CMS Quality Incentive Programs

Physician Quality Reporting System (PQRS) and
Electronic Prescribing (eRx) Incentive Program

Updated: 1/9/2012

Overview

Two CMS (Centers for Medicare and Medicaid Services) quality improvement programs continuing in 2012 provide the opportunity for incentives for participation: the Physician Quality Reporting System (PQRS) (incentive: up to 0.5% of total Medicare allowed charges) and the Electronic Prescribing Incentive Program (incentive: up to 1% of total Medicare allowed charges). PQRS, first established in 2006, offers incentives to Medicare providers who report on quality performance measures and assesses penalties to those providers who fail to report. The e-prescribing program offers incentives to clinicians who use a qualified e-prescribing system, as well as penalties for those not reporting use of a system. Participation in both programs involves the reporting of designated administrative codes on billing claims. Physicians who successfully participate in these programs in 2012 will be listed on the new public Physician Compare Website. Actual performance on the measures, versus successful reporting, is expected to be reported on the website starting in 2013.

Detailed specifications for these programs are on the CMS PQRS Page and the CMS E-Prescribing Incentive Page. Check this page (psych.org/PQRS) periodically for updates and more information on these programs.

Physician Quality Reporting System (PQRS)

The PQRS program continues in 2012 with 210 measures for claims-based reporting. More information is available on the CMS website about other methods of reporting (registries, measures groups, group practice, and electronic health records) which may be an option in certain circumstances. Several measures are pertinent to psychiatrists, including four measures on major depressive disorder, three measures on screening for unhealthy substance use, one measure on tobacco use screening and cessation counseling, and one measure on medication reconciliation. In addition, a dementia measure set is available for use as a group, meaning if used, all 9 measures within the set must be reported. Physicians who report on at least 3 measures applicable to their practice between January 1 and December 31, 2012 will receive a bonus of up to 0.5% of their total Medicare allowed charges for that period. If less than 3 measures apply to the eligible psychiatrist, 1-2 measures must be reported in at least 50% of encounters where a measure applies. The incentive is awarded for reporting on applicable measures, however, measures with a 0% performance rate will not be counted. Starting in 2015, there will be a 1.5% payment adjustment (financial penalty) for physicians who do not participate; the tracking for those who receive the 2015 penalty will begin in 2013. Preregistration is not a requirement to participate in the 2012 PQRS: submission of quality data codes for the 2012 PQRS quality measures to CMS through claims, a qualified registry or electronic health record (EHR) will indicate intent to participate in the 2012 program. To align the PQRS with the Medicare EHR Incentive Program, all clinical quality measures available for reporting under the Medicare EHR Incentive Program will be included in the 2012 PQRS. This will allow physicians to report data on quality measures under the EHR-based reporting option.

PQRS 2012 Measures

The following measures may be most pertinent to psychiatry, but others may apply to individual practices. The complete list of PQRS measures and specifications for 2012 can be found here.

Measure #9
Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD

Description: Percentage of patients aged 18 years and older diagnosed with new episode of major depressive disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase.

Measure #46
Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility

Description: Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented

Measure #106
Major Depressive Disorder (MDD): Diagnostic Evaluation

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified during the measurement period

Measure #107
Major Depressive Disorder (MDD): Suicide Risk Assessment

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who had a suicide risk assessment completed at each visit during the measurement period

Measure #124
Health Information Technology (HIT) - Adoption/Use of Electronic Health Records (EHR)

Description: Documents whether provider has adopted and is using health information technology. To report this measure, the eligible professional must have adopted and be using a certified, Physician Quality Reporting System qualified or other acceptable EHR system

Measure #134
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Description: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented

Measure #173
Preventive Care and Screening: Unhealthy Alcohol Use – Screening

Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months

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

Description: 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

Measure #247
Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence

Description: Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12-month reporting period

Measure #248
Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence

Description: Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period

Mentioned previously, the Dementia Measure Set has been added to this year’s PQRS performance measures. Please note this measure group must be reported on as a whole. To report on this group, CMS’s requirements for “measures groups” reporting must be followed. Learn more about those requirements here.

Dementia Measures Group
Measure #280
Dementia: Staging of Dementia

Description: Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period

Measure #281
Dementia: Cognitive Assessment

Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period

Measure #282
Dementia: Functional Status Assessment

Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of patient’s functional status is performed and the results reviewed at least once within a 12 month period

Measure #283
Dementia: Neuropsychiatric Symptom Assessment

Description: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of patient’s neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

Measure #284
Dementia: Management of Neuropsychiatric Symptoms

Description: Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period

Measure #285
Dementia: Screening for Depressive Symptoms

Description: Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Measure #286
Dementia: Counseling Regarding Safety Concerns

Description: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

Measure #287
Dementia: Counseling Regarding Risks of Driving

Description: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and driving alternatives within a 12 month period

Measure #288
Dementia: Caregiver Education and Support

Description: Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period

Other Measures

A measure such as Advance Care Plan (#47) may also apply for psychiatrists who routinely use certain general medical CPT evaluation and management codes (e.g. 99201). Additionally applicable to psychiatrists, but only available for EHR-based reporting, is Drugs to be Avoided in the Elderly (#238).

Electronic Prescribing Incentive Program (eRx Incentive)

The Electronic Prescribing Incentive Program continues in 2012. Clinicians who meet the requirements for being a successful e-prescriber will be eligible for an additional 1% bonus in 2012. Being a successful e-prescriber means reporting 25 instances of electronic prescribing using a qualified system during the course of the calendar year. Physicians who do not demonstrate use of electronic prescribing 10 times in the first 6 months of 2012 will be subject to a 1.5% payment reduction in 2013, and a reduction in 2014 of 2% (see this page for more information on this issue).

Adoption/Use of Medication Electronic Prescribing Measure

Decription: Documents whether the eligible professional has adopted a “qualified” eRx system and the extent of use in care settings defined in the specification’s denominator (see measure specifications for more detail).

The Electronic Prescribing Incentive Program Measure includes the psychiatric pharmacologic management procedure code 90862. A psychiatrist using a qualified electronic prescribing system is eligible for the full bonus (1% of all Medicare Part B charges) if s/he reports electronic prescriptions associated with at least 25 unique patient visits over the course of the year, and at least 10% of his/her total estimated Medicare Part B charges derive from procedure codes that are included in the measure (e.g. 90862, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 99201, etc., see the measure specifications for the full list). An administrative code, G8553, is reported on the claim for an encounter where at least one prescription was generated and transmitted electronically. A physician cannot participate in both the Electronic Prescribing Program and the Electronic Health Record (EHR) Incentive Program.

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