Chances are you woke up feeling a little more tired this morning due to the “spring ahead” time change. If that’s the case, I have just the boost to wake you up—PQRS in 2015! Just when you thought you were out of the weeds with PQRS for a while, we’re bringing it back into the spotlight, specifically the CKD measures group, as it needs a little more attention than in years past.
Quick facts
We’ve covered the 2015 PQRS requirements and the payment adjustments in previous posts, but here’s a quick Reader’s Digest version:
- There is a plethora of PQRS reporting options in 2015: claims, qualified registry, GPRO, direct EHR, data submission vendor (DSV), and qualified clinical data registry (QCDR).
- The total penalty for failure to report PQRS is 4% for solo providers and groups with 2-9 providers (2% value modifier penalty + 2% PQRS penalty).
- The total penalty for failure to report PQRS is 6% for groups with ten or more providers (4% value modifier penalty + 2% PQRS penalty).
- There is no incentive payment for 2015 PQRS reporting.
The qualified registry reporting option will probably be the more popular choice again for nephrologists in 2015. The qualified registry contains more renal-friendly measures (via the CKD measures group) which in turn will most likely allow you to successfully participate and obtain a better performance score.
2015 CKD Measures Group
The CKD measures group underwent quite a transformation this year. Just when you thought you had it down, one measure gets retired and three more get added. The new line up resulted from the 2015 Medicare PFS final ruling, which stated that a measures group had to contain a minimum of six individual measures, with at least one cross-cutting measure.
The new CKD measures group consists of the following measures:
- #47 Care Plan (NEW)
- #110 Preventive Care and Screening: Influenza Immunization
- #121 Adult Kidney Disease: Laboratory Testing (Lipid Profile)
- #122 Adult Kidney Disease: Blood Pressure Management
- #130 Documentation of Current Medications in the Medical Record (NEW)
- #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (NEW)
You may notice that measure #123 (Patients on ESA therapy with hgb Level > 12.0 g/dL) is no longer an option. That may be a good thing due to all the confusion surrounding the inverse performance score. The three newly added measures may look familiar as they also exist within the Meaningful Use CQM framework—but readers beware! Although the new CKD measures may look the same as the CQM measures, the denominator is calculated differently (more on this later).
Lastly, measures groups containing a measure with a 0% performance rate will be considered unsatisfactorily reporting PQRS.
CKD patient sample
Just like last year, providers must select 20 unique patients (a majority of which must be Medicare Part B FFS patients).
The 20 selected patients must meet ALL of the following criteria:
- 18 years of age or older
- Have a diagnosis of CKD stage 3 (re-added this year), 4 or 5:
ICD-9-CM [for visits occurring between 1/1/2015 – 9/30/2015]: 585.3, 585.4, 585.5
ICD-10-CM [for visits occurring between 10/1/2015 – 12/31/2015]: N18.3, N18.4, N18.5 - Have a visit during the 2015 calendar year accompanied by one of the following CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
Most practices will run a report later in the year (normally through their practice management system) to identify their patient sample. However, because the stakes are so high and the measures so different, practices may want to have a game plan early on to ensure providers are documenting what’s needed to fulfil each measure. For example, you wouldn’t want to realize late in the year that you forgot to document a care plan on all of your patients because it may not be part of your normal workflow.
A closer look at the measures
Measure #47 (NQF 0326): Care Plan
Our first measure is a cross-cutting measure and a newbie to the group this year. Unlike the other CKD measures, this measure is only applicable to patients aged 65 years and older.
Definition: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or who have documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
An advance care plan (or advance directive) is designed to respect patient’s autonomy and determine his/her wishes about future life-sustaining medical treatment if the patient becomes unable to indicate wishes.
In order to meet this measure, providers must document in the patient’s medical record that an advance care plan was discussed and a surrogate decision maker was either identified or declined. If the patient or provider declined to discuss an advance care plan (due to the patient’s spiritual beliefs), this would also be an acceptable answer.
Not discussing an advance care plan (with no reason specified) would be considered failure to meet the measure.
The specification to this measure doesn’t state an appropriate time interval to ask or re-ask about an advance care plan. Therefore, if an advance care plan is already documented in the patient’s medical record prior to the visit, the provider can either re-ask (if they feel it is necessary) or default to the answer already documented.
I predict this measure may catch providers off guard. It may not be part of your daily workflow or documentation requirements.
Measure #110 (NQF 0041): Preventive Care and Screening: Influenza Immunization
This measure should be very familiar by now. It has been part of the CKD measures group from the beginning and also is considered a cross-cutting measure.
Definition: Percentage of patients aged 18 years and older seen for a visit (between January and March for the 2014-2015 influenza season OR between October and December for the 2015-2016 influenza season) who received an influenza immunization OR who reported previous receipt of an influenza immunization.
In order to meet this measure, providers must administer the flu shot or document that the flu shot was already given (either by the provider or by another entity). Not asking the patient about the flu shot would be considered failure to meet the measure.
A patient is excluded from this measure (will not count negatively against the performance score) if the flu shot was not given due to the following reasons: patient declined, patient has an allergy (or other medical reason), or the flu shot was not available.
This measure should not be reported when patients have a visit outside of the flu season. (In other words, not reporting this measure from April to September will have no effect on the provider’s reporting or performance rate.)
Measure #121 (NQF 1668): Adult Kidney Disease: Laboratory Testing (Lipid Profile)
This is another veteran of the CKD measures group that has stayed a constant.
Definition: Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (stage 3, 4 or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period.
In order to meet this measure, patients must have a fasting lipid profile performed (within the last 12 months from the date of service) and documented in their medical record. The fasting lipid profile can be ordered by another provider as long as the results exist in the reporting provider’s medical record.
Not performing a fasting lipid profile (with no reason given) would be considered failure to meet this measure.
A patient is excluded from this measure if the lipid profile was declined by the patient or other patient reasons.
Measure #122: Adult Kidney Disease: Blood Pressure Management
This measure has also been around for a while, however this year the additional requirement of a proteinuria diagnosis has been removed.
Definition: Percentage of visits for patients aged 18 years and older who have a diagnosis of CKD stage 3, 4 or 5, (not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR ≥ 140/90 mmHg with a documented plan of care.
In order to meet this measure, patients must have a normal blood pressure reading (<140/90 mmHG) or an elevated blood pressure reading (≥ 140/90 mmHg) with a documented plan of care. If multiple blood pressure measurements are taken at a single visit, use the most recent measurement taken at that visit.
CMS defines a documented plan of care as including one or more of the following:
- Recheck blood pressure within 90 days
- Initiate or alter pharmacologic therapy for blood pressure control
- Initiate or alter non-pharmacologic therapy (lifestyle changes) for blood pressure control
- Documented review of patient’s home blood
Not performing a blood pressure check during the visit or not documenting a plan of care for an elevated blood pressure would be considered failure to meet this measure.
Measure #130 (NQF 0419): Documentation of Current Medications in the Medical Record
This is another new CKD measure but it may look familiar to some of you participating in Meaningful Use. This measure is also offered as an MU CQM but the patient sample is tweaked when it is reported via the CKD measures group.
Definition: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency, and route of administration
This one can be quite tricky because not all details about the medications may be available to the provider if he/she didn’t prescribe the medication originally—but as the definition states, providers must use all immediate resources available (or document to the best of their ability with the information at hand).
In order to meet this measure, providers must document in the medical record that they’ve obtained, updated, or reviewed a medication list on the date of the encounter.
Not documenting that a medication list was obtained, updated, or reviewed (with no reason specified) would be considered failure to meet the measure.
A patient is excluded from this measure if the provider deems the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Finally, we made it to the last measure! This is also a new one added this year and one that lives within the MU CQM framework.
Definition: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
This measure is pretty simple to meet. If the patient has been asked about tobacco use and is a non-tobacco user, that’s the end of the story. If the patient is a tobacco user then the provider must document that he/she provided cessation intervention (either in the form of brief counseling [<3 minutes] and/or through pharmacotherapy).
Not screening the patient for tobacco use or not documenting cessation intervention (if the patient was a tobacco user) would be failure to meet the measure.
A patient is excluded from this measure if the provider feels there is a reason not to screen for tobacco (e.g., limited life expectancy or other medical reasons).
What are your next steps?
As you can probably tell, the new measures require additional attention during the patient visit. Take a look at each measure carefully and determine how you should incorporate the requirements into your workflow and, most importantly, your documentation.
For those using the Acumen PQRS registry, we will again offer the CKD measures group for reporting in 2015. More information on registry availability and documentation recommendations will be available to our customers in the near future, so please stay tuned!
Diana Strubler, Senior Product Analyst, Health IT Standards, joined Acumen in 2010 as an EHR trainer then quickly moved into the role of certification and health IT standards subject matter expert. She has successfully led Acumen through three certifications while also guiding our company and customers through the world of Meaningful Use, ICD-10 and PQRS.
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