PQRS 2012 for Anesthesiologists and Pain Specialists

Editor's note: This article by Tony Mira, president and CEO of Anesthesia Business Consultants, an anesthesia & pain management billing and practice management services company, originally appeared in Anesthesia Business Consultants eAlerts, a free electronic newsletter. Sign-up to receive this newsletter by clicking here.

The end of the year is a good time to review Medicare's Physician Quality Reporting System (PQRS). Several clients have recently raised questions about the PQRS program and it is likely that a number of other readers could use a refresher course.

The PQRS Incentive Payment Amount in 2012 and Beyond

One major change is the reduction of the incentive amount from 1.0 percent of Medicare allowed payments in 2011 to 0.5 percent in 2012, 2013 and 2014. If 0.5 percent of allowables hardly seems worth the effort – performing and reporting $200,000 worth of allowed services would earn an anesthesiologist a PQRS bonus of just $1,000 – perfecting one's reporting so as to avoid the future penalty or "payment adjustment" for not reporting satisfactorily under the PQRS may be a sufficient incentive. In 2015, the negative payment adjustment will be 1.5 percent, and it will be based on reporting during calendar year 2013. In 2016 and subsequent years, physicians who fail to meet the PQRS requirements will see a 2.0 percent reduction in their Medicare payments. Using the $200,000 example again, not reporting PQRS measures successfully would cost a physician $4,000 over the course of a year.

Successful Reporting

The most straightforward way for anesthesiologists, pain physicians and nurse anesthetists to report the PQRS quality measures is claims-based individual measures. The "eligible professional" (EP) simply includes the appropriate 5-digit Quality Data Code (QDC) on the claim submitted to Medicare. The EP must:

• Report at least three PQRS measures; OR
• If fewer than three measures apply to the eligible professional, 1-2 measures; AND
• Report each measure for at least 50% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

The reporting period is the full calendar year January 1 through December 31. CMS has eliminated the 6-month reporting period over considerable protest from the physician community. The 6-month period benefited practices that started reporting later in the year as well as EPs who moved from a practice that was participating in the PQRS to another than was not, or vice versa, and thus were unable to meet the 50% threshold for the first 6-month period. CMS justified its decision on the grounds that "data based on a 12-month reporting period provides more meaningful insight to patient experience and care than data collected during a shorter, 6-month reporting period." (Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012, Final Rule, 76 Fed. Reg. 73026, 73318 [November 28, 2011].)

Note also that CMS has now clarified that "Measures with a 0% performance rate will not be counted." A 0% performance rate means that the EP reported that s/he did not perform the relevant quality intervention for any of the claims submitted for the measure in question. Some anesthesia practices, for example, routinely reported QDC 4048F-8P ("Prophylactic antibiotic was not given within one hour [if fluoroquinolone or vancomycin, two hours] prior to the surgical incision [or start of procedure when no incision is required], reason not otherwise specified") on all of their claims for the procedures for which antibiotic prohylaxis would normally be appropriate to avoid any potential problems with inaccurate documentation. Physicians in other specialties took a similar fail-safe approach. Although the PQRS rewards reporting ¸not performance as such, 0% performance rates seem contrary to the behavior that the program is intended to incentivize, and they will no longer be rewarded.

In 2012, as in 2011, anesthesiologists have the option of registry-based reporting. They can qualify for the PQRS bonus by joining the Anesthesia Quality Institute (AQI) and reporting the quality measures to the AQI's National Anesthesia Clinical Outcomes Registry (NACOR), which will submit the data to CMS on their behalf. The requirements for registry-based reporting are considerably more stringent than the requirements for claims-based reporting, however. Thus, EPs must:

• Report at least three PQRS measures, AND
• Report each measure for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Very few anesthesia practices lend themselves to reporting three or more measures. For that reason alone, claims-based reporting may be a more secure option than registry-based reporting, especially since the threshold for the former method is fifty rather than eighty percent of the EP's eligible cases. Nevertheless, high-performing practices with the necessary resources – and there certainly are some – may elect registry-based reporting. Providers that report through registries also have the option of reporting measures groups rather than individual measures. There are 22 measures groups for 2012: Diabetes Mellitus; Adult Kidney Disease; Preventive Care; CABG, Rheumatoid Arthritis; Perioperative Care; Back Pain; CAD; Heart Failure; IVD; Hepatitis C; HIV/AIDS; CAP; Asthma; COPD; IBD; Sleep Apnea; Dementia; Parkinson's; Elevated Blood Pressure; Cardiovascular Prevention; and Cataracts. All measures included in measures groups would be reportable as part of a group or individually, except for the measures in the back pain measures group. Additional information on reporting measures groups through registries or individually will be forthcoming if readers express interest.

The PQRS includes two further methods of reporting quality measures, neither of which present advantages for or are even open to the vast majority of anesthesiologists. EHR-based reporting involves the submission of at least three measures in at least eighty percent of eligible cases, or alternatively three core and three additional measures from the EHR Incentive Program, whether directly from the EHR or through an EHR "data submission vendor." The group practice reporting option (GPRO), available only to groups of 25 or more physicians beginning in 2012, requires self-nomination and selection by CMS followed by reporting all the measures included in a web interface for a prepopulated beneficiary sample. For charts explaining these two options as well as the claims-based and registry-based reporting methods, see CMS' Decision Tree.

The 2012 Set of Measures

The three basic measures for anesthesiologists are unchanged:

• Measure #30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
• Measure #193 Perioperative Temperature Management
• Measure #76 Prevention of Catheter-Related Bloodstream Infections

As in the past, physicians and nurse anesthetists can qualify for the PQRS bonus without reporting on all three measures. If an EP does report on fewer than three measures, however, CMS will use the Measure Applicability Validation (MAV) test to determine whether there are other measures that the EP should have reported. The MAV is a two-part test. First CMS will examine whether other services were clinically related and therefore potentially applicable. "Clinical relation," for these purposes, has been defined in a set of measure "clusters." Second, CMS will apply a minimum threshold test to see whether another measure in the cluster was applicable to the EP's practice because s/he had reported it at least once. If the EP reports any measure 15 or more times throughout 2012, it will apply.

Last year's two anesthesia clusters have reappeared in the 2012 MAV Process paper:

(When reporting #76 alone, it is not subject to MAV)

The 2012 PQRS program includes a total of 211 quality measures available for claims and/or registry reporting; 26 of these measures are new to the PQRS program. We are still reviewing the specifications but it does not appear that the additional measures are relevant to anesthesiology or pain practice. Two measures that we identified last year for use by pain specialists have not changed. They are:

• Measure # 124 Health Information Technology (HIT) – Adoption/Use of Electronic Health Records
• Measure #130 Documentation of Current Medications in the Medical Record

A third measure that was modified in 2011 and that might be reported on claims for outpatient visits is:

• Measure #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

The tobacco use prevention measure is obviously intended for use principally in a primary care office, but as long as a clinician screens all his or her patients over the age of 18 (denominator), and offers some counseling or pharmacotherapy to patients who smoke, that clinician should be able to report Measure #226 on his or her claims. It is worth noting the following evidence, cited in the measure, for the value of modest physician counseling on smoking:

All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health & Human Services-Public Health Service, 2008)

Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) (U.S. Department of Health & Human Services-Public Health Service, 2008)

Readers should consult the 2012 Physician Quality Reporting System Measure Specifications Manual for the detailed requirements and reporting instructions for each of the measures of interest.

There are an additional 51 measures available for EHR-based reporting, which includes all the Medicare EHR Incentive Program measures (44), the other PQRS measures that CMS had available for reporting in 2011 EHR reporting option (5), and two new additional CMS-developed measures.

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