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The problem with claims submission for PQRS

If you are currently using or considering claims to participate in the CMS Physician Quality Reporting System (PQRS), consider one of the other excellent participation options: Registry or Data-Submission Vendor, or directly from your EHR.

Here’s why.

Claims submission is a bit of a technological step backwards. When we are trying to encourage the adoption and use of electronic health records, why use a paper method to submit quality data. Even if you have paper charts, you can still use a Registry to submit quality data.

It is distracting. Your ambulatory practice is a volume-based operation. The more efficiently and effectively you work, the better your practice performs for you. Claims submission is a distraction from your patient, a distraction from other diseases, symptoms, and interventions that should have your attention, and it’s a distraction from appropriate E&M coding and documentation with which doctors still typically struggle.

As a model for quality improvement, claims submission is neither scalable nor sustainable. Most of us need to report three measures to qualify under PQRS. Those three measures can be under the same topic, such as diabetes or can each represent a different topic like diabetes, heart failure and preventive care. Attention to three topics, at most, generates an effective submission. Most of us care for dozens if not hundreds of different diagnoses, complaints, and risk factors. I can’t see how the claims process scales as the quality reporting process evolves and we struggle to be accountable across dozens or hundreds of topics.

Claims submission is failure prone. Quality codes have to be submitted with the primary claim. No claim can be amended in the future to include a forgotten quality code. Any lapse in attention to the process can render the efforts of the rest of the year moot. In addition, there are abundant examples of codes that are entered erroneously, inappropriately scrubbed from the claim, or otherwise failed to transmit.

The table, below, shows in 2011, that physicians reporting via a Registry had an 88% success rate compared to 77% rate for claims for individual measures.


Source: CMS 2011 Reporting Experience 2008-2012

A Couple of Possible Advantages to Claims

PQRS can serve as a valuable reminder, when you are seeing a patient, to attend to a specific set of desirable interventions. A claims submission is something that anyone can do without any additional up-front investment. And it is the only way for a specialty with fewer than three applicable measures to participate in PQRS.

Disadvantages of Claims outweigh the advantages

There are better ways to build reminders into the system that are more scalable and sustainable. Any cost savings on the up-front investment are likely to be offset by reductions in efficiency and increased doctor and staff-time to appropriately code every applicable visit. The only enduring reason, in my opinion, for anyone to remain firmly in the claims submission world is the absence of three applicable measures for your specialty. With the new Group Practice Reporting Options (GRPO) Registry submission process in 2013–even that reason goes way. Read more about GRPO here.

Registry, Data-Submission Vendor and EHR Direct are far better options.

From: 2010 Reporting Experience Including Trends (2007-2011) Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program (CMS 2012)

All-in-all, it’s a good time to start participating in PQRS and to evolve beyond the claims submission process. There is a lot of good and productive work you can do whether you are still using a paper chart or have migrated to EHR. You can have an effective program if you are alone or in a large group.

Look for my posts on:

• Three good reasons to participate in PQRS

• How to earn the 2012 eRx Incentive Payment

• How to avoid the 2014 eRx Incentive Payment

• How to Earn the 2012 PQRS Incentive Payment

• How to avoid the 2015 PQRS Incentive Adjustments

• Combined reporting for eRx and PQRS

• Combined reporting for PQRS and Meaningful Use

• How to build a PQRS submission from a paper record without interrupting patient care


While you’re at it, watch for my postings on other topics and don’t forget other CMS initiatives like

• eRx

• Meaningful Use

• the Shared Savings Program

• the EHR incentive pilot


It’s not enough to be providing great care, in the emerging value-based healthcare world you are going to have to prove it.


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