Auditing PQRS & MU_NAMAS_120914 2

Auditing PQRS & Meaningful Use To Maintain Compliance

Presented by

David J. Zetter, PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP

2014 NAMAS ConferenceAsheville, 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.

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…

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

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

Eligible Providers Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered

Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician

Eligible Providers Nutritional Professional Audiologists Physical Therapist Occupational Therapist Qualified Speech – Language Therapist

PQRS Eligibilty

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)

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.

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

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

PQRS Workflow

Mock Audits

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

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…

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

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

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

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

When does the process really start? Mock audits Is it too late? Initial review process Additional requests for

information/documentation Secure communications process

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.

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

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

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

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.

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

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

Possible Documentation (preparation) 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

Possible Documentation (preparation) Immunization registries data submission Reportable lab results to public health agencies Syndromic surveillance data submission

5 STEPS OF AUDIT SURVIVAL

Resist the PURGE Look back Space constraints

Audit logs & polling data Attestation evidence

Binders vs. PDF

Plan ahead Produce the data Space constraints

Audit logs & polling data Attestation evidence

Binders vs. PDF

The Unexpected Deep dive into risk assessment

Proof of focus – EHR and modules Audit, report & reaction w/I attestation period

Don’t trip

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

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

For Follow-up QuestionsContact:

David J. Zetter, PHR, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, CMUP

717.691.7100

Email: djzetter@zetter.com

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Auditing PQRS & MU_NAMAS_120914 2

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