© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 1
Medicare PQRS Coding
With Mario Fucinari DC, MCS-P, MCS-I
Certified Insurance Consultant
Certified Medical Compliance Specialist (MCS-P)
Sponsored by Foot Levelers
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© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 2 Medicare’s Definition of Medical Necessity
1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services must have a direct therapeutic relationship to the patient’s condition. (Medicare does not pay for pain).
2. You must have a reasonable expectation of recovery or improvement of function.
3. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. A diagnosis of pain is not sufficient for medical necessity
Medicare Medical Necessity
Acute subluxation - treatment for a new injury, identified by x-ray or physical exam. The treatment is expected to improve, arrest, or retard the patient’s condition.
Chronic subluxation - A patient's condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.
Maintenance Therapy
Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care.
– ____A treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or ____therapy that is performed to maintain or prevent deterioration of a chronic condition. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.
Physician Quality Reporting Initiative (PQRS 2014)
The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries.
Providers do not need to sign-up or pre-register in order to participate in the PQRS program. Submission of the quality data codes for the measures will indicate your intent to participate in the PQRS. However, to qualify for a Physician Quality Reporting incentive payment an eligible professional must meet the criteria for satisfactory reporting specified by CMS.
The 2014 results will drive the "payment adjustments" (penalties) in 2016. The Centers for Medicare & Medicaid Services (CMS) will impose a 1.5% penalty in 2015 (for 2013) and a 2% penalty for 2016 and after, if you have not met the threshold for the use of the PQRS codes. The PQRS measures will only count if you report the measures on active care patients. Do NOT report PQRS measures on maintenance care claims. Reporting is counted according to the number of claims that have a spinal CMT code (98940/98941/98942).
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 3 The database will consider the percentage of claims with a spinal CMT code that also have successfully reported PQRS measure codes. If the number is greater than the threshold (50% for 2014), they will generate a check based on the total allowed services for that year.
CMS has indicated that PQRS will serve as the basis for its Value-Based Modifier initiative. In the coming years, CMS intends to move Medicare from the position of passive payer to a purchaser of high-quality, efficient care through a value-based purchasing initiative. The Affordable Care Act of 2010 mandates that by 2014, CMS must begin to apply a value-based modifier under the Medicare Physician Fee Schedule. In other words, cost and quality data will be factored into the calculation of payments for physicians.
Starting in 2015, some payments will be affected by the value-based modifier; by 2017, most physician payments will incorporate a quality calculation. Given this fact, participation in PQRS offers doctors a valuable opportunity to prepare for the transition from fee-for-service reimbursements to payments based on quality performance.
Starting in 2016, chiropractic payments will be affected by the value-based modifier.
In 2016, those doctors that do not report PQRS measures will also be assigned the lowest level of Value-Based Payment Modifier of -1%.
Total # of Individual PQRS Measures:
There are 288 measures for 2014. Most of the Quality Measures do not pertain to chiropractic. Others may pertain indirectly, but are not eligible for a measure, since they are included in other services and are not mutually exclusive. Some measures require only a one time submission. Three of the measures must be reported by chiropractors:
1. Pain Assessment #131
2. Functional Outcomes Assessment #182
3. Preventive Care and Screening: Screening for High Blood Pressure #317
PQRS # 131 Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
Definition: Pain Assessment - A clinical assessment of pain using a standardized tool
for the presence andcharacteristics of pain; characteristics may include location, intensity, quality, and onset/duration.
Standardized Tool – An assessment tool that has been appropriately normalized and
validated for thepopulation in which it is used. Examples of tools for pain assessment, include, but are not limited to:
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 4 Brief Pain Inventory (BPI), Faces Pain Scale (FPS) (for mentally disabled)
McGill Pain Questionnaire (MPQ) Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS)
Numeric Rating Scale (NRS) Oswestry Disability Index (ODI)
Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS)
Verbal Numeric Rating Scale (VNRS) a.k.a. Borg scale Visual Analog Scale (VAS).
Follow-Up Plan – Proposed outline of treatment to be conducted as a result of pain
assessment. Follow-up must include a planned reassessment of pain and may include
documentation of future appointments,education, referrals, pharmacological intervention, or notification of other care providers as applicable.
The documented follow-up plan must be related to the presence of pain. “Return next visit for re-assessment of pain”
Associated Follow-up Options: • Follow-up appointment,
• Referral,
• Notification to another provider,
• OR indicate the initial treatment plan is still in effect.
Not Eligible – A patient is not eligible if one or more of the following reasons exist: - Severe mental and/or physical incapacity where the person is unable to express
himself/herself ina manner understood by others. For example, cases where pain cannot be accurately assessedthrough use of nationally recognized standardized pain assessment tools.
- Patient is in an urgent or emergent situation where time is of the essence and to delay treatmentwould jeopardize the patient’s health status.
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 5
Pain Assessment Codes to use:
Pain assessment documented as positive utilizing a
standardized tool AND a follow-up plan is
documented OR
G8730
Pain assessment documented as negative, no
follow-up plan required
G8731
Documentation that patient is not eligible for a pain
assessment OR
G8442
Pain assessment documented, follow-up plan not
documented, patient not eligible/appropriate
G8939
NO documentation of pain assessment, reason not
given OR
G8732
Documentation of positive pain assessment; no
documentation of a follow-up plan, reason not
given
G8509
PQRS # 182 Functional Outcome Assessment:
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
Measure #182, the Functional Outcome Assessment measure, has an additional definition for quality data code G8942, which now is reported to reflect functional outcome assessment documented, no functional deficiencies identified, care plan not required, or functional outcome assessment and care plan documented in the previous 30 days.
DESCRIPTION:
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
INSTRUCTIONS:
This measure is to be reported each visit indicating the appropriate numerator code; however, the assessment is required to be current as defined for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 6
coding. Documentation of a current functional outcomes assessment must include identification of the standardized tool used.
Clarification:
The intent of the measure is for the functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required at each visit due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality-data code G8942 should be used for reporting purposes.
Definitions:
Standardized Tool – An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris
Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS). The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.
Functional Outcome Assessment – Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms.
Current – A patient having a documented functional assessment within the previous 30 days. Functional Outcome Deficiencies – Impairment or loss of physical function related to
neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Care Plan – A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient’s health care problems. Care plans may also be known as a treatment plan.
Not Eligible – A patient is not eligible if the following reasons(s) exist: - Patient refuses to participate
- Patient unable to complete questionnaire Oswestry Disability Index (ODI)
Revised Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability/Activity Questionnaire (RM) Neck Pain Disability Index Questionnaire (NDI) Physical Mobility Scale (PMS)
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 7
Function Begins from the Ground Up!!
Functional Assessment Code
Documentation of a functional outcome assessment using a standardized tool AND documentation of a care plan based on identified deficiencies on the date of the functional assessment. OR
G8539
Documentation of a functional outcome assessment using a standardized tool; no functional deficiencies identified, care plan
not required OR
G8542
Documented functional outcome assessment and care plan within the previous 30 days
G8942 Documentation that the patient is not eligible for a functional
outcome assessment
G8540 Functional outcome assessment documented, care plan not
documented, documentation the patient is not eligible for a care plan
G9227
Functional outcome assessment using a standardized tool not documented , reason not given OR
G8541 Documentation of a functional outcome assessment using a
standardized tool; care plan not documented, reason not given
G8543
3. PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
• This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period.
• Eligible professionals who report the measure must perform the blood pressure screening at the time of a qualifying visit and may not obtain measurements from external sources.
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 8 • The documented follow up plan must be related to the current BP reading as indicated,
example: “Patient referred to primary care provider for BP management.” Blood Pressure Classifications:
• Normal • Pre-Hypertensive • First Hypertensive • Second Hypertensive BP Classification Systolic BP mm HG Diastolic BP mm HG Recommended Follow-up
Normal BP < 120 AND <80 No Follow-Up required Pre-Hypertensive BP ≥ 120 AND ≤ 139 OR ≥ AND ≤
89
Rescreen BP within a minimum of 1 year AND recommend lifestyle modifications
OR Refer to Primary Care Provider First Hypertensive
Reading
≥ 140 OR ≥ 90 Rescreen BP within a minimum of 1 year AND recommend lifestyle modifications
OR Refer to Primary Care Provider Second Hypertensive
BP Reading
≥ 140 OR ≥ 90 Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions (see definitions)
OR Referral to Primary Care Provider
Follow-up plan of care
• Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
• BP screening intervals, lifestyle modifications and interventions based on the current BP reading
Lifestyle Modifications: • Weight reduction,
• Dietary approaches to stop hypertension, • Dietary sodium restriction,
• Increased physical activity, or • Moderation in Alcohol consumption
© Copyright 2014 Medicare PQRS Coding, Mario Fucinari DC, CCSP, MCS-P Page 9
Blood Pressure Screening Code
Normal blood pressure reading documented, follow-up not required
OR
Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented
G8783 OR G8950 Blood pressure reading not documented, documentation the
patient is not eligible OR
Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented,
documentation the patient is not eligible
G8784 OR G8951
Blood pressure reading not documented, reason not given OR
Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not
given
G8785 OR G8952
Example: (Circle one of the following) Pain Assessment
G8730 Pain Assessed, present G8731 Pain assessed, but no pain G8732 Pain NOT assessed Outcomes Assessment (OATS) G8539 OATS done today
G8942 OATS not done today; but within the last 30 days G8542 OATS done today; no deficiency
G8541 OATS NOT done in the last 30 days Blood Pressure Screening
G8783 Normal BP
G8950 HyperBP with follow-up G8785 BP not documented
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