Quality Queries and Quandaries:
Emil Engels, MD, MBA, CPC
‘The secret of getting ahead is getting started.’
At the invitation of Anesthesiology News, this is the second in a series of columns attempting to answer many of the questions regarding quality reporting. This column will address topics such as the following: How do I report via a qualified registry? Which measures should an anesthesia provider report? What is a cross-cutting measure? How will the Measure-Applicability Validation (MAV) process judge me?
As discussed in last month’s column, anesthesia providers can participate in the Physician Quality Reporting System (PQRS) through claims, qualified registries, qualified clinical data registries (QCDRs) and electronic health records. Most clinicians use one of the first three methods to submit data to the Centers for Medicare & Medicaid Services (CMS). Given the uncertainty with claims-based reporting, many anesthesia providers are moving to qualified registries and QCDRs.
But how does one make the switch from claims reporting to a qualified registry? How do you find a qualified registry and what measures do you need to report? How will you be judged?
References on quality reporting abound on the internet, but most are confusing and difficult to decipher. Typing “PQRS Qualified Registry” into a search engine yields thousands of results, and anesthesiologists, certified registered nurse anesthetists and anesthesiologist assistants must put the puzzle pieces together themselves. To ease the task, this article will provide a roadmap to help understand and participate in qualified registry reporting.
What are the requirements for qualified registry reporting?
The requirements to report via a qualified registry are the same as for claims: Eligible professionals must report nine PQRS measures across three National Quality Strategy (NQS) domains, plus a cross-cutting measure if applicable, on 50% of Medicare fee-for-service patients. (QCDR reporting requirements are different and will be discussed in a future column.)
Each PQRS measure is assigned to one of six NQS domains, which represent the aspect of patient care most exemplified. Domains include categories such as patient safety, effective clinical care and efficiency/cost reduction. A cross-cutting measure is a PQRS measure that has broad applicability across multiple specialties. The requirement to report a cross-cutting measure is triggered by a “face-to-face encounter.”
What measures are eligible for qualified registry reporting?
Claims-based reporting will ultimately become obsolete. New PQRS measures from CMS can only be reported via registries. As a result, anesthesia providers using registries have many more choices. (Pain specialists have different options that will be discussed in a future column.) The list of PQRS measures for registries includes:
How can you answer questions about quality reporting?
The best way is to reach out to the QualityNet Help Desk atQNetSupport@hcqis.org. The author recommends that you save all correspondence with the help desk, in case you have to appeal a decision in the future.
Does an anesthesia provider need to report all seven measures via the qualified registry to be successful (plus a cross-cutting measure, if applicable)?
The QualityNet Help Desk was asked the following question: “If I choose to do qualified registry reporting for PQRS, will I be considered successful if I report one cross-cutting measure and only the Anesthesiology Care Cluster (PQRS Measures 424, 426, 427 and 430)? Or am I also required to report PQRS Measures 44, 76 and 404?” The help desk’s answer was that you must report on PQRS Measures 44, 76 and 404, if you are able. In other words, anesthesia providers must report on all seven qualified registry–eligible measures, if able.
What is a cross-cutting measure?
A cross-cutting measure is a PQRS measure that has broad applicability across multiple specialties. The requirement to report a cross-cutting measure is triggered by a “face-to-face encounter.” A list of triggering face-to-face encounters can be found on cms.gov.
For the average anesthesia provider, the relevant triggering codes would be evaluation and management codes, including subsequent hospital care and critical care codes. Interestingly, some codes, such as Current Procedural Terminology (CPT) 31500 (Emergency Intubation), are on the triggering codes list but are not listed in the denominator of any cross-cutting measures. In other words, even though CPT 31500 is a triggering code, it is not “denominator eligible,” and therefore does not require the reporting of a cross-cutting measure. The QualityNet Help Desk confirmed this when asked about CPT code 31500. CMS analyzes claims-based data to determine whether a cross-cutting measure was applicable. If a provider has 15 denominator-eligible events, then CMS will look for a cross-cutting measure. If not, then CMS would not hold an eligible provider accountable for reporting any of the cross-cutting measures.
Two common cross-cutting measures reported by anesthesia providers are #47, Advance Care Plan, and #130, Documentation of Current Medications in the Medical Record.
What is the MAV process and will anesthesia providers pass with seven measures?
For anesthesia providers, there are less than nine PQRS measures available to report. If a provider reports less than nine measures, the MAV is activated. According to CMS, “MAV is a process applied as part of the PQRS Program to individual eligible professionals (so-called EPs) or group practices that report less than nine measures, or nine or more measures with less than three NQS domains to determine if there were related measures that may have been reported.” MAV is also used to determine if a provider is required to report a cross-cutting measure. An excellent reference can be found at: www.cms.gov/?Medicare/?Quality-Initiatives-Patient-Assessment-Instruments/?PQRS/?Downloads/?MAV_CBT_508.pdf.
There is a different MAV process applied, depending on whether you are reporting via claims or a qualified registry.
In simple terms, here is how MAV works: CMS looks at which measures you report. Did you report nine measures across three NQS domains and a cross-cutting measure? If not, could you have done so? Did you have at least 15 encounters that qualified for measures? If you reported all eligible measures, then MAV will deem you a successful provider, even if the number of measures reported is less than nine.
Anesthesia providers who report the seven anesthesia qualified registry–eligible PQRS measures above, along with a cross-cutting measure (if applicable) should pass the MAV process. Note that any group that decides to take this approach should confirm the approach with CMS by sending an email toQNetSupport@hcqis.org.
What are the differences between a qualified registry and a QCDR?
Qualified registries and QCDRs differ in several notable ways. First, the reporting requirements are different. Qualified registry participants must report nine measures across three NQS domains and one cross-cutting measure (if applicable). In contrast, QCDR participants are required to report nine measures across three NQS domains and two outcome measures. (QCDRs and outcome measures will be discussed in the next column.) With a qualified registry, providers need to report on 50% of their Medicare fee-for-service patients. To report via QCDR, a provider is required to submit data on 50% of all patients, including those with commercial insurance. Finally, those who participate through a qualified registry can only report official PQRS measures. QCDRs can develop additional non-PQRS measures to make reporting easier.
Another interesting fact about qualified registries and QCDRs is that they submit data to CMS during the first quarter following the performance year. For example, 2016 data will be submitted to CMS during the first quarter of 2017. When participating in PQRS via claims, one is required to submit performance data with each claim. In addition, you cannot resend a claim for the sole purpose of submitting PQRS information.
Where do I find a qualified registry?
The 2015 list of CMS qualified registries can be found at www.cms.gov/?Medicare/?Quality-Initiatives-Patient-Assessment-Instruments/?PQRS/?Downloads/?2015QualifiedRegistries.pdf.
As of March 2016, the American Society of Anesthesiologists’ (ASA) Anesthesia Quality Institute/National Anesthesia Clinical Outcomes Registry has been certified as a qualified registry (in addition to being a QCDR).
The author believes strongly in the value of ASA membership. ASA membership offers numerous benefits, including educational resources, practice management information, and access to its qualified registry or QCDR. As a member, a health professional can participate in either the qualified registry or the QCDR at no additional charge. The ASA charges nonmemb ers for use, but these fees can be reduced if providers become educational members of the ASA. For more information, visit www.aqihq.org.
Look for future columns on QCDRs, PQRS for pain physicians and a discussion of MACRA, Merit-Based Incentive Payment System and alternative payment models.