The Benefits of Changing from Claims-based to Registry Reporting Mechanisms
Success varies widely by mechanism for Medicare Part B eligible professionals making quality reporting submissions to satisfy Physician Quality Reporting System (PQRS) requirements. The Medicare 2014 Reporting Experience (issued April 15, 2016) identifies the claims reporting mechanism as the most commonly used and least reliable mechanism of quality reporting. Citing its unreliability, Medicare announced in the FY 2015 Physician Fee Schedule Final Rule that the claims mechanism will be discontinued at a future date. This puts organizational investments in claims submission methodology at risk. Fortunately, a capable registry can repurpose claims performance codes required for reporting through the claims mechanism. Such repurposing can turn an unsuccessful claims submission into a successful registry submission. It can allow an organization that has engineered and invested in a successful claims submission process to continue using that process to make registry submissions after Medicare stops accepting the claims reporting mechanism.
History and Use of the Claims Reporting Mechanism
Claims submission was the first mechanism authorized by Medicare in 2007 for PQRI reporting and remains the leading reporting mechanism despite a sharp reduction in usage in 2014 compared to 2013, according to CMS.
The explanation for the decline in the claims mechanism requires a basic knowledge of the claims billing process and how it relates to quality reporting. Claims processing timeliness (CPT) code data are components of the health insurance claim form approved by the National Uniform Claim Committee (NUCC). The form documents a payment claim from a medical service provider to a payor, in our case Medicare. Providers using the claims mechanism apply one or more claims performance codes, commonly known as CPTII, G-codes, or qualified data codes (QDC) to a Medicare claims form. Claims performance codes are made to resemble CPT codes and are submitted on the claim form as you would a CPT code. Claims performance codes have no billing significance but can be interpreted by Medicare as performance for a specific measure.
Claims performance codes used for requesting payment can also be used for the claims reporting mechanism for quality reporting. The claims-based mechanism has the advantage of providing high-quality performance based on analysis by the practitioner on measures that lack structured data capable of extraction from an EMR. This opens up a wide variety of measures from which to select for reporting.
In using the claims mechanism, the practitioner applies base claims performance codes to a Medicare Billing 837P (professional) billing form, the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically, or to Form CMS-1500, the standard paper claim form to bill Medicare fee-for-service (FFS) contractors when a paper claim is allowed. This documents performance at an instance of patient care on a particular measure and service date. This is inherently more difficult than it initially appears. The practitioner must consider documenting the care episode as it progresses. This can be a distraction to the patient visit and adds a barrier to the patient-doctor relationship, especially when the care instance involves multiple measures.
Let’s say that I am a primary care provider who is seeing a female patient, age 55, with diabetes and cardiovascular disease. The patient is eligible for five of the measures that I intend to report to Medicare: PQRS Measure 110 (flu shot); PQRS Measure 112 (mammogram); PQRS Measure 1 (HGBA1C); PQRS Measure 6 (antiplatelet therapy); and PQRS Measure 117 (diabetic eye exam). Not only do I need to see the patient, evaluate the chief complaint, assess whether all preventive assessments and treatments are up to date and ensure that diabetes and cardiovascular diseases are adequately monitored and controlled, I also need to remember that I am committed to report the performance status of this patient against five of the measures that I intend to submit to Medicare. To report the measures appropriately I need to be familiar with the 22 QDC (see Table 1) codes that are used to report performance for the five measures and to correctly add the right QDC codes with modifiers to the billing form that accurately reflect my performance.
Table 1. A detail of the QDC codes and modifiers that are applicable to these five measures.
In listing and mentally processing numerous, historically dependent data points in real-time, the potential for error is high. This explains why the claims reporting mechanism, though convenient and meaningful, is also the least reliable PQRS reporting method as illustrated in the chart on below (click image for larger detail).
Flaws in the Claims Reporting Mechanism
The claims reporting mechanism is unforgiving; submissions must be in real time, with no opportunity for revision. There are multiple points of potential failure, including failure to report a measure when applicable, misapplication of the QDC codes to the situation, failure to include the multiple QDC codes that may be required for a single performance assignment, and system problems including the automated removal or scrubbing of codes from billing forms that do not associate to an actual charge.
Medicare lists the following common errors associated with the claims reporting mechanism contributing to the exceptionally high failure rate:
- Failure to identify eligible patients or claims;
- QDC submission errors;
- Failure to submit QDCs for at least 50 percent of eligible instances.
Perhaps the most important reason practitioners and billing companies need to look beyond the claims reporting mechanism is that CMS has stated its intention to discontinue the method at some future point.
Given all these impediments, why has claims-based reporting remained so popular among practitioners? Perhaps they perceive no need for resources beyond the tools already available. They may reason that submission success is merely a matter of adding reporting codes to each claim, thereby making the time investment to learn new methods unnecessary. In addition, the go-it-alone approach has the appearance of being free. Providers may fail to take into account the value of their personal time, the value of their staff time, the opportunity cost of losing time to quality reporting that might be more productively and profitably spent taking care of patient needs, or the cost associated with a failed submission. Billing companies also have a powerful incentive to continue support for the claims mechanism. Many have invested heavily in automated systems that meet the dual purpose of submitting claims for payment as well as claims mechanism PQRS reporting.
Opportunities Using the Registry and GPRO Mechanisms
So will the investments by practices in highly functional billing systems and richly coded records have been for naught? Will practices that have diligently coded their records to make successful quality submissions every year be left with an accumulation of useless data? Not necessarily, because there is a means of providing quality reporting service while greatly increasing the probability of incentive eligibility. The key is redirecting the flow of CPT code data to a capable quality reporting registry using the measures groups, individual measures, or Group Reporting (GPRO) mechanisms, all of which provide higher probability of incentive eligibility compared to the claims mechanism.
Unlike claims submissions using data collected in real time as patients are seen and lacking the ability for correction once submitted, registry submissions are assembled and completed at the end of the service year. Registry submissions can be corrected and resubmitted any time prior to the submission deadline of March 31. A typical registry process, as illustrated by processes at Mingle Health, is as follows:
- Client provides a year-to-date sample of Medicare claims data from which the registry can determine eligible instances for all possible PQRS measures. This is the foundation for calculation of each measure denominator.
- The registry will help the practice choose the measures and submission mechanism for the best expected PQRS submission, taking into account:
a. Output of the measure analysis, above;
b. Knowledge of provider-specific or TIN/practice specific potential incentive or penalty;
c. Specialty and scope of practice;
d. Strengths and weaknesses of the clinical information system or other potential sources of performance data.
- Exchange clinical performance data and calculate performance numerators for each of the denominators.
- Audit and assess the accuracy of the performance numerators and adjust extraction algorithms and translations to improve performance calculations.
- After the end of the year, collect final data sets, calculate numerators and denominators, make any final adjustments to measure selections and extraction algorithms, and assemble a final report to submit to Medicare.
A capable registry can use QDC and claims performance codes as a foundation for an effective registry submission. A complete set of applied QDC codes should contain any claims data set shared with the registry. The registry will first determine eligible instances for the denominator as usual from the claims data set. The registry will then use the QDC codes contained in the claims data set to calculate performance for each eligible instance to populate the numerator. At this point, the registry is able to give the practice opportunity to correct any deficiencies in the analysis. Missing or erroneous performance data can be manually added or updated, overcoming what would have been a critical flaw in the corresponding claims submission.
Embrace the Change
A line in an old Bob Dylan tune goes, “… and the times, they are a changing” – although he may not have had the claims reporting mechanism in mind when writing the lyric. Nevertheless, changes in Medicare policy point to the demise of the claims reporting mechanism. Practices and billing companies reliant on the claims mechanism can positively embrace change by repurposing claims data into registration submissions and greatly increase the odds for quality reporting submission success and incentive eligibility.
Mingle Health is proud to participate in the MVP program of the Healthcare Billing and Management Association (HBMA). Are you a member? Learn more about the partnership and discounts on PQRS Solutions by Mingle Health available to you and your clients here.
Not sure if your practice should participate in PQRS? You should know that there’s money on the line if you don’t submit. Download our free guide to learn more.