American Urological Association - 2017 Quality Reporting Program

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Home Practice Resources Accreditations and Reporting 2017 Quality Reporting Program

2017 Quality Reporting Program

Things to note about changes from PQRS in 2016 to 2017 Quality Reporting:

  • If you do not participate in 2017, you will incur a -4 percent payment adjustment (penalty) on your Medicare Part B payments in 2019.
  • In 2017, CMS is allowing providers to "Pick Your Pace," meaning you can determine how much you wish to report. The amount of data reported and the scores you receive will determine if/or how much of an incentive you may receive.
  • The minimum amount of data you must report in order to avoid the penalty is one measure for one patient.
  • The amount of data that must be reported for full participation in the Quality Reporting program is 6 measures. At least one of these measures must be an outcome measure, but if an outcome measure is not available, a high priority measure may be used. There are no domain or cross cutting measure requirements in 2017. Participants must report on a minimum of 20 patients for each measure selected, and at least 1 patient must be a Medicare Part B patient (if using a reporting mechanism other than claims reporting).
  • Those participating may report individually or as a group.

Reporting as an Individual or a Group

Providers may report as individuals where they are independently scored on the data they submit to CMS. Alternatively they may report as a group, which CMS defines as 2 or more eligible clinicians (as identified by individual National Provider Identifiers or NPIs) who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). The group’s score is a composite of all the clinicians’ scores.

Reporting Options

There are several different reporting options which may be selected to participate in the Quality Reporting program.

Claims reporting is the most frequently used process for urologists. However, it may only be used by those who are reporting individually. It involves reporting extra CPT Category II codes along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the processor. Participants must report at least 50 percent of only the Medicare Part B patients to which a measure applies.

Qualified Registry reporting may be used by both individuals and groups. It is accomplished by contracting with a CMS-approved data processing service that can compile patient claims data and generate reports on a provider or practice's behalf directly to the MIPS processor. Those using a Qualified Registry must report at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved Qualified Registries.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. Individuals and groups may report via a QCDR. Those using a QCDR must report at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved QCDRs. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org.

Electronic Health Record (EHR) reporting involves either submitting one’s data directly to CMS or to a vendor who will then submit it to CMS on the provider or practice’s behalf. Check with your EHR vendor to find out what option(s) is available to you. Both individuals and groups may use EHR reporting, and this method may allow you to qualify for bonus points in Advancing Care Information. Those using EHR reporting must submit data for at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient).

Web Interface reporting is available for groups of 25 or more clinicians who register with CMS before the June 2017 deadline. Users must report on all 15 Web Interface measures for the entire calendar year of 2017 for the first 248 eligible assigned MIPS beneficiaries. If a group does not have 248 such beneficiaries, the group must report on 100 percent of their assigned beneficiaries. For more information, see the CMS Web Interface Fact Sheet.

Measures

There are over 300 individual measures to consider for Quality reporting in 2017. In order to help urologists find specialty specific measures, CMS created a Urology Measures Set. If you select 6 measures from this list, you do not need to report an outcome measure. However, you must select at least 1 high priority measure from the list. The AUA has also compiled a list of measures which are most applicable for urologists. If you select six measures from this list, you must report at least one outcome measure.

When selecting measures, participants should consider the clinical conditions they treat, any practice improvement goals, and quality information that may be already be reported to other payers or entities. One should also consider and utilize work which is already being done in their practice while selecting measures. However, participants may want to review current billing codes as well as previous years’ Quality and Resource Use Reports (QRURs) to help identify measures or activities that best suit one’s practice.

Measure Specifications and Flowcharts [pdf]

  • Measure #23 – Perioperative Care, Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) [Claims, Registry]
  • Measure #46 – Medication Reconciliation [Claims, Registry]
  • Measure #47 – Advance Care Plan [Claims, Registry]
  • Measure #48 – Urinary Incontinence, Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
  • Measure #50 – Urinary Incontinence, Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
  • Measure #102 – Prostate Cancer, Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [Registry, EHR]
  • Measure #104 – Prostate Cancer, Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients [Registry]
  • Measure #110 – Preventive Care and Screening, Influenza Immunization [Registry, EHR]
  • Measure #113 – Colorectal Cancer Screening [Registry, EHR]
  • Measure #119 – Diabetes, Medical Attention for Nephropathy [Registry, EHR]
  • Measure #122 – Adult Kidney Disease: Blood Pressure Management [Claims, Registry]
  • Measure #128 – Preventive Care and Screening, Body Mass Index (BMI) Screening and Follow-Up [Registry, EHR]
  • Measure #130 – Documentation of Current Medications in the Medical Record [Claims, Registry, EHR]
  • Measure #131 – Pain Assessment and Follow-Up [Claims, Registry]
  • Measure #143 – Oncology: Medical and Radiation – Pain Intensity Quantified [Registry, EHR]
  • Measure #144 – Oncology: Medical and Radiation – Plan of Care for Pain [Registry]
  • Measure #145 – Radiology: Exposure Time Reported for Procedures Using Fluoroscopy [Claims, Registry]
  • Measure #226 – Preventive Care and Screening, Tobacco Use, Screening and Cessation Intervention [ClaimsRegistry, EHR]
  • Measure #236 – Controlling High Blood Pressure [Claims, Registry, EHR]
  • Measure #238 – Use of High-Risk Medications in the Elderly [Registry, EHR]
  • Measure #265 – Biopsy Follow-Up [Registry]
  • Measure #317 – Preventive Care and Screening, Screening for High Blood Pressure and Follow-Up Documented [ClaimsRegistry, EHR]
  • Measure #321 – CAHPS for PQRS Clinician/Group Survey
  • Measure #357 – Surgical Site Infection (SSI) [Registry]
  • Measure #358 – Patient-centered Surgical Risk Assessment and Communication [Registry]
  • Measure #408 – Opioid Therapy Follow-up Evaluation [Registry]
  • Measure #412 – Documentation of Signed Opioid Treatment Agreement [Registry]
  • Measure #414 – Evaluation or Interview for Risk of Opioid Misuse [Registry]
  • Measure #422 – Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury [Claims, Registry]
  • Measure #428 – Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence [Registry]
  • Measure #429 – Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy [Claims, Registry]
  • Measure #431 – Preventive Care and Screening, Unhealthy Alcohol Use: Screening & Brief Counseling [Registry]
  • Measure #432 – Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
  • Measure #433 – Proportion of Patients Sustaining a Major Viscus Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
  • Measure #434 – Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
  • Measure #436 – Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques [ClaimsRegistry]
  • Measure #453 – Proportion Receiving Chemotherapy for the Last 14 Days of Life [Registry]
  • Measure #454 – Proportion of Patients Who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life [Registry]
  • Measure #455 – Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life [Registry]

Quality Benchmarks

The purpose of the Physician Quality Reporting System (PQRS) was to improve the care provided to patients by having providers complete certain services. These services were reported to CMS, and it was as simple as that. You either did the required work and received credit for the act or you did not and you were penalized. While the Quality Reporting program maintains many PQRS aspects (the measures used, the reporting mechanisms, etc.), the program will not continue the “pass/fail” grading system used by PQRS. Under the Quality Reporting program, participants are scored on how complete and successful their reporting is in comparison to others who are reporting. For each measure and for each reporting mechanism, a series of benchmarks have been established. CMS has created a matrix where each measure has been divided into deciles, ranging from 3 to 10. A participant will be able to use this matrix to determine into which decile his/her work falls and thus determine his/her score for that particular measure. For example, let’s say a urologist is reporting Measure #130 Documentation of Current Medications in the Medical Record using claims reporting. The range for this measure is:

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

96.11-98.73 %

98.74-99.64 %

99.65-99.99 %

       

100 %

To achieve 10 points for this measure, a participant must have a perfect score, meaning he/she correctly reported on all the patients to which this measure was applicable. If he/she missed a couple of patients, his/her score would obviously decrease. For this particular measure, the participant’s score would drop down to 5 points at the maximum for anything less than perfection, but a score could be much lower because the score would need to be very close to perfection in order to get the 5 points.

The scoring on Measure #130 is very tough because it is considered a “topped out” measure by CMS. This means that it has been widely used, and users score very well on it. CMS will begin to phase out many of the topped out measures in the coming years. CMS is trying to discourage participants from using these measures by awarding such low point values. In contrast, Measure #113 Colorectal Cancer Screening is not topped out; therefore, the ranges are wider:

Measure #113 Colorectal Cancer Screening, Claims Reporting

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

29.50-42.36 %

42.37-53.84 %

53.85-64.40 %

64.41-75.40 %

75.41-84.67 %

84.68-93.13 %

93.14-99.99 %

100 %

A participant cannot score less than 3 points in 2017 for any measure reported, but CMS may not continue this in the future. Also, if a measure is new for 2017, CMS will award 3 points for that measure no matter how well the participant scores.

Each measure, and its reporting mechanism, has its own unique benchmarks. So, participants will want to assess the potential benchmarks when they contemplate which measures to report. Also, reporting a measure through claims reporting will have a different benchmark than reporting it through a registry. Here is an example using Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older.

Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older, Claims Reporting

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

6.25 -20.42 %

20.43-64.72 %

64.73-96.76 %

96.77-99.99 %

     

100 %

Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older, Registry/QCDR Reporting

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

16.31-29.03 %

29.04-42.90 %

42.91-57.07 %

57.08-76.52 %

76.53-89.12 %

89.13-96.91 %

96.92-99.99 %

100 %

The matrix of benchmark scores is located in the resource library of CMS’s Quality Payment Program website and is labeled 2017 Quality Benchmarks.

Quality Reporting Program Scoring

If a clinician is participating in MIPS for either 90 days or a full year, a score for the Quality reporting program will be determined. This score will account for 60 percent of one’s overall MIPS score. More information on compiling this score is available on the AUA website.

To figure a provider’s Quality reporting program score, one must determine the benchmark for each measure used. Those scores are added together and divided by 60. The score is displayed as a percentage, but a maximum score cannot exceed 100 percent. For example, if you scored perfectly on all 6 measures and achieved 10 points for each, you would have 60 divided by 60 for 100 percent. However, most people will fall below that. For example, someone’s scores could be 3, 8, 7, 4, 5, and 9 = 36 points. This divided by 60 would give you 60 percent.

In 2017, it is possible to earn bonus points.

  • 2 bonus points for each additional outcome and patient experience measure
  • 1 bonus point for each additional high-priority measure
  • 1 bonus point per measure for using Certified Electronic Health Record Technology (CEHRT) to submit measures to a registry/QCDR or CMS
  • If a practice has 16 or more eligible clinicians, CMS will calculate the All-Cause Hospital Readmission measure for the claims the practice submitted for the year. The calculation is added to the final MIPS score. Providers do not need to do any work for this calculation; it is all done by CMS.

Questions?

Quality Payment Program Help Desk
Phone: 866-288-8292
Email:QPP@cms.hhs.gov

AUA
Phone: 410-689-3925
Email: quality@auanet.org

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