Educational Articles

PQRS

There are many acronyms the federal government uses, and we've heard of some of the big ones such as HIPPA and EMTALA. However, not many of us have heard of PQRS (Physician Quality Reporting System).

"PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments (read penalties) to promote reporting of quality information by eligible professionals (EPs). This applies only to Medicare patients for now. Beginning in 2015, psychologist and other eligible professionals participating in the program are expected to report on quality measures. The program will also apply a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services." Although PQRS is a standalone program, it touches on other CMS programs that require quality reporting, such as the e-Prescribing (eRx) Incentive Program, the EHR Incentive Program, the Medicare Shared Savings Program, and the Value-Based Payment Modifier.

CMS has retired 50 measures from the PQRS program in 2015, including the following 4 out of the 7 measures from the 2014 emergency care cluster:

#28:  Aspirin for AMI

#55:  12 Lead ECG for Syncope

#56: Community Acquired Pneumonia (CAP): Vital Signs

#59:  CAP: Empiric Antibiotic

On January 19, 2015, CMS released the 2015 Measure Applicability Validation (MAV) process, and they identified the following Claims-Based MAV for Emergency Care. 

Measure #54 - 12 Lead Electrocardiogram Performed for Non-Traumatic Chest Pain

  • What coders need to see documented in the ED chart:
  • Physician documentation indicating that there was a 12-lead EKG performed or documentation why an EKG was not performed (i.e. not performed for medical reasons or patient reason). Avoid reason not specified.

 

Measure #254 - Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

  • What coders need to see documented in the ED chart:
  • Documentation indicating that the patient received a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location or documentation indicating why an ultrasound was not performed (i.e. patient had a recent ultrasound or patient has documented confirmation of an intrauterine pregnancy).

 

Measure #255 - Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

  • What do the coders need to see documented in the ED chart:
  • Documentation in the medical record of an order for Rh-Immunoglobulin (Rhogam) if the patient is Rh-Negative or not ordered for documented reasons (i.e. the patient already had one or one can be found in prior documentation).

 

Measure #317 - Preventive Care & Screening:  Screening for High Blood Pressure and Follow-up Documentation

  • What do the coders need to see documented in the ED chart:
  • If BP has a systolic below 120 and diastolic below 80:
  • No additional documentation is necessary.
  • If BP has a systolic above 120 or diastolic above 80:
  • We need to know if the patient has an established diagnosis of hypertension.
  • If there is an established hypertension diagnosis, follow-up is not required and no additional documentation is necessary.
  • If BP has a systolic above 120 or diastolic above 80, and the patient does not have an established diagnosis of hypertension:
  • We need documentation of the ED physicians follow-up recommendations.
  • The PQRS guidelines mention several options including re-screening BP at different intervals, lifestyle modifications and other interventions. The option that makes the most sense for emergency physicians is "Referral to Alternative/Primary Care Provider."
  • The example given by CMS is "Patient referred to PCP for BP management."

 

Other PQRS Measures potentially relevant to emergency physicians in 2015, are listed below: 

Measure #76 - Prevention of CRBSI: Central Venous Catheter (CVC) Insertion Protocol 

  • What do the coders need to see documented in the ED chart:
  • Regardless of age, in patients who undergo central venous catheter (CVC) insertion, we must document that the CVC was inserted with all elements of maximal sterile barrier technique (hat, gown, gloves, mask, drape), hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.

 

Measure #91 - Acute Otitis Externa (AOE): Topical Therapy

  • What do the coders need to see documented in the ED chart:
  • Document in patients aged 2 years and older with a diagnosis of AOE that they were prescribed topical antibiotics.
  • CMS wants to know the percentage of patients with AOE who are treated with topical medications.
  • This is reported to CMS as a percentage of patients with AOE.

 

Measure #93 - Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance in Inappropriate Use

  • What do the coders need to see documented in the ED chart:
  • Document or show that in patients aged 2 years and older with a diagnosis of AOE that they were not prescribed systemic antimicrobial therapy.
  • CMS wants to see that we are not prescribing unnecessary oral antibiotics for otitis externa. We should document specific indications and use the diagnosis of malignant otitis externa and not use the diagnosis of acute otitis externa.
  • This is reported to CMS as a percentage of patients with AOE.

 

Measure #187 - Stroke and Stroke Rehabilitation:  Thrombolytic therapy (tPA)

  • What do the coders need to see documented in the ED chart:
  • In patients aged 18 years and older with a diagnosis of acute ischemic stroke, we need to be diligent about documenting the time of last known well, any contraindications or reasons why t-PA was not given, or why t-PA was not initiated within three hours of last known well.
  • This is reported to CMS as a percentage of patients who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well.

 

Measure #326 - Atrial Fibrillation and Atrial Flutter:  Chronic Anticoagulation Therapy

  • What do the coders need to see documented in the ED chart:
  • In patients aged 18 years and older with non-valvular atrial fibrillation (AF) or atrial flutter, we should be documenting thromboembolic risk factors by assessing CHADS2 risk stratification. If the patient has one or more high risk factors or one or more moderate risk factors, we need to document treatment with warfarin or other FDA approved anticoagulant drug. If the patient is not treated, we need to document either reasons why or contraindications to the use of appropriate medications.
  • This is reported to CMS as a percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter with appropriate indications, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism.

 

An eligible provider can still satisfy PQRS and avoid the penalty by reporting on less than 9 measures, but would be subject to the MAV process to determine whether he/she reported on as many measures as are applicable, and will also determine if they could have reported on any cross cutting measures. It should be noted that 99% of emergency providers will not have any Medicare patients that fall into measures #91, #93, #254, and #255 above, so it is highly unlikely that those measures would be counted toward the nine measure goal for most providers. Emergency physicians should also beware of reporting on any measures outside of their cluster (with the exception of #76 and #317) as reporting additional measures may trigger additional clusters as noted in the list above.

 

For more information on PQRS and the Value Modifier please visit www.acep.org/quality/pqrs.

 

These measures are tied into the physician's NPI. Eventually, it is speculated that Medicare will pay physicians at different rates depending on their performance and participation in the program.

In summary, the PQRS is a program implemented by CMS to make sure we are giving quality standard care and at reasonable cost. This program was enacted in 2007. It allowed physicians to recover an additional 2% on their Medicare reimbursement. There is a change in the program to implement a 1.5% withholding (AKA penalty) in 2015, and it goes to 2.0% withholding in 2016, if not participating. It benefits the group to participate in terms of financial reimbursements and benefits the patient in terms of making sure they get quality care as put forth by CMS and in comparison to other physicians. Bottom line is CMS wants to make sure we follow their guidelines and either will reward or penalize based on compliance. The best thing we can do is be aware of the measures and document, document, document.

 

REFERENCES:

1. Are You Ready for PQRS changes?  Stacie Schilling Jones MPH in ACEP Now February 2015

2. ABEM PQRS MOC Added Incentive Payment Program FAQs

3. ACEP Clinical & Practice Management

4. CMS.gov

5. ACEP PQRS

6. Todd Thomas, President ERCODER