Do you use claims to submit PQRS? Do you have confidence in your performance? Are you including at least 50% of your eligible instances?
Claims-based reporting can provide a solid quality submission based on measures that lacks good, structured data that can be extracted from the Electronic Health Record (EHR) system. This opens up a wide variety of measures to incorporate into a PQRS submission. This form of reporting (claims-based) is applicable when the measure specifications don’t lend themselves well to electronic extraction when data is not recorded in a format that can be extracted, or when the practice does not have access to affordable technical assistance for data extraction. Some organizations have invested a lot of money into people and systems to make claims-based submissions.
Often, when manually scored at the time of visit, the analysis process detracts from time that would otherwise be available to treat patients. In addition, based on the most recent CMS experience report, claims-based reporting has a 62% success rate compared to a 99% success rate for registry reporting.
These are common errors associated with claims-based submissions by practitioners:
- Forgetting having submitted a patient as eligible for a measure in the past, then submitting a duplicate entry.
- Forgetting NOT having submitted a patient as eligible for a measure in the past and failing to make the submission.
- Failing to accompany a measure-specific Quality Data Code (QDC) that did not also have the required procedure code.
- Here are a few challenges that contribute to claims-based reporting submission errors.
The process is inherently manual. The practitioner applies a base claims code to a Medicare billing form to document performance at an instance of patient care on a particular measure and service date. This adds a barrier to the patient-provider relationship, especially when the care instance involves multiple measures.
Measure submission requirements can often be quite complex with a series of codes required to make a single patient submission. Common problems that can invalidate an entire submission include: failure to apply one of a required series of codes, misunderstanding the relationship between codes, and misinterpreting an inverse measure (who knew that if all your codes said “performance met” you would fail the measure?).
Another problem pertains to unknowingly omitting patients from the reporting data set. Failure to report on 50 percent of patients triggers submission failure. Claims reporting requires that the quality reporting submission must accompany the original claim – CMS does not allow a claim to be amended following its submission.
Despite the best of intentions, third parties, including billing companies, also contribute to claims-based quality reporting failures by scrubbing out codes that lack an associated charge.
Many practices and the companies that serve them have invested in automated systems for claims submissions. Automating the process has lessened the onerous administrative burdens associated with claims, and perhaps just in time since Medicare seems poised to discontinue claims altogether. CMS has already taken the measure groups option out of the mix, stating their intention at an unspecified date to stop accepting individual measures linked to claims. The implications for practice management and profitability are at once sobering and exciting.
Repurpose Claims Data for Registry Reporting Method
You can succeed with PQRS by switching to the registry reporting method and choosing a vendor capable of using pertinent data—including claims data—stored in the providers’ systems.
The process involves identifying eligible instances for each measure from the billing data, finding the performance codes associated with each measure, translating the performance codes into performance levels, and repurposing the claims data into registry submissions.
This presents the tremendous advantage that upon discontinuance of claims submissions, practices can still use their claims system data as the foundation for making successful registry submissions.
Do you have additional advice to share about repurposing claims submissions? Share it below in the comments.
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