Configuring PQRS/MIPS

Commure Pro’s Physician Quality Reporting System (PQRS) tool allows physicians to participate in the Merit-based Incentive Payment System (MIPS) sponsored by the Centers for Medicare and Medicaid Services (CMS). This feature is designed to allow physicians to accurately report quality measures for covered professional services furnished to Medicare beneficiaries. If Commure Pro PQRS is implemented at your organization, each time a provider enters a charge transaction, it is evaluated to determine if it fits the MIPS quality reporting criteria. Patient information such as age and gender, and the charges and the diagnoses that the provider enters, are all taken into account. The reporting frequency for the each measure determines how often the provider is prompted to answer the Commure Pro Clinical Metrics form (each time a provider uses a particular charge code, once per visit, once per calendar month, once per reporting period, and so on). When appropriate, the provider is prompted to answer a series of clear and concise quality measure questions. The answers to the quality measure questions can then be reported to CMS using either the Registry method or the Claims Billing method, both of which are described below. All quality measures can be reported using the Registry method, while only some can be reported using Claims Billing method. Your organization must use one method or the other, and cannot use both at the same time. In addition, each year Commure Pro evaluates whether or not we will participate as a registry. Contact your Commure Pro representative to find out if Commure Pro will be a qualified registry in the planned reporting year, as it affects how you should configure the system.

• Registry method: After a provider answers the quality measure questions, the answers are recorded by the Commure Pro application. Administrators and providers are able to monitor their performance throughout the year using the Charges > PQRS Report option. At the end of the reporting period, if Commure Pro is participating as a qualified registry, then Commure Pro sends the data collected to the CMS.

• Claims Billing method: After a provider answers the quality measure questions, those answers are translated into one or more CPT II codes and modifiers which are automatically added to the charge transaction. The codes are then submitted along with the original charges to your billing system, and are then reported to the CMS when the claim is submitted for payment.

This chapter describes the administrative tasks required to configure the Commure Pro PQRS feature, for clients who wish to use either the Registry method or the Claims Billing method. Most of the configuration steps are the same for both methods; the only difference is in a few user settings. See Steps for Configuring PQRS. For instructions on how to use this feature on a daily basis, from both the provider’s and administrator’s perspective, see Completing PQRS/MIPS Clinical Metrics Forms and Managing Charge Transactions with PQRS/MIPS Data respectively.

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Availability of the PQRS Feature on Web versus Handheld Platforms

Once configured, the PQRS feature can be used as follows:

• On the web platform, providers can submit quality data by responding to clinical metrics questions after submitting charge transactions that meet a measure’s criteria. If enabled in their user profile, they can also see the auto-added CPT II codes (Claims Billing method) or the PQRS Reporting tab (Registry method).
• On the Android and Apple platforms, providers can submit quality data by responding to clinical metrics questions after submitting charge transactions that meet a measure’s criteria. If enabled in their user profile, they can also see the auto-added CPT II codes (Claims Billing method).

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Using a PQRS with Other Charge Capture Features

PQRS can be used in conjunction with the following features:

• Charge Data Master (CDM). The PQRS process does not interfere with a CDM, or vice versa. Once the transaction is submitted, it is evaluated to see if it meets the quality reporting criteria, and if so, the appropriate quality measure questions are presented to the provider. In addition, if the charge codes entered by the provider are mapped in the CDM, and if the transaction meets all of the criteria for applying CDM codes, then the appropriate CDM codes are retrieved. See Implementing a Charge Data Master (CDM).
• Custom Charge Capture Screens. The usage of a Custom Charge Capture Screen to generate charge codes does not interfere with the PQRS process in any way. Once the transaction is submitted, it is evaluated to see if it meets the quality reporting criteria, and if so, the appropriate quality measure questions are presented to the provider. See Configuring Custom Charge Capture Screens.
• Hold for Review. PQRS can be used in conjunction with the Hold for Review feature. Once a transaction is submitted as held for review, it is still evaluated to see if it meets the quality reporting criteria, and if so, the appropriate quality measure questions are presented to the provider. See Configuring the Hold for Review Workflow.
• Selection of NDC Codes. The usage of a charge code that has NDC codes mapped to it (and the selection of a drug and NDC code during charge entry) does not interfere with the PQRS process in any way. Once the transaction is submitted, it is evaluated to see if it meets the quality reporting criteria, and if so, the appropriate quality measure questions are presented to the provider. See Configuring the Selection of NDC Codes During Charge Capture.
• RVU Management. The association of an RVU with a charge code (including auto-sorting those codes, possibly multiplying the RVU values, and possibly adding modifiers after saving the transaction) does not interfere with the PQRS process in any way. Once the transaction is submitted, it is evaluated to see if it meets the quality reporting criteria, and if so, the appropriate quality measure questions are presented to the provider. See Configuring RVU Management. PQRS cannot be used in conjunction with the following features:
• Batch Charge Entry. When using the Batch Charge Entry option, the Commure Pro Clinical Metrics screen does not display after saving a batch of charges, even if the charges qualify for quality reporting. See Configuring Batch Charge Entry.
• Automated Code Entry. Any charges that are entered manually that would normally trigger the Commure Pro Clinical Metrics questions, will continue to do so. Any charges, modifiers, and/or diagnoses that are automatically generated by Automated Code Entry are not evaluated for quality reporting and will not trigger a form (even if they would normally meet the quality criteria). See Configuring Automated Code Entry.

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Steps for Configuring PQRS

PQRS set up involves several tasks. Some of the tasks are performed by your Commure Pro implementation consultant, while others are performed by an administrator at the client site.

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Importing Quality Measures

Per the CMS, all quality measures can be reported using the Registry method, while only some can be reported via Claims Billing method. Once your organization determines which reporting method it will be using, your Commure Pro representative will import the appropriate set of measures (the registry measures or the claims billing measures) during your initial installation. At the beginning of each new subsequent year, your Commure Pro representative is responsible for importing all new or updated quality measures to your system. During the annual update process, the quality measures must be imported prior to importing the PQRS/MIPS standard code edits, or the code edit import will fail. With the pre-load of measures upon initial installation, or the later import of updated measures by a Commure Pro representative, a spreadsheet of measures as defined by the CMS is loaded into the system. It includes information about each measure such as the measure name, description, reporting frequency, associated questions and responses, associated CPT II codes for each response, and so on. Typically, the import spreadsheet is not modified in any way. However, if desired, you can ask your Commure Pro representative to modify the Reporting Frequency for one or more measures prior to importing it during the annual update process (or for new installations, the spreadsheet must be modified and re-imported). For example, a given measure might have a Reporting Frequency of “Once per Period,” which means that the measure’s questions will be presented to a provider only once per patient (that meets the measure’s criteria) during the given Reporting Period. However, if you want the measure’s questions to be presented to the provider more often, your Commure Pro representative could change the Reporting Frequency to a shorter frequency in the spreadsheet. In addition, a custom Reporting Frequency of “Once Per Quarter” is also available for this purpose. Please keep in mind that if you make this change, it can impact quality reporting as follows:

• If using the Registry method: We do not recommend changing the Reporting Frequency for any measures if you are using this method.
• If using the Claims Billing method: If you change the Reporting Frequency for a measure, such that the questions are presented to the provider more often than expected by the CMS, and the provider actually responds each time, this will result in more charge transactions (than expected) with CPT II codes being submitted to the CMS for that measure. However, over-reporting to the CMS is not detrimental and will not result in more than 100% performance met. After a Commure Pro representative loads the quality measures for the new year, the following changes are made to the inactive measures from the previous year:
• Inactive measures are flagged in the database with a status of “Retired.”
• In the Admin > System Management >PQRS Measures option, inactive measures are displayed at the bottom of the list, with the word Retired appended to the measure name. In addition, inactive measures do not display the Active checkbox or the Edit link.
• The code edits associated with inactive measures will stop firing, even if the code edits are not deleted or deactivated in the Admin > Institution > Charge Capture > Code Edits > Configure Code Edits option. Level 0 administrators (typically Commure Pro staff) can import the quality measures by following the steps below.

1. Select Admin > System Management > PQRS Measures Import.
2. Click Browse, and then navigate to and choose the appropriate PQRS Measure file.
3. Click Upload to import all of the measures in the spreadsheet.

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Activating Quality Measures and Questions

Level 0 administrators (typically Commure Pro staff) must specify which measures are active. All measures are inactive by default. All activated measures will display a Commure Pro Clinical Metrics form whenever a charge is completed that has the relevant criteria (CPT codes, ICD codes, patient age and gender), and that also has a corresponding code edit that is active.

1. Select Admin > System Management > PQRS Measures. The Measure Summary is displayed.
2. Click the Active checkbox for each measure that you want to implement.

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Customizing Quality Measures

Once the quality measures have been uploaded to the Commure Pro system, your Commure Pro implementation consultant will activate the measures that your organization wants to use. Level 0/1/2 administrators can then use the Edit link to customize all active measures. You can mark a measure as required/not required, or edit the text used for the question or its responses. (See also Importing Quality Measures for information about customizing the Reporting Frequency for a measure.) Level 1 and 2 administrators can use the Measure Summary screen to validate collected quality data. For general information about reporting functionality, please see Quality Measures and Charge Analytics. To edit a measure:

1. Select the Admin > System Management tab.
2. Select the PQRS Measures option. The Measure Summary screen is displayed. The Measure Summary lists all the measures that were uploaded to your Commure Pro system. You can view both measure labels and descriptions as provided by CMS. The Active checkbox indicates which measures are required by your organization. Active measures are collected and reported to CMS during the defined PQRS Reporting Period. Also, any measure and/or its ancillary questions and responses that were customized are flagged with the red flag ( icon.

3. Click the Edit link to open the Edit Measure screen. The top portion of the Edit screen contains the label and other descriptive information about the measure you selected.
   • Measure #: A unique identifying number for the measure as specified by CMS. The number assigned to the measure is a whole number.
   • Measure Title: A descriptive title for the measure as specified by the CMS.
   • Question #: A unique number that identifies each question that is associated with the measure.
4. You can modify details for both questions and answers by entering the following information in each section of Edit screen. On the Details section of the screen, do the following:
   • Required checkbox: Select this checkbox to indicate that the measure is required by your organization for quality reporting. When checked, the physician is required to answer each question in the measure, as appropriate.
   If you want a multi-question measure to be required, select the Required checkbox only for the first question on the measure — do not mark any other questions in the measure as Required. The remaining questions are already configured to display or not, depending on how the user responds to the first or subsequent questions in the measure.
   When you select the Required checkbox, Commure Pro automatically disables two buttons on the Clinical Metrics screen:
   • Submit button is disabled until all the required questions are answered.
   • Cancel button is disabled if there are any required questions regardless of whether or not the questions were answered.
   • Standard Question Text: (Default) Shows the Commure Pro generated question for a measure, which the physician must answer.
   • Custom Question Text: Enter a custom description for a measure that will be displayed when users review measure questions. The Response Details section contains the standard description and custom description for the answers displayed for each question. You can do the following:
   • Standard Response Text field: Shows the Commure Pro generated response text that is associated with the measure’s question.

• Custom Response Text: Add a customized response description for each question.
• CPT: CPT II code numbers as specified by CMS that are associated with the measure. This is a non-editable field.
• Modifier: Displays a modifier’s identifying number if available. This is a non-editable field. This modifier is always used in conjunction with the CPT II code. Please note that not all codes have modifiers.
• Performance: Displays the performance criteria assigned to each response. This is a non-editable field. The performance criteria indicates the provider’s quality of care to the patient for the measure, and not his performance in terms of answering/not answering the question. For example, if the measure’s question asked about the patient’s hemoglobin count, then a response that equated to a count in the normal range would indicate that the provider was giving good care, and so a performance criteria of “Met” would be assigned to that response. If the response equated to a hemoglobin count that was less than optimal, then the provider would not be managing the patient very well, so a performance criteria of “Not Met” would be assigned to that response. And if the response were a valid reason that the quality action/care could not be performed, then “Excluded” would be assigned.
  • N/A: Performance is not applicable (not measured) for this response, usually because it is a negative response to a parent question, and so the dependent question(s) are never presented to the provider. This value is also assigned to custom quality measures that are not applicable to CMS.
  • Dependent: Performance is not measured for this response, because this is a positive response to a parent question; performance is instead measured for the dependent question(s).
  • Met: Indicates that a quality action was performed as defined by the measure specification.
    In some cases, the “Met” versus “Not Met” criteria designated by the CMS are actually the opposite of what one would expect. For these measures, “Not Met” means that the provider is providing the correct patient management, so having a lower “Met” percentage is actually better.
  • Not Met: Indicates that a quality action was not performed without a reason as defined by the measure specification.
  • Excluded: Indicates that a quality action was not performed for a valid reason as defined by the measure specification.

5. When you are finished adding the customized text in the appropriate fields for each question, click Save. You are returned to the Measure Summary screen. A red flag icon appears in the Custom column to indicate that the measure has been customized.

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Configuring the Reporting Period

Once the PQRS feature has been implemented, Level 0 and 1 administrators can configure the reporting period. This setting below controls the timeframe within which your organization can collect quality data and generate reports prior to submitting them to CMS. Admin - Institution - Charge Capture - PQRS Reporting Period The options for this setting are:

• January-December (default) is the annual reporting period. When selected, the reporting institutions can collect quality data over the course of the calendar year for annual submission to the CMS.
• July-December is the six-month reporting option that is designed to enable those organizations that have implemented PQRS late in the year. When selected, the reporting institutions can collect quality data for the last six months of the calendar year for submission to the CMS.

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Configuring User Settings

To fully implement PQRS, there are several user settings that must be enabled, as described in the table below.

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Configuring Providers to Capture Quality Data

The manner on which you configure your providers depends on the reporting method you plan to use (registry or claims billing), as well as whether or not Commure Pro is participating as a qualified registry for that year. There are several settings that must be configured.

• In all cases, the setting below must be set to Yes to indicate that the user is a Provider. Admin - User - User Permissions - Provider
• If you are reporting through Commure Pro’s registry, each provider’s Tax ID number (TIN) and National Provider ID number (NPI) must be present in the Commure Pro system so that it can be included in the quality data that is sent to the CMS at the end of the year. (If you are using the Claims Billing method or a third-party registry vendor, there is no harm in maintaining this information in the Commure Pro system.) Although there is not an explicitly named field for the NPI and TIN numbers on the Provider Info screen, Commure Pro does support custom alias numbers for providers. For some clients, the Commure Pro application may have already captured each provider’s NPI and/or TIN either through the ADT interface or through a provider upload, although the naming of the aliases may vary from client to client. To accommodate this variation, your Commure Pro representative can implement two configuration properties that identify which provider alias is the NPI, and which is the TIN, for use with the Registry. Admin - User - Provider Info - Provider Info
• The setting below determines how the quality information is captured for each provider. Admin - User - Charge Capture - PQRS Registry Participant
  • Yes: Choose Yes if you plan to report using the Registry method and Commure Pro is participating as a registry in the planned reporting year. When a provider completes a Commure Pro Clinical Metrics form, their responses are stored by the application and will be reported to CMS at the end of the reporting period via the Commure Pro registry. The user also has access to the PQRS Reporting tab which shows how well each provider is doing in terms of completing the Commure Pro Clinical Metrics forms.
  • No: Choose No if you plan to report using the Claims Billing method, or if you plan to report using the Registry method via a third-party registry vendor. When the user completes a Commure Pro Clinical Metrics form, their responses are translated to CPT II codes which are added to the charge transaction and then sent to your billing system. If you are using the Claims Billing method, the CPT II codes are reported to the CMS when the claim is submitted for payment from your billing system. Or if you are using a third party registry vendor, the registry vendor can mine the claims data in your billing system to retrieve the quality information and then send it to the CMS.

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Enabling the Ability to View Auto-Added CPT II Codes

If your organization is using the Claims Billing method, then each time a provider completes the questions on a Commure Pro Clinical Metrics form, one or more CPT II codes are automatically added to the charge transaction. This is true for charges entered on both the web and handheld platforms. A user can view the auto-added CPT II codes when they look at the charge transaction only if an administrator grants them the ability to do so, via the following setting: Admin - User - Charge Capture - Show PQRS Charges to User

• Yes: The user can see the charges that were manually entered on the charge transaction, as well as any CPT II charge codes that were automatically added to the transaction as a result of the provider completing the Commure Pro Clinical Metrics form. In general, if a user can view the auto-added charges, they may be able to edit them as well (as long as they fall within the basic parameters relating to editing charges, such as the transaction’s charge status and the time frame allowed for edits).
• No: The user can view only the manually entered charges.

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Configuring User Access to the Charges > PQRS Reporting Tab

If your organization is using the Registry method and Commure Pro is participating as a qualified registry in the planned reporting year, your providers can view the Charges > PQRS Reporting tab to see how well they are doing in terms of completing the Commure Pro Clinical Metrics forms, and also for the forms that they did complete, how well they are meeting the performance criteria for each measure. Your Commure Pro representative must configure an XML customization to allow users to access to the PQRS Reporting tab. Using the XML customization, you can grant access to specific users (such as the specific providers who are registry participants as well as select administrators), to entire departments, or to all users of your system. You may want to create a department that contains all registry participants and a select set of administrators, and then enable the XML customization for that department. Then as new providers are hired or become participants, you can simply add them to the department.

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Enabling Access to the Forms > Measures Tab

Level 1 or 2 administrators can review quality measures to determine if the measures have been completed in compliance with CMS guidelines. The Forms > Measures tab allows administrator to search for and review the completed quality measures that are associated with submitted charge transactions. You can determine which users are allowed access to the Measures subtab, by enabling or disabling the settings below.

• Configure the setting below to allow Level 1/2 administrators to view the completed quality measures on the Forms > Measures tab. Admin - User - Forms - Form View Access
  • Within the User’s Departments: The user can view forms available within their departments.
  • Within the User’s Facilities: The user can view forms available within their facilities.
  • All Forms: The user can view forms from all departments and facilities.
  Do not select None or No Other Forms.
• Configure the setting below to allow Level 1/2 administrators to search for the completed quality measures on the Forms > Measures tab. Admin - User - Forms - Form Search Access
  • User’s View Access: The user can search for the same forms that they are allowed to view, as specified by the Forms View Access setting above.
  Do not select None or User’s View Access + Not Shared.

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Quality Measures and Charge Analytics

Quality data and all the associated CPT II charges and modifiers are collected and stored in the PQRS Report table. To build custom reports from this table, you will need access to the Charge Analytics tool. For detailed information and instructions on the Charge Analytics tool, please refer to the Commure Pro’s Charge Analytics User’s Guide and Dimensional Insight’s NetDiver 6.3 User Guide. Commure Pro Support audits and tracks PQRS issues and errors. For more detailed information, please contact your Commure Pro representative.

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Reporting Quality Measures

You can also track and report quality measures in Commure Pro. The tracking and reporting function enables you to report quality measure submissions via the Device Session and Submission Status tabs. For more information on how to track and report submission data, see Device Sessions Reports and Submission Status Reports.

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Device Sessions

When a user submits quality measures from their handheld device the following information can be viewed on Device Submissions Report:Submitted date and time, the Device type and ID, Type of submission (“PQRS MeasureSubmission”), Status of the submission, Patient name, and UserName of the user submitting the quality measure.

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Submission Status

You can view submission status report for quality measures that were submitted. The following information may be available:Type of submission (“PQRSMeasureSubmission”), Status of submission, Submission Record ID, Session ID, Submitted Time and date, Submission Record Changes.