Chiropractic Coding & Compliance Alert

Published on Tue Sep 23, 2014 PDF

Reporting 3 quality measures is all you need.

Call it good news or bad news: Chiropractors can only use claims-based reporting for quality reporting on Medicare Part B claims, but they also have fewer measures to contend with than their counterparts in other specialties. Read on for the latest on how successfully – or unsuccessfully – reporting quality measures will soon affect your bottom line.

Background: CMS developed the Physician Quality Reporting System (PQRS) as a result of the Tax Relief and Health Care Act of 2006 to give eligible providers a financial incentive to participate in a quality reporting program related to Medicare claims. Participation is still voluntary, but that will change in 2015. 

Starting point: “The PQRS is currently tied to the Value Based Modifiers that CMS is implementing over the next few years,” says. Dr. Ron Short, DC, MCS-P, CPC, CEO, Heartland Consulting Group, Pittsfield, Ill.  “Failure to participate in the PQRS will result in the automatic assignment of the lowest level Value Based Modifier which will result in an additional 1% reduction in reimbursement from Medicare.  The Value Based Modifiers will be in effect for chiropractors in 2017.” 

Participation Determines Incentives and Penalties 

PQRS applies to all Part B covered services under the Medicare Physician Fee Schedule (PFS). Eligible providers who currently participate in the program by submitting documentation related to certain services (or measures) receive a 0.5 percent “bonus” payment for all eligible Medicare services rendered during the calendar year. Incentive bonuses usually are paid in November.

Adjustments: CMS finalized Calendar Year 2013 as the performance period for the 2015 PQRS penalties. Therefore, if CMS determines that an eligible professional did not successfully and satisfactorily report data on quality measures for covered professional services during last year’s PQRS reporting period (Jan. 1 – Dec. 31, 2013), those providers will see their Medicare reimbursement decrease by 1.5 percent (98.5% of the fee schedule amount that would otherwise apply to such services) beginning in 2015. 

Important: Calendar Year 2014 is the performance period that will affect a provider’s 2016 Medicare reimbursement. If CMS is not satisfied with the PQRS reports of an eligible provider in 2014, he will not qualify for the 0.5% payment incentive and will see a payment decrease of 2 percent applied to his 2016 Medicare reimbursement. Continued failure to successfully participate in PQRS will result in a 2.0% penalty based on performance two years prior.

Better late than never: If you have never participated in PQRS, begin immediately. Even though you’ll be assessed penalties for not participating in 2013, you can avoid future pay cuts by catching up in 2014. It is not necessary to register to participate in the PQRS program, but participants must have a National Provider Identifier (NPI) number in order to participate and must treat Part B beneficiaries. “There is a second reporting period, July 1 to December 31.  Anyone who reports 50% of their Medicare patients in that time period will qualify,” says Short.

Know How to Report Chiropractic Services 

Other medical specialties have a choice regarding how they report their applicable quality measures, but that’s not the case for chiropractors.  The claims-based reporting method (on your Medicare Part B claims) is the only available method to the chiropractic profession. DCs do not have to report PQRS using the other four methods (registry-based, qualified Electronic Health Record [EHR], Qualified Clinical Data Registry [QCDR] or the Group Practice Reporting Option [GPRO]). 

Here’s why: None of the 51 measures reportable through EHR relate to chiropractors, and there isn’t a Qualified Registry that applies to chiropractic. For 2014, CMS increased the number of individual measures a provider must report on from three (3) to nine (9), However; only three measures apply to DC for reporting.

Criteria: Other specialties must report on nine individual quality measures in order to meet PQRS guidelines. Only three reporting measures apply to chiropractic, however:

• Measure #131: Pain Assessment and Follow-Up
• Measure #182: Functional Outcome Assessment
• Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (New for 2014)

To qualify for the incentive bonus and avoid the 2016 payment adjustment you must:

• Report satisfactorily on all three measures applicable to DCs during the 12-month reporting period in 2014. 
• “Successfully report PQRS measures on at least 50% of your Medicare patients during the reporting period to avoid the payment adjustment in 2016,” advises Short.
• To report PQRS measures, providers must place the appropriate G codes on the CMS 1500 Physician Claim Form used for billing professional services to Medicare. The G codes will correlate to an action that was taken (or not taken) by the provider.
• Report Measures #131 and #182 on every visit, for every Medicare patient who is at least18 years old and where you have reported a spinal CPT® code (98940, 98941, or 98942). In 2014, you must satisfactorily report on both of these measures at least 50 percent of the eligible visits and successfully perform each measure at least once.
• In addition, report Measure #317 a minimum of once per reporting period (Jan. 1 – Dec.31, 2014) for every Medicare patient who is at least 18 years old and where you have reported a spinal chiropractic CPT® code. Again, you must satisfactorily report on this measure at least 50 percent of the time and successfully perform the measure at least once to qualify for the incentive.
• Reporting both measures correctly for at least 50 percent of the eligible Medicare Part B PFS claims means that, during the 12-month reporting period, the provider has satisfactorily reported the measure for at least 50 percent of the Medicare Part B eligible patients (i.e., where the patient is minimum 18 years old and a spinal CPT® code has been billed). Your best option is to report PQRS measures on every visit to increase the chances of meeting the satisfactory reporting requirements for the incentive and to avoid the payment adjustment.

A chiropractor need not be driven to PQRS solely because of financial reasons, because the cost a typical office would bear for the additional effort needed to report PQRS would offset the benefit and the cost of penalty for now. However, in the long run, PQRS can help chiropractors:

• Assess the quality of care they are providing to their patients
• Quantify how often they are meeting a particular quality parameter.
• Using the feedback report provided by CMS, one can compare his performance on a given measure with his peers.

Nut shell: “All three PQRS measures report activities that chiropractors should be performing in their practices already,” adds Short. “Reporting these measures is simply a matter of inserting the correct G-codes in the CMS 1500 form when billing the services.” “The more that they delay implementation of PQRS in their practices, the more money they will have adjusted from their payments.”

Editor’s note: Next month, look for tips on how to report the measures and G codes with finesse.