PQRS for LCSWs

1. PQRS for LCSWs Laura W. Groshong, LICSW Director, Government Relations April 26, 2014, 12-1 pm EDT

2. Disclaimer CSWA has done its best to collect accurate information on the information provided in this webinar. There will undoubtedly be changes to the Physician Quality Reporting System going forward, which will modify the information presented here in the future. CSWA will provide additional information as it becomes available.

3. Get Ready for a Wild Ride • Learning about the new concepts which will anchor mental health and health care reimbursement will revise many concepts we have worked by for decades

4. Areas to be Covered • Business Plans for LCSWs as Context • Physician Quality Record Systems (PQRS) • Changes to Health Care

5. The End of the World as We Know It? • Therapists considering dropping out of solo practice to join groups: “The increasing complexity of running a practice has meant more therapists are taking down their shingles or forming groups with other therapists to share the burden, executives at national mental health groups say. Others have joined large medical groups that offer mental health services as part of comprehensive care.” (NPR.org, 10/24/13) http://www.npr.org/blogs/health/2013/10/24/234737302/therapists-explore-dropping-solo-practices-to-join-groups?goback=%2Egde_4267431_member_5799134027814297601#%21

6. Biggest Health Care Changes • Massive changes in health care delivery • ‘Out of network’ reimbursement likely to end in next 5 years; instead in-network, new risk sharing systems (ACOs, health homes) or private pay • In 5-10 years LCSWs working with third-party payers are likely to be required to do record keeping through interoperable electronic systems

7. Impact of Affordable Care Act and Mental Health Parity Act • “Integrated care” in ACA likely to lead to LCSWs working in virtual clinic-like organizations in capitated systems • Cost of hiring billers and/or buying EHRs may make joining groups more appealing to cover administrative costs • Parity will make mental health more integrated into medical care, but up to LCSWs to explain what mental health treatment needed • More marketing necessary for clinicians who want to remain in private pay system

8. From FFS to P4P –Underlying Goal • Medicare goal to end fee-for-service (FFS) payment, go to pay for performance (P4P) – likely to be adopted by private insurers • Less treatment and better outcomes lead to higher reimbursement rates • Role of insurers unclear as ACOs/health homes roll out • For now, LCSWs need to learn how to explain mental health treatment needs, esp. long-term

9. LCSWs and Overall Changes to Health Care Reimbursement We feel that we are being locked into systems which are at odds with being in control of our own practices

10. Unlock the Changes:New Business Plans for LCSWs • Business plan good base for all new health service delivery changes • Courses offered by SAMHSA: Strategic Business Planning; Third-party Billing and Compliance; Eligibility and Enrollment; Third-party Contract Negotiation; and Meaningful Use of Healthcare Technology (not for clinicians at this time) • Go to http://bhbusiness.org/Special-pages/Home.aspx to register!

11. New Business Plans for LCSWs (cont.) • Another option for learning to navigate new business models: • Behavioral Health First Aid at http://bhbusiness.org/Special-pages/Home.aspx

12. Consultants on Clinical Business Practices • Rob Reinhardt, LPC – EHRs – www.tameyourpractice.com • Steve Walfish, PsyD – business practices - Financial Success in Mental Health Practice:  Essential Tools and Strategies for Practitioners (2008); Earning a Living Outside of Managed Mental Health Care: 50 Ways to Expand Your Practice (2010) - http://thepracticeinstitute.com/the-tpi-team

13. On to Physician Quality Reporting System (PQRS) Climbing the PQRS mountains…..

14. PQRS is Part of Medicare • LCSWs are automatically part of the Medicare provider network HOWEVER • To become eligible for reimbursement, LCSWs must “opt in” through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf

15. LCSWs Can Opt Out of Medicare • If an LCSW decides not to become part of the Medicare provider network, the LCSW must do two things: • The LCSW must send an “Opt Out Form” to the Medicare Administrative Center (MAC) that oversees the LCSW’s region (see CSWA website) • The LCSW must send an exact copy of the “Medicare Private Contract” that the LCSW will use with any Medicare beneficiary to guarantee that no claims will be submitted by the LCSW or the beneficiary for the LCSW’s services

16. LCSWs Can Opt Out of Medicare (cont.) • No templates of Opt Out Form or Private Medicare Contract provided by CMS • Editable templates of the Opt Out Form and the Private Medicare Contract can be found in the Members Only Section of the CSWA website: (www.clinicalsocialworkassociation.org) • Go to CSWA Templates to download • Can join CSWA on website and access Templates

17. Physician Quality Reporting System (PQRS) • Started as Physician Quality Reporting Initiative in 2007 • Changed to PQRS in 2010 • PQRS which will provide ‘incentive’ (bonus) for data submitted in 2013 and 2014 two years later, i.e., 2015 and 2016 of .5% • PQRS will also provide ‘payment adjustment’ (penalties) if reporting threshold is not met

18. CMS Guidelines for PQRS • “We urge solo practitioners and physicians in smaller groups to participate in the PQRS now, because we will propose in future rulemaking to apply the value-based payment modifier to smaller groups and solo practitioners. (CMS, 2012)” http://www.ama-assn.org/amednews/2012/11/12/gvsa1112.htm • Translation: clinicians do not use PQRS measures by 2015 will see increasing penalties in payments

19. CMS Contact Information on PQRS • Telephone: 866-288-8912, x3 • Email: qnetsupport@sdps.org

20. ‘Eligible’ Mental Health Professionals for PQRS • 1. Medicare physicians • Doctor of Medicine • Doctor of Osteopathy • Doctor of Podiatric Medicine • Doctor of Optometry • Doctor of Oral Surgery • Doctor of Dental Medicine • Doctor of Chiropractic • 2. Practitioners • Physician Assistant • Nurse Practitioner • Clinical Nurse Specialist • Certified Registered Nurse • Anesthetist (and Anesthesiologist Assistant) • Certified Nurse Midwife • Clinical Social Worker • Clinical Psychologist • Registered Dietician • Nutrition Professional • Audiologists • 3. Therapists • Physical Therapist • Occupational Therapist • Qualified Speech-Language Therapist

21. “Eligibility” for PQRS • “Eligibility” actually misnomer – requirement for all “eligible” groups or will have reimbursements penalized • Will have “eligibility” for bonus in 2015 and 2016 – in 2017 will be only penalty (1.5 in 2015 for 2013 data; 2% for 2016 for 2014 data) • Starting in 2017 will only be penalties of 2% per year if PQRS data not submitted

22. Reason for PQRS • PQRS designed to reduce costs of most expensive disorders, e.g., diabetes, congestive heart failure, major depressive disorder, chemical dependency, to provide assessments and preventive care HOWEVER: • PQRS not lined up with DSM/ICD codes – must be creative to implement as mental health clinicians (see below)

23. PQRS and Mental Health • PQRS is not easily applied to chronic disorders, including mental health, more for assessment • PQRS concept started in Medicare but likely be used by all insurers/health care delivery systems within next 5 years • Most important general document for finding PQRS data that applies to LCSWs: 2013 Physician Quality Reporting System (PQRS) Claims/Registry Measure Specifications Manual (637 pp.)

24. Mental Health Diagnoses and PQRS • Remember: DSM/ICD Diagnoses not linked to PQRS Measures! • Mainly assessment and prevention measures for LCSW patients, i.e., depression assessment, suicide risk assessment, smoking assessment, substance use assessment, etc., regardless of actual ICD-9 diagnoses • List of codes for LCSWs to follow

25. PQRS Effect on Medicare Payments • PQRS will affect Medicare reimbursement rates with bonus (.5% in 2015 and 2016) or penalty (1.5% in 2015, 2% in 2016) for 2015 and 2016 claims • PQRS bonuses end in 2016, then only penalties • Must have three QDCs for 50% of Medicare patients to be eligible for PQRS bonus in 2016 (from 2014 data submitted) and be MAV compliant

26. Six Areas of PQRS Usage • Denominator and Numerator – information that must be included to be PQRS compliant • Measures – 350 areas that are ‘measured’ by Medicare as Denominator and Numerator (9 for LCSWs) • Quality Data Codes (QDCs) – codes entered on CMS-1500 representing the use of a measure

27. Six Areas of PQRS Usage cont. • Domains – 11 areas that assess the overall reason for including a given measure • Medicare-Applicability Validation (MAV) – validates that there are less than 9 measures available to the provider (applies to LCSWs) and leads to • Clusters – 27 ‘clusters’ of CPT codes that should be included if one is used

28. PQRS ‘Denominator’ • Denominator= patient group/encounter/dx, i.e., CPT and ICD Codes, treatment location, i.e., what LCSWs already submit • ICD-9 Codes for mental health disorders, especially major depressive disorder, AND • CPT Codes for LCSWs: 90791, 90832, 90834, 90837, 90839, 90845, 90846, 90847, 90849, 90853

29. PQRS ‘Numerator’ • Numerator = treatment according to Quality Data Codes (QDCs) using new G-codes and F-codes for measures • Can be submitted if new ‘episode’, i.e., patient not treated for diagnosed condition for at least 4 months • Go to Clinical Social Work Association link for complete list of connected G-codes and F-codes: http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20PQRS%20Options%20for%20LCSWs%20(revised)%20-%209-24-13%20(2).pdf

30. PQRS Domains • Six general areas which are used to describe underlying goal of measure: • Efficiency and Cost Reduction (ECR) • Effective Clinical Care (ECC) • Community/Population Health (CPH) • Patient Safety (PS) • Communication and Care Coordination (CCC) • Person/Caregiver-Centered Outcomes (PCCO) • Use as many as possible!

31. PQRS Measures Purpose • PQRS Measures created to ‘measure’ most expensive diagnostic categories and contain costs • Measures reported on CMS-1500 forms as Quality Data Codes once a year for most Measures used by LCSWs • Exception: Measure #130, Documentation of All Medication, must be submitted for each session

32. List of PQRS Measures • Go to http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs • Then go to “Educational Resources” (left side) • Then go to http://www.cms.gov/2014_PQRS_MeasuresList_12132013.pdf • Change every year!

33. PQRS Quality Data Codes • PQRS Measures are like general categories, i.e., depression • PQRS Quality Data Codes (QDCs) are like specific categories, i.e., a new specific code • Again, QDCs get reported on CMS-1500!

34. PQRS Clusters (MAV) • Medicare-Applicability Validation (MAV) • Automatically used when less than 9 measures available, as with LCSWs • 27 ‘Clusters’ to make sure all possible measures reported on

35. PQRS Clusters (MAV) cont. • Based on CPT codes, e.g., 90791, 90834, 90837 • If any CPT code used by LCSW in a cluster, all other measures must be reported if in scope of practice • Three clusters for LCSWs: #1 (General Preventive Care); #11 (Depression); #22 (Substance Use Disorders)

36. PQRS Clusters (MAV) cont. • Cluster 1 (General Preventive Care) = Measures #130 (Medications), #226 (Tobacco Use) • Cluster 11 (Depression) = Measures #106 (Depression Screening), #107 (Suicide Assessment), #134 (Follow Up Plan), #226 (Tobacco Use) • Cluster 22 (Substance Use Disorders) = Measures #130 (Medications), #226 (Tobacco Use), #247 (Treatment for Alcohol Dependence), #248 (Treatment for Depression with Substance Dependence)

37. Measures Used by LCSWs • The next 9 slides summarize the QDC, Domain, Cluster, and reporting schedule for each measure used by LCSWs

38. PQRS Measures =Major Depression Evaluation • #106 Adult Major Depressive Disorder Comprehensive Depression Evaluation: Diagnosis and Severity • Domain: ECC • QDC: G8930 (for assessment of depression severity at the initial evaluation) • Clusters: #11 • Report: Once a year or every new episode (must be four months since end of last treatment for MDD)

39. PQRS Measures = Suicide Risk • #107 (Suicide Risk Assessment) • Domain: ECC • QDC: G8932 for suicide risk assessed at the initial evaluation; 3092F for major depressive disorder in remission; or G8933 for suicide risk not assessed at the initial evaluation • Clusters: #11 • Report: Once a year or every new episode (must be four months since end of last treatment)

40. PQRs Measures - Medications • #130 (Medication Documentation) • Domain: PS • QDC: G8427: Current Medications Documented; G8430: Current Medications not Documented • Clusters: #1 and #22 • Report: EVERY SESSION

41. PQRS Measures – Depression Treatment Plan • #134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan • Domain: CPH • QDC: G8431: Positive screen, documented follow-up plan; G8510: Negative screen, follow-up not required; G8433: Screening not done, patient not eligible • Clusters: #11 • Report: Once a year or every new episode (must be four months since end of last treatment)

42. PQRS Measures – Unhealthy Alcohol Use • #173 Preventive Care and Screening: Unhealthy Alcohol Use • Domain: CPH • QDC: 3016F: Patient screened for unhealthy alcohol use using a systematic screening method 3016F-1P: unhealthy alcohol use screening not performed, • Clusters: #22 • Report: Once a year or every new episode (must be four months since end of last treatment)

43. PQRS Measures – Elder Maltreatment • #181 Elder Maltreatment Screen and Follow-Up Plan • Domain: PS • QDC: G8733: Documentation of a positive elder maltreatment screen and follow-up plan G8734: Elder maltreatment screen documented as negative • Clusters: None • Report: Once a year

44. PQRS Measures – Tobacco Use • #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention • Domain: CPH • QDC: 4004F: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user 1036F: Current tobacco non-user; patient screened for tobacco use and Identified as a non-user of tobacco • Clusters: #1, #22 • Report: Once a year

45. PQRS Measures – Alcohol Dependence • #247 Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence • Domain: ECC • QDC: 4320F: assessment of psychosocial and pharmacologic treatment options for alcohol dependence • Clusters: #22 • Report: Once a year

46. PQRS Measures – Depression and Substance Dependence • #248 Substance Use Disorders: Screening for Depression among Patients with Substance Abuse or Dependence • Domain: ECC • QDC: 1220F: screening for depression among patients with substance abuse or dependence 1220F-1P: screening for depression among patients with substance abuse or dependence not completed for medical reasons, documentation required. • Clusters: #22 • Report: Once a year

47. Two Ways to Submit PQRS • Claims reporting – through CMS-1500 – most practical way for private practitioners • Must be submitted once a quarter for most QDCs • Easiest way to submit QDCs every time bill • Registries – will collate PQRS information – to use must have 80% of all Medicare cases with 3 measures reported OR a 20 patient sample

48. PQRS Claims Reporting – CMS-1500 Details • Put G-codes into 24D - right under CPT codes • Put in ‘pointer’ for each DSM/ICD diagnosis in 24E • Be sure to add $.01 in 24F for each G-code • For more information on CMS-1500 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf • For sample new CMS-1500 form (02/12), go to: http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20-%20CMS-1500%20Changes%20-%203-14.pdf

49. Reactions to Past 20 Slides

50. PQRS and EHRs • PQRS will be automatically loaded into approved programs • LCSWs not required to use EHRs by 2015, as physicians are, but may be required after 2015 to avoid payment penalties or to even receive third-party reimbursement • No incentives or meaningful use requirements at this time • Important to become ‘literate’ in EHR systems for future