Posts Tagged eligible provider
My Notes on the March 22, 2011 CMS Open Door Forum on Physician Quality Reporting System (PQRI) for the Beginner
Today’s CMS Open Door Forum was a good one. The slides (pdf here), although reviewed quickly during the call, are a comprehensive resource for anyone needing in-depth information on qualifying for incentives through PQRI. The information is complex, but anyone can start the process tomorrow and successfully get their check (next year.)
PQRI has been renamed PQRS.
These are the key points of the information presented:
- You can tell if you are eligible for the incentive program by checking the main PQRS site here. Scroll down to Downloads and click on “List of Eligible Professionals.”
- There is no registration required to report quality data.
- PQRS should not be confused with incentives offered for ePrescribing or meaningful use of a certified Electronic Health Record – these are three distinct systems.
- There are new Physician Quality Reporting Measure Specifications every year – use the correct year.
- Reporting can be done as individual eligible providers or as groups, however groups needed to be self-nominated by January 31, 2011, so that door is closed for this year.
- Eligible providers can choose to report for 12 months: January 1”“December 31, 2011 or for 6 months: July 1-December 31, 2011 (claims and registry-based reporting only.)
- There are two reporting methods for submission of measures groups that involve a patient sample selection: 30-patient sample method and 50% patient sample method. An “intent G-code” must be submitted for either method to initiate intent to report measures groups via claims. If a patient selected for inclusion in the 30-patient sample did not receive all the quality actions and that patient returns at a subsequent encounter, QDC(s) may be added (where applicable) to the subsequent claim to indicate that the quality action was performed during the reporting period.
Physician Quality Reporting analysis will consider all QDCs submitted across multiple claims for patients included in the 30-patient samples.
- Eligible professionals who have contracted with Medicare Advantage (MA) health plans should not include their MA patients in claims-based reporting of measures groups using the 30 unique patient sample method. Only Medicare Part B FFS patients (primary and secondary coverage including Railroad Medicare) should be included in claims-based reporting of measures groups.
- Choose which group measures OR individual measures (3 minimum) you want to report on based on your method of reporting. Review your choices here.
- If you plan to report using a registry or EHR, make sure the systems are qualified by checking here.
- Here is the schedule for PQRS incentives and “payment adjustments” (financial dings.)
- Incentives (based on the eligible professional’s or group’s estimated total Medicare Part B PFS allowed charges)
- 2007 ”“1.5% subject to a cap
- 2008 ”“1.5%
- 2009, 2010 ”“2.0%
- 2011 ”“1%
- 2012, 2013, 2014 ”“0.5%
- Payment Adjustments (you lose money)
- 2015 ”“98.5%
- 2016 and subsequent years ”“98.0%
What follows are the Questions and Answers from the listeners.
Q: Do PQRS measures need to be reported once per encounter or once per episode?
A: It depends on the measure. Check the list to see what each measure requires.
Q: Is there a code to submit if we cannot qualify due to low numbers of Medicare patients?
A: No, CMS will calculate this and will know you cannot qualify and you will be exempt from the payment adjustment.
Q: Can both admitting physicians and consulting physicians submit the same quality codes?
A: Yes, all eligible providers working with a patient can report the same code if appropriate.
Q: How do we know if we qualified for the eRx incentive for 2010?
A: Payments will come early fall and feedback reports will be available that break down each provider’s incentive.
Q: For the eRx incentive, is it 10 eRxs before June 30, 2011 and 25 before January 31, 2011 for each PROVIDER or each PRACTICE?
A: Each provider.
Q: What is the difference between the numerator and the denominator in PQRS?
A: The numerator is the clinical quality action (for instance, putting a patient on a beta blocker) and the denominator is the group of patients for whom the quality action applies (which patients with appropriate diagnoses are eligible for beta blocker therapy.)
Q: Do all the preventive measures in this group have to be utilized?
A: Not all measures will apply to all patients, for instance mammograms for females only.
Q: Is there a code to be placed on the claim that says a measure is not applicable for this patient?
Q: How do you know if a measure code on a claim has been accepted?
A: You will receive a rejection code on your EOB that indicates the code was submitted for information purposes only. Remittance Advice (RA) with denial code N365 is your indication that Physician Quality Reporting codes were passed into the National Claims History (NCH) file for use in calculating incentive eligibility.
Q: How can a new provider get started with quality reporting?
A: Any provider can start any time by reporting through claims, a registry or an EHR.
Q: Should providers bill for PQRI under their individual number or under their group number?
A: Under their individual number.
Q: Can a physician delegate the eRx process to a staff member, just as they might have a nurse write a prescription for them?
Q: Can you clarify the three incentive programs and which a practice can participate in at the same time?
A: The Physician Quality Reporting System, eRx Incentive Program, and EHR Incentive Program are three distinctly separate CMS programs.
The Physician Quality Reporting System incentive can be received regardless of an eligible professional’s participation in the other programs.
There are three ways to participate in the EHR Incentive Program: through Medicare, Medicare Advantage, or Medicaid.
If participating in the EHR Incentive Program through the Medicaid option, eligible professionals are able to also receive the eRx incentive.
If participating in the Medicare or Medicare Advantage options for the EHR Incentive Program, eligible professionals can still report the eRx measure but are only eligible to receive one incentive payment. Eligible professionals successfully participating in both programs will receive the EHR incentive.
Eligible professionals should continue to report the eRx measure in 2011 even if their practice is also participating in the Medicare or Medicare Advantage EHR Incentive Program because claims data for the first six months of 2011 will be analyzed to determine if a 2012 eRx Payment Adjustment will apply to the eligible professional.
If an eligible professional successfully generates and reports electronically prescribing 25 times (at least 10 of which are in the first 6 months of 2011 and submitted via claims to CMS) for eRx measure denominator eligible services, (s)he would also be exempt from the 2013 eRx payment adjustment.
The transcript and a recording of today’s call will be posted on the CMS website within a few weeks.
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But aren’t eligible providers getting that money as an inducement, actually a prize for hoop-jumping, having purchased a certified EMR and now using it meaningfully?
Oh, man, I knew there was a catch to this deal.
Next you’ll be telling me that Medicare’s reimbursement will be shrinking 21.2% November 30, 2010 and an additional 6.1% January 1, 2011.
NOTE: Read my latest post on how to register and attest for the EHR Incentive Programs here.
Where Did the Idea of Meaningful Use of Electronic Medical Records Come From?
The American Recovery and Reinvestment Act of 2009 was signed by President Obama on February 17, 2009. The Law includes the Health Information Technology for Economic and Clinical Health Act or the HITECH Act. The HITECH Act establishes programs under Medicare and Medicaid to provide incentive payments for the Meaningful Use of Certified Electronic Health Records technology.
The goal of the HITECH legislation is to improve healthcare outcomes, to facilitate access to care and to simplify care. It is believed that the installation of electronic health records in medical practices is only the beginning. The goals of HITECH will be met when the EHR is used in a meaningful way.
What is Meaningful Use (MU)?
There are three identified components of Stage I Meaningful Use. They are:
- Use of a certified EHR in a meaningful manner such as e-prescribing.
- Use of Certified EHR Technology for the exchange of health information (exchange data with other providers of care or business partners such labs or pharmacies)
- Use of Certified EHR Technology to submit clinical quality and other measures.
The first stage of Meaningful Use is capturing and sharing the data. Meaningful Use Stage II is advanced clinical processes and Stage III is starting to look Meaningful Use of an EHR in the context of improved healthcare outcomes.
There are 25 specific criteria for MU Stage I listed in this article in Healthcare IT News:
 Objective: Use CPOE (Computerized Physician Order Entry)
Measure: CPOE is used for at least 80 percent of all orders
 Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP (Eligible Provider) has enabled this functionality
 Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.
 Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
 Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.
 Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.
 Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data
 Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.
 Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded
 Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.
 Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.
 Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.
 Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over
 Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.
 Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP
 Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.
 Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.
 Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information
 Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.
 Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.
 Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.
 Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.
 Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.
 Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).
 Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.
Have the Details of MU been finalized?
The comment period for the NPRM (Notice of Proposed Rule Making) for Meaningful Use is currently open but will close on March 15, 2010. You can read the NPRM here. Many individuals and organizations have expressed concern that the timeline for implementing EHR and meeting MU criteria is too short for the majority of providers. The American Academy of Family Physicians (AAFP) recently sent a 7-page letter to acting CMS Administrator Charlene Frizzerathat included the following concerns:
- The administrative burden of reporting computerized physician order entry measures “is excessive to the point of being unachievable for most eligible providers.”
- The rule could require manually entering results from laboratories that don’t have an interoperable interface with the physician’s electronic health record.
- The term “health information” is used throughout the proposed rule, but is never defined.
- A requirement that a patient’s health information be shared with that patient within 48 hours doesn’t take in account that physicians or their staff may not be able to process the information if that 48-hour period includes weekend days.
- There is no incentive for physicians who meet less than 100% of the proposed requirements, so it is an all-or-nothing approach.
The Medical Group Management Association recently surveyed (see Modern Healthcare story here) 445 physician practice administrators in February 2010 with the following feedback:
- Nearly all are aware of the upcoming incentive programs for meaningful use of electronic health records, but fear the programs will reduce physician productivity.
- 68% of respondents expect physician productivity will decrease if all 25 proposed meaningful use criteria are implemented.
- Nearly one-third believe the decrease in productivity will be greater than 10 percent.
- Almost 25% of practices without an EHR doubt some of their providers will ever attempt to qualify for incentives.
- Among practices with an EHR, nearly 84 percent believe some of their physicians will attempt to qualify for Medicare or Medicaid incentives by the end of 2011.
How Do I Comment on the MU Standard?
You can submit your comments on the NPRM on MU here.
You can read comments already submitted here.
How Do I Know if My EHR is Certified?
No EHRs have been certified for the CMS Incentive Program and the certifying bodies have not yet been announced. It seems reasonable that CCHIT will be one certifying body, but there are expected to be others. If your vendor tells you that his EHR is certified before the rule has been finalized and the certifying bodies have been announced, ask him “For what?”
What Does it Mean to Be Eligible? (description courtesy of Everything HITECH)
This term encompasses three general types of payers to establish eligibility: 1) Medicare Fee For Services (FFS), 2) Medicare Advantage (MA) and 3) Medicaid.
For hospitals to be eligible, they can be acute care (excluding long term care facilities), critical access hospitals, children’s hospitals.
For providers, these include non-hospital-based physicians who receive reimbursement through Medicare FFS program or a contractual relationship with a qualifying MA organization. The Act defines the term “hospital based” eligible professional to mean an EP such as a pathologist, anesthesiologist,or emergency physician, who furnishes substantially all of his or her Medicare covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital’s qualified EHR’s (Fed Reg p. 1905). The determining factor is the site of service as to whether the service is hospital based or not. If the EP provides at least 90 % of their services in a hospital inpatient, hospital outpatient or hospital emergency room setting (Point of Service codes 21, 22, 23), then they are considered a hospital based EP and not eligible for EHR incentive payments (i.e. providing substantially all of his or her Medicare covered professional services).
There is a difference between Medicare and Medicaid when it comes to defining an eligible professional for EHR incentive payment purposes. Medicare defines an eligible professional as (Fed Reg p. 1996):
- doctor of medicine or doctor of osteopathy
- doctor of dental surgery or dental medicine
- doctor of podiatric medicine
- doctor of optometry
Medicaid, on on the other hand, defines an eligible professional as (Fed Reg p. 2001):
- certified nurse-midwife
- nurse practitioner
- physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic, led by a physician assistant.
What are the Guidelines for Providing Patients With Their Medical Records Electronically?
Under HIPAA, patients currently have the ability to access their medical records. Meaningful Use does not change HIPAA in that regard. You may charge patients for the expense related to providing paper or electronic medical records. Each state has its own schedule for charging for medical records (state-by-state schedule here.)
Do Eligible Providers Have to be Participating With Medicare to Receive the Incentive Money?
No, the eligibility requirements only relate to the benchmarks for the percentage of Medicaid patients you have, or amount of allowed Medicare charges you have.
Can Eligible Providers Work at Locations Other Than Hospitals and Private Practices and Receive the Incentive Money?
The location where the provider works is not the issue. The issue is whether or not the provider meets the requirements, either for Medicare or Medicaid, to be considered eligible for the program.
It doesn’t matter where the provider accesses the certified EHR. If they meet the eligibility criteria, and they are using a certified EHR, they can collect on the stimulus money.
What Are Health Provider Shortage Areas?
Physicians practicing in determined “health provider shortage” (detailed info here) areas will be eligible for a 10% bonus payment.
How Does This Incentive Relate to ePrescribing or PQRI?
If the PQRI Program is extended in its current form, practices can participate in both PQRI and an EHR Incentive Plan.
If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously.
Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR!
How Do EPs Get Paid For Meaningful Use of a Certified EHR?
For the first payment year only, all an EP or hospital has to do is to be a “meaningful user” for a continuous 90-day period during the payment year. Hospitals’ payment year is October 1 to September 30 and EPs’ payment year is the calendar year. You must start and complete the 90-day period within the payment year with no overlapping.
Also, if you can qualify as a Medicaid Eligible Provider (or Hospital), are in the process of adopting, implementing or upgrading your EHR and your Medicaid patient volume is at least 30% (Pediatricians only need 20% minimum and Hospitals need 10% minimum), you can collect your incentive money without meeting Meaningful Use criteria.
Attestation forms and forms of other types are most likely the way that EPs will provide information to apply for the incentive funds, although the details have not yet been released.
What Does it Mean to Transition From One Program (Medicaid or Medicare) to Another?
EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs will be able to participate in only one program, and will have to designate which one they would like to participate in. After their initial designation, EPs are allowed to change their program selection only once during payment years 2012 through 2014.
How Do I Get My EHR Stimulus Money?
- Decide whether you are an eligible provider for any of the programs.
- If you are, buy a certified EMR (once certification has been defined.)
- Use your EMR in a way that demonstrates your meaningful use of the product.
- Pass “GO” and collect your money.
ARRA (Stimulus Bill) Acronyms
”¢ A/I/U ”“Adopt, implement or upgrade
”¢ CAH ”“Critical Access Hospital
”¢ CCN ”“CMS Certification Number
”¢ CDS ”“Clinical Decision Support
”¢ CMS ”“Centers for Medicare & Medicaid Services
”¢ CY ”“Calendar Year
”¢ EHR ”“Electronic Health Record
”¢ EP ”“Eligible Professional
”¢ eRx ”“E-Prescribing
”¢ FFS ”“Fee-for-service
”¢ FY ”“Federal Fiscal Year
”¢ HHS ”“U.S. Department of Health and Human Services
”¢ HIT ”“Health Information Technology
”¢ HITECH Act ”“Health Information Technology for Electronic and Clinical Health Act
”¢ HITPC ”“Health Information Technology Policy Committee
”¢ HIPAA ”“Health Insurance Portability and Accountability Act of 1996
”¢ HPSA ”“Health Professional Shortage Area
”¢ IFR ”“Interim Final Rule
”¢ MA ”“Medicare Advantage
”¢ MCMP ”“Medicare Care Management Performance Demonstration
”¢ MITA-Medicaid Information Technology Architecture
”¢ MU ”“Meaningful Use
”¢ NPI ”“National Provider Identifier
”¢ NPRM ”“Notice of Proposed Rulemaking
”¢ OMB ”“Office of Management and Budget
”¢ ONC ”“Office of the National Coordinator of Health Information Technology
”¢ PQRI ”“Medicare Physician Quality Reporting Initiative
”¢ Recovery Act ”“American Reinvestment & Recovery Act of 2009
”¢ TIN ”“Taxpayer Identification Number
For more information who is eligible and for how much, read my post “ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?”