Demystifying PQRS in Physical Therapy Medicare Requirements

What to Expect Out of a Physical Therapy EMR or Practice Management System

Now that we are 2 months into 2013, the big rush to PQRS adoption for Clinicient users is largely behind us.  Still, I continue to hear a lot of questions about PQRS in discussion groups and from therapists evaluating EMR and Practice Management systems.  Here are some of my thoughts.

What is PQRS?

The Physician Quality Reporting System (PQRS) is a way for CMS to encourage (and soon to require) healthcare providers to use screening and assessment tools during the evaluation and re-evaluation of a patient that might identify risk factors that could impact the course of treatment.  The goal was to improve the quality of care through better information gathering upfront.

CMS tracks successful adherence by having the therapist report each time one of the quality measures is performed.  If a provider reports enough quality measures over the course of a calendar year, then they receive a 0.5% bonus for their efforts.  Beginning in 2013, the effort to report also helps you avoid a 1.5% penalty in 2015 for not participating. Yes, making an effort to participate in 2013 is the way CMS will know whether to penalize you in 2015.

Who can participate?

Any Part B submitters may participate.  This has caused confusion because all PT, OT and qualified SLPs are eligible, but as CMS puts it, only those billing at the individual NPI level may participate.

Does it matter what reporting method I use?

This is probably the most intriguing discussion I’ve heard.  CMS wanted to make sure all qualified healthcare providers could participate so they thought of several ways to submit the info to CMS.  Of the four methods offered, outpatient rehab has the choice of two: Registry and Claims–based reporting.

The Registry method allows a software platform to submit the PQRS directly to CMS on a periodic basis. The Claims-based method allows a software platform to submit the data to CMS on each claim that corresponds to a qualified visit. Each has a different threshold for meeting reporting requirements, with the Registry being a little higher in aggregate reporting requirements than Claims-based.

Stand-alone EMR systems would lean toward using the Registry based process since they can control submission quality that way.  Using Claims-based, for them, means sending it to a partner billing system and losing visibility and control over successful reporting.

An integrated system which provides both EMR and billing from one platform would likely choose Claims-based reporting since that is a simple effective way to control the successful submission.  It also allows you to review the claim before the submission, which cannot be done using the Registry-based method.  This can be a benefit since you cannot resubmit the PQRS.

Regardless, of the reporting method, the important work is being done at the point of documentation.

What should I expect from my software platform?

What really matters is how the therapist is helped to build a PQRS compliant note.  PQRS uses the age of the patient, the diagnosis code and the type of evaluative CPT code recorded in the visit to determine which quality measures are eligible for the patient and how many must be completed to qualify.  PQRS also has guidelines as to what assessment or measure should be documented to support completion of a quality measure.

Your EMR should:

1. Prompt you with a list of measures that qualify
2. Offer clear guidance to the therapist of what CMS considers completion of the measure
3. Tie those measures to notes that support the work
4. Alert the therapist at sign-off if there aren’t enough measures recorded to qualify
5. Alert management any time a visit doesn’t meet the threshold to qualify
6. Track therapist completion throughout the year.
7. Package the codes up and submit them to CMS.

Does this have anything to do with Functional Limitation Reporting or CBOR?

Finally, I’ve heard considerable confusion about relationship of PQRS, the new functional limitation reporting and g-codes. PQRS and Functional Limitation Reporting have nothing to do with each other. They share only one thing, they both use G-Codes to report information to CMS. G-codes are just a set of 5 digit codes that can be submitted like CPT codes but CMS uses them to cover additional requirements. Most people are familiar with G0283 being CMS’ own code for E-stim, but now they’ve branched out and used the series for both PQRS and Functional Limitations.

One other key difference is that PQRS is only for Part B and optional although it has a monetary impact.  Functional Limitation will be required, result in denials and all outpatient rehab providers need to prepare for it regardless of whether you submit institutional or professional claims. More on Functional Limitation later…

For now, I hope this helps outline some of the more critical aspects of PQRS.

If you want more information, please comment below.  I’d be happy to go deeper.

Additional Resources:

Video: PQRS submission with Clinicient is a free with our service, and has been a benefit our customers have been enjoying, as well as the bonus revenue, since the “PQRI” program began years ago. To see how easy it is, watch this 2 minute video.