Driving

288 – Dementia: Caregiver Education and Support 

(domain: effective clinical care; reporting option: dementia measures group) 

For detailed measure group specifications see: CMS: 2014 PQRS Group Measures Specifications Manual.

Continuing AOTA Advocacy

AOTA is continually working to limit payment penalties for occupational therapists, explore registry building, develop new quality outcomes measures for function, and to ensure that occupational therapists can report on all appropriate existing measures. We would like to hear from occupational therapists who are participating in PQRS and other quality reporting programs. Please email us at regulatory@aota.org to share your experiences, and to pass along tips and suggestions to other AOTA members.

Resources

CMS Overview Fact Sheet on PQRS

CMS: PQRS - How to Get Started 

CMS: Implementation Guide for PQRS 2014 (zip file)

CMS: Measure Specifications for PQRS 2014 (zip file)

Example of a CMS-1500 Claim Form for PQRS 2014

CMS Live FAQs Page

CMS: PQRS Registry Reporting 

CMS: 2014 PQRS Qualified Registry Vendor Criteria

CMS: EHR Incentive Program Reporting 

CMS: QCDR Reporting

CMS: GPRO for PQRS 

CMS: PQRS Analysis and Payment

CMS: PQRS Payment Adjustment Information 

QualityNet Help Desk:
The help desk is available Monday – Friday, 7am–7pm CT
Tel.  1.866.288.8912 (TTY 1.877.715.6222),  Email Qnetsupport@sdps.org

PQRS for CY2013 (Capital Briefing, OT Practice, February 25, 2013)

Sign-up for the CMS PQRS Listserv

CMS: 2014 PQRS Claims MAV

CMS: 2014 PQRS Registry MAV

CMS: 2014 PQRS Group Measures Specifications Manual 

CMS: 2014 PQRS Individual Measures Specifications Manual 

 

- Jennifer Hitchon, JD, MHA, Counsel & Director of Regulatory Affairs.