PQRS Part 2 - Transcript

Slide 1: Introduction

My name is Diane Pedulla and I’m the Director of Regulatory Affairs in Government Relations Office of the APA Practice Organization. In this video, we continue our discussion on how to participate in the Physician Quality Reporting System, with a more in depth look at how to complete and submit an eligible claims form. If you missed part one, the introduction to the Physician Quality Reporting System, it is available online at apapracticecentral.org.

Slide 2: What will you need?

To start, these are the documents you’ll need.

First, you should have access to the Physician Quality Reporting System Measure Specifications Manual. The manual provides a description of each available measure, as well as the applicable codes and instructions for reporting on each measure.

CMS Website

To view the manual, visit the CMS website. Then, click on How to Get Started and scroll to the downloads section at the bottom. The manual is the third link listed on this page.

Slide 2, What will you need? Continued

Next, you will need the CMS 1500 claims form that you use for submitting claims to Medicare.

Slide 3: Part II - How to report

For 2011 and 2012, there are ten measures on which psychologists are most likely to report. You only need to report on 50 percent of the applicable cases in order to be eligible for bonus payments.

The ten measures involve clinical depression and Major Depressive Disorder, suicide risk assessment, elder maltreatment screening, tobacco and alcohol use, body mass index, medication verification and pain assessment.

Now that you have everything you need, begin by selecting the applicable measures that you would like to report.

Review each measure’s specifications, note which patients and services each measure applies to, and decide if you will be reporting for the full calendar year, or only for the period from July through December, 2011.

Slide 4: Measure #181: Elder maltreatment screen and follow-up plan

For purposes of this video, we’re going to use Measure 181, the elder maltreatment screen and follow-up plan as our example.

This measure is intended to identify abuse of an older adult by a caregiver. Elder abuse can involve physical, emotional or psychological harm, as well as financial exploitation or neglect, both intentional and unintentional.

Slide 5: Measure #181: Specifications

To determine if you meet the specifications of the measure, ask yourself three questions:

First, which patients qualify? For this measure, any of your patients age 65 and older are eligible.

Second, to what services does the measure apply? Answer: initial patient evaluations for adults age 65 and older.

Finally, which service or billing codes apply?

This measure can be used with a variety of different codes, which are listed in the Specifications Manual.

Codes 90801 and 90802 are for psychiatric diagnostic interviews, while 96116 is for behavioral status exam and 96150 a health and behavior assessment.

Explanations of these codes can be found in the American Medical Association’s Current Procedural Terminology Manual. Known as CPT codes, they’re used to identify and define health care services. Insurance companies and federal programs such as Medicare use CPT codes for billing purposes.

Four other codes, 97003, 97802, 97803 and G0270 would not be used by psychologists as they represent evaluations for occupational therapy and medical nutrition therapy services.

Typically, most of the billing codes for this measure are used only once, but for services under code 96116, the measure is reported each time that the code is submitted.

Slide 6: How to report the measure

To report the measure, you must next select from the Specifications Manual a quality-data code (known as the numerator) that best describes the action taken. For example, whether or not an elder maltreatment screen was performed. 

There are several numerator codes to indicate different courses of action.

Slide 7: Measure #181: Numerator codes

G8534 is the documentation of an elder maltreatment screen and follow-up plan.

G8537 is when an elder maltreatment screen was documented but a follow-up plan was not documented and the patient was not eligible.

G8535 is used when there is no documentation of an elder maltreatment screen and the patient is not eligible.

G8536 indicates no documentation of an elder maltreatment screen and the reason is not specified

Finally, G8538 is used when an elder maltreatment screen documented but the follow-up plan is not documented, and no reason is specified.

CMS 1500 Claims Form

Once you’ve determined the numerator, you’re ready to report.

Using the same CMS 1500 claims form used to report the service. First list the billing code, then use the line directly below to report the measure.

When reporting the measure, list the same date and place of service used for the billing code. In the section for the billing code, list the numerator code that matches the action taken.

In this example, we selected code G8534 to show that the provider had documented both an elder maltreatment screen and a follow-up plan.

Then in the charges section, list 0.00. However, if your software program will not accept this, you may list 0.01.

Slide 8: Some additional tips

There are a few things to keep in mind when reporting:

First, measures for services provided in 2011 must be reported by February 28, 2012.

Second, measures must be reported when the claim for services is submitted – they cannot be submitted retroactively. However, if the service was provided before you elected to participate, but the claim has not yet been submitted, that service can be reported on when you submit the claim.

Finally, reporting by a group practice must reflect the individual provider’s NPI number in order for each individual provider to receive credit for successfully reporting.

Slide 9: Benefits of reporting

Participating in the Physician Quality Reporting System has many advantages.

First, there’s a 1 percent bonus payment on all 2011 Medicare charges for successful reporting, which means that you have reported on at least 50 percent of the applicable cases.

Second, a feedback report from CMS on your individual participation and the amounts earned through PQRS.

And third, an indication in Medicare’s physician locator system that you participate in PQRS. This demonstrates your interest in improving quality of care for Medicare beneficiaries.

Slide 10: Physician Compare

Physician Compare, a locator system for physicians and other health care professionals, is available on the Medicare website. Beginning in 2013, the Physician Compare system will include performance information from providers who participated in PQRS in 2012.

Slide 11: For additional information

For additional information, you can visit the website for the Centers for Medicare and Medicaid Services, or contact your Medicare Administrative Contractor, who handles your Medicare claims.

If you have any additional questions about the system, you may also contact the Government Relations department at (202) 336-5889.

Thank you!