PQRS Measures: Don’t Get Confused by the Cluster Reporting


PQRS for anesthesia could be confusing and you might be spending hours upon hours researching and reviewing endless web pages to learn how to participate in the Physician Quality Reporting System (PQRS) program. This expert guidance provided by our expert will certainly help you ease your burden.

The eligible providers for anesthesia of course is your anesthesiologist, your CRNA or an AA and a physician's assistant and a nurse practitioner.

The physician's assistant and nurse practitioner, you're not going to have that many of those in anesthesia group. However, some people do have PAs and nurse practitioners working for them. But we don't see that that's going to really come into play for anesthesia at this time. Some of the pain management practices, it might. But in an anesthesia practice, you won't have that. It's strictly anesthesia. Remember, the CMS PQRS is analyzed on the data that's reported by one individual practitioner; his data or her data.

So if you have a group of 10 doctors or 100 doctors and only one physician reports the PQRS, if that physician reports it and gets enough claims in there with the PQRS data, that physician will receive a bonus of 2% of his or her money that allow charges as per CMS rules and regulations. And CMS is going to analyze that based on that successful reporting.

Our expert mentioned in a CMS conference that the bonus payment – and a lot of doctors don't know where is this money going – it doesn't go to the individual practitioner if he or she is in a group. It will all be sent to the bank account or the payment address of the group under the group's TIN. But there will be available, individual reports, for the doctors that actually reported successfully in the group. And those reports are on the CMS website where they're available for viewing.

So right now, the physicians that are looking at these reports are not very happy with them. And MGMA did a survey on this, too. And they got reports that physicians are not very happy about it.

A number of the doctors weren't even able to access their reports. And then when they did, they felt like the format was very, very difficult to understand.

And as one practice administrator put it, he said they wasted many hours trying to get those to their reports and it should be much more straightforward and simple. But anybody who has worked with Medicare and CMS knows that it's not always straightforward and simple as is.

What is a “measure group”?

The measure groups are actually a group of care issues that are associated with a particular condition or a particular disease.

Now, anesthesia doesn't have what we would - like the diabetes or coronary or anterior back pain and certain treatments that they do for a diabetic patient; a measure that will improve the outcome of that diabetic patient to cut down cost and better care for the patient.

Anesthesia doesn't really have a focused measure like that because anesthesia practitioners administer anesthesia for any number of conditions.

So what we have now are the clusters, what they call a “cluster”.

Because in the context of treating coronary/artery disease and all of these various actions that a cardiologist or a cardio-thoracic surgeon will take is a little bit different with anesthesia. We have the individual clusters now; the clusters instead of those measure groups. We assume that CMS is also communicating with the specialty groups when they create these clusters.

This is going to be a team effort that is going to require fast provider interaction to determine what measures a group want to report or should report; what measures are applicable to your group. And the providers need to take an active role.

So you're going to need to interact with the doctors. They have to identify the measures that are applicable to the services that they routinely provide and then select those measures that make sense based on the volume and the practice. And the physicians definitely need to communicate with the staff.

More and more, in our medical billing and coding and reporting services, physicians and staff need to communicate. And education needs to be passed both ways; not just one way or another.

So we have the two clusters as per the healthcare guidelines – the antibiotic and the reporting of the catheter measures; and then we have the catheter measure and the perioperative warming, the blanket warming or the body temperature warming.

The MAV, measure applicability validation, does apply to anesthesia now because we do have the clusters. So the way it works, when the provider reports an anesthesia measure for, let's say, antibiotic,  feels that that practice will probably have other measures in that cluster – antibiotic and the catheter – and CMS says, “Well, if they are reporting the antibiotic, there will probably be other cases where they should be reporting the catheter placement.”

So they are going to look at the number of medical coding claims. So we've got a little clinical relation test here. If he reports for 80% of the patients within a cluster and they look at, let's say the catheter, and it's not reported, then they're going to fail. Measure 30 and 76 are in that cluster.

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