Auditing PQRS & MU_NAMAS_120914 2

© 2014 Zetter HealthCare
Auditing PQRS & Meaningful Use
To Maintain Compliance
Presented by
David J. Zetter,
PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP
2014 NAMAS Conference
Asheville, NC
December 9, 2014

Standard Disclaimer
 This material is designed to offer basic information.
The information presented is based on the
experience, training and interpretation of the
author of governmental programs. Although the
information has been carefully researched and
reviewed for accuracy and completeness at the
time of presentation, neither the author, nor
NAMAS or DoctorsManagement accept any
responsibility or liability with regard to errors,
omissions, misuse or misinterpretation.
2

Learning Objectives
 Gain better understanding of PQRS
Responsibilities
 Gain better understanding of Meaningful
Use Responsibilities
 How to be Proactive
 How to Prepare and What you will Need for
an Audit
 Be NOT afraid…
3

PQRS
 No alignment between MU and PQRS
 Need to know PQRS to audit it
 Beginning in 2015, the program will begin
applying a payment adjustment to eligible
professionals who do not satisfactorily
report data on quality measures for covered
professional services in 2013
 2014 is the last year to receive a .5% incentive
for reporting
4

PQRS
 Eligible Providers
 Doctor of Medicine
 Doctor of Osteopathy
 Doctor of Podiatric
Medicine
 Doctor of Optometry
 Doctor of Oral Surgery
 Doctor of Dental
Medicine
 Doctor of Chiropractic
5
 Physician Assistant
 Nurse Practitioner
 Clinical Nurse Specialist
 Certified Registered
Nurse Anesthetist
 Certified Nurse Midwife
 Clinical Social Worker
 Clinical Psychologist
 Registered Dietician

PQRS
 Nutritional Professional
 Audiologists
 Physical Therapist
 Occupational Therapist
 Qualified Speech – Language Therapist
6

PQRS Eligibilty
7

PQRS Reporting
 Medicare Part B FFS or Railroad Medicare
 Claims-based (2013 and prior)
 Registry
 Qualified Electronic Health Record (EHR) or
EHR product
 Qualified Clinical Data Registry (QCDR)
 Group Practice Reporting Option (GPRO)
8

PQRS Reporting
 Avoiding 2.0% payment adjustment in 2016
 Physicians working for more than one
organization need to meet the reporting criteria
for each tax identification number (TIN) under
which (s)he works during the 2014 PQRS program
year to avoid the 2016 PQRS payment adjustment
for each TIN.
9

PQRS Reporting
 Measures Groups: entry of 20 unique patient charts
(11 of which have to be Medicare Part B FFS
patients)
 Individual Measures Reporting: choose at least 9
individual measures from at least 3 National Quality
Strategy (NQS) domains and report at least 50% of
the applicable Medicare patient visits
10

PQRS Reporting
 Payment Adjustment Avoidance: allows the
reporting of at least 3 measures and 50% of eligible
patient visits in order to avoid the 2016 -2% payment
adjustment – (but not gain the incentive) for 2014
PQRS reporting
 GPRO (Group Practice Reporting Option): groups of
2 or more operating under a single TIN and the same
reporting requirements as Individual Measures
Reporting, but applied to a group practice
11

PQRS Workflow
12

Mock Audits
 Record of documentation
 Measure groups
 Individual measures
 Data mine or reports
 Data entry
 Proof of submission
 Live results
 CMS Feedback
 Guarantees
13

PQRS Audits
 AMA calls to bench PQRS audits
 Inadequate preparation and response time
 Conflicting requirements not under physicians’
control
 Reporting period challenges
 PV Modifier is coming…
14

Meaningful Use Audits
 Take the money and run?
 Proof is in the pudding
 Figliozzi & Company
 Electronic letter from CMS address
 Possible on-site review
 Demonstration of EHR
15

 650 & 10,000
 4.9 & 21.9
 Success!
 Audits are here to stay
16

 Checklist
 Point person
 MU registration
 EH’s – final cost report
 Medicaid volume calculation
 Proof of ownership
 Certification ID
17

 Checklist (cont.)
 Proof of adoption, implementation or upgrade
 Allowable costs for purchase of CEHRT
 Medicare share calculation
 Attestation submission
 Other administrative evidence
18

 When does the process really start?
 Mock audits
 Is it too late?
 Initial review process
 Additional requests for
information/documentation
 Secure communications process
19

 The Keys
 CMS -> Medicare and dually eligible
Medicaid/Medicare providers
 States -> Medicaid providers
 Numerous pre-payment edit checks built into
the Programs' systems
 Detect inaccuracies in eligibility, reporting, and
payment.
20

 The Keys
 Great documentation
 6 year retention schedule
 Reports MUST match exactly
 Snapshots vs rolling totals
 Report must match organization & provider
 NPI, Provider or Organization name
21

 Ex: Stage 2, summary of patient care records
for more than 50% of transitions of care or
referrals. Denominator is the total number
of transitions and referrals that occurred
during reporting period, while numerator is
actual number of case summaries sent
electronically to other facilities or clinicians.
The numerator and denominator translate
into a percentage the CMS is looking to
confirm
22

 The Keys
 Yes or No answers
 Don’t fret, just plan ahead
 Appeals process (one chance)
23

 Ex: Requires providers to prove the ability to
share clinical data electronically with
another care provider that has a different
EHR system -- to prove the organization's
interoperability capabilities.
24

 Possible Documentation (preparation)
 Copies of EHR purchase invoices
 Licensing agreement
 List of offices and use of CEHRT
 Proof that 50% or more of patient encounters seen
using CEHRT
 Maintain other charts?
 Proof that 80% of patients seen in period were
maintained in CEHRT
25

 Possible Documentation
 Copies of EHR reports w/ evidence produced for
named EP, EH or CAH
 Reports with patient lists included in numerators
and denominators
 Step-by-step screenshots of EHR system with
measures included
 Copy of security risk analysis for each year being
audited
26

 Copy of security policies derived from risk
analysis
 Drug-Drug/Drug-Allergy Interaction Checks and
Clinical Decision Support
 Electronic exchange of clinical information
 Proof of any exclusion
27

 Immunization registries data submission
 Reportable lab results to public health agencies
 Syndromic surveillance data submission
28

5 STEPS OF AUDIT SURVIVAL
 Resist the PURGE
 Look back
 Space constraints
 Audit logs & polling data
 Attestation evidence
 Binders vs. PDF
29

 Plan ahead
 Produce the data
 Space constraints
 Audit logs & polling data
 Attestation evidence
 Binders vs. PDF
30

 The Unexpected
 Deep dive into risk assessment
 Proof of focus – EHR and modules
 Audit, report & reaction w/I attestation period
 Don’t trip
31

 Upgrades? Think about it.
 Proof of CEHRT the entire time
 Which reports to use?
 Act Fast
 Quick response to audit request
 Request an extension
 Work with the auditor
32

RECAP
 Reviewed of PQRS Responsibilities
 Review of Meaningful Use Responsibilities
 Ready to be Proactive
 Preparation & Tools
 Be NOT afraid…
33

© 2014 Zetter HealthCare 34
For Follow-up Questions
Contact:
David J. Zetter,
PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP
717.691.7100
Email: djzetter@zetter.com
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