2016 PQRS SUMMARY OF REQUIREMENTS

INCLUDING DOCUMENTATION CHANGES & UPDATES
FOR RADIOLOGY

February 5, 2016

Dear MSN Clients,

The PQRS program continues to evolve and get more complex every year. The following is a summary of the requirements for 2016. Items that are new for 2016 appear in RED. To learn more about the basics of the PQRS program, please click on the following: PQRS Program Basics

2016 PQRS: For Individual Eligible Professionals (EP);
Individual measures via claims

To meet the 2016 PQRS requirement, Eligible Professionals (EP) need to report at least 9 measures, covering at least 3 NQS (National Quality Strategy) domains, or report 1-8 measures if less than 9 apply to the EP, for 50% of Medicare Part B FFS patients during the reporting period. Measures with 0% performance rate will not count. EPs reporting less than 9 measures will be subject to Measure Applicability Validation (MAV) process. If you are unfamiliar with the MAV process, click What is MAV?

MSN recommends the MAV process which requires a provider to report on Cluster 9 (Diagnostic Imaging) including measures 145, 146, 147, 195, 225, and 436 and any applicable cross-cutting measures. There are four (4) new measures added in 2016 applicable to radiology. However, for purposes of reporting on Cluster 9, only measure # 436 is new in 2016, and there has been a change to Measure #145. See more information below.

Common Radiology PQRS Measures

Measure 76: CVC Insertion Protocol (Sterile Barrier)
is not required for diagnostic radiologists to report in 2016; you do not need to start reporting Measure 76 in 2016 but if you have been reporting, please continue

Measure 145: Fluoro Exposure Time Reporting (change in 2016):

Document radiation exposure indices or exposure time AND number of fluorographic images (if radiation exposure indices are not available) for procedures using fluoroscopy
Performance NOT met if radiation exposure indices, exposure time or number of fluorographic images not documented

Definition of Radiation Exposure Indices (for the purposes of this measure the indices should include at least one of the following):
Skin Dose Mapping
Peak Skin Dose (PSD)
Reference Air Kerma (Ka,r)
Kerma-area Product (PKA)
*If the fluoroscopic equipment does not automatically provide any of the above radiation exposure indices, exposure time and the number of fluorographic images taken during the procedure may be used.

Example Documentation:
“Fluoroscopy time was 843 seconds and six images were obtained”.

Measure 146: Screening Mammography:

Document BI-RADS® 0 – 6

Measure 147: Bone Scan Correlation:

Document the correlation of any previous relevant imaging studies or document if there were no previous films for review
Performance NOT met if the bone scintigraphy report is not correlated in the final report with existing imaging studies

Measure 195: Stenosis Measurement in Carotid Imaging Reports
(2010 Measure 11 is now Measure 195 and has been revised to include all diagnoses)
*Note: This measure covers any Modality Carotid Procedure – CTA, MRA, Angio, US

Document Direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement. Includes direct angiographic stenosis calculations based on the distal lumen as the denominator for stenosis measurement OR an equivalent validated method referenced to the above method (e.g., for duplex ultrasound studies, velocity parameters that correlate the residual internal carotid lumen with methods based on the distal internal carotid lumen)
It is permissible to state NASCET criteria were utilized
Performance NOT met if the study did NOT include direct or indirect reference to measurements of distal internal carotid diameter

Example documentation:
A short note can be made in the final report, such as:

“Severe left ICA stenosis of 70-80% by NASCET criteria”
Or
“Severe left ICA stenosis of 70-80% by criteria similar to NASCET”
Or
“70% stenosis derived by comparing the narrowest segment with the distal luminal diameter as related to the reported measure of arterial narrowing.”
“Severe stenosis of 70-80% – validated velocity measurements with angiographic measurements, velocity criteria are extrapolated from diameter data as defined by the Society of Radiologists in Ultrasound Consensus Conference Radiology 2003; 229;340-346.”
Or
“NASCET measuring was not required for this procedure” (For carotid angiography to look for vasospasm, e.g.)
Measure 225: Radiology: Reminder System for Screening Mammograms (Added 2011)
Document if the patient, that is over 40 years old and has a screening mammogram, is entered into a reminder system with a target due date for the next mammogram
The reminder system should be linked to a process for notifying patients when their next mammogram is due and should include the following elements at a minimum: patient identifier, patient contact information, date(s) of prior screening mammogram(s) (if known), and the target due date for the next mammogram

Example Documentation:
“A 1 year screening mammogram is recommended. A reminder letter will be scheduled.
If the patient is asked to return for additional views, you may say, “A reminder letter will be scheduled at the appropriate time pending additional views.”
Another option would be: “This facility utilizes a reminder system to ensure that all patients receive reminder letters and/or direct phone calls for appointments. This includes reminders for routine screening mammograms, diagnostic mammograms, or other Breast Imaging Interventions when appropriate. This patient will be placed in the appropriate reminder system.”

Measure 436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques (New Measure Applicable in 2016)

Document that one or more of the following dose reduction techniques were used:
Automated Exposure Control
Adjustment of the mA and/or kV according to patient size
Use of iterative reconstruction
Performance NOT met if the study did NOT include one or more dose reduction techniques

Please note, you may use the following site specific attestation in your CT reports to meet the requirements of Measure 436: “All CT scans at this facility use dose modulation, iterative reconstruction, and/or weight based dosing when appropriate to reduce radiation dose to as low as reasonably achievable”.
Please be advised that you need to verify that the CT equipment performs one of the dose lowering techniques prior to including this attestation in your dictated report.

**MSN WILL AUTOMATICALLY REPORT ON MEASURES 145, 146, 147, 195, 225 & 436**

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2016 UPDATE – CROSS-CUTTING

Effective 1/1/15, and continuing in 2016, Eligible Professionals (EPs) are required to report 1 cross-cutting measure if they have at least 1 Medicare patient with a face-to-face encounter (and/or an Evaluation & Management Encounter code is billed

MSN recommends Measure 130 as the most applicable to radiology
If you report E&M Services, please inform MSN of your reporting choice
For a complete list of Cross Cutting Measures… click Here

Cross-cutting Measures Applicable to Radiology

Measure 111: Pneumonia Vaccination Status for Older Adults
Document if a patient (65 years of age and older) has ever received a pneumococcal vaccination
To meet the criteria the patient has to have received a vaccine or the vaccine is administered on DOS
There are no allowable performance exclusions for this measure; performance NOT met if the vaccine was not administered or previously received
If you report Measure 111 you may be enrolled in Cluster 17 for the MAV process and may be required to report on Measure 110 – Preventative Care and Screening: Influenza Immunization. MSN will evaluate your MAV risk
Measure 130: Documentation of Current Medications in the Medical Record
Document that the patient’s (18 years and older) current medications have been recorded, updated and reviewed
This must include all known prescriptions, over-the-counters, herbals, and nutritional supplements and must contain the medication’s name, dosages, frequency and route of administration
To meet the criteria, the eligible professional/physician may either attest to documenting in the medical record that they obtained, updated or reviewed the patient’s current medications OR document in the E&M report all known prescriptions, over-the-counters, herbals, and nutritional supplements and include the medication’s name, dosages, frequency and route of administration
Performance not met if the current medications are not documented as obtained, updated or reviewed by the eligible professional, reason not given
If you report measure 130 you may be enrolled in Cluster 3 for the MAV process and may be required to report on Measures 51 & 52 (COPD). MSN will evaluate your MAV risk

Measure 131: Pain Assessment and Follow-up
Document a clinical assessment for the presence of absence of pain using a standardized tool (Faces Pain Scale, Brief Pain Inventory, McGill Pain Questionnaire, e.g.), for patient’s 18 years and older
AND
Document an outline of care for a positive pain assessment; this must include a planned follow-up appointment or referral, a notification to other care providers or indicate the initial treatment plan is in effect
The documented follow-up plan must be related to the presence of pain. Example documentation includes “Patient referred to pain management specialist for back pain” or “Return in two weeks for re-assessment of pain.”
Performance MET if the pain assessment is negative and no follow-up plan is required
Performance MET if the pain assessment is not documented because the patient is not eligible
This includes cases where the patient has a severe mental and/or physical incapacity where the person is unable to express themselves in a manner understood by others
Performance MET if the pain assessment is documented as positive but the follow-up plan is not documented because the patient is not eligible
This includes patients that are in an emergent situation where delaying treatment would jeopardize the patient’s health status
Performance NOT met if there is not a documentation of pain assessment, reason not given
Performance NOT met if the follow-up plan is not documented, reason not given
If you report measure 131 you may be enrolled in Cluster 13 for the MAV process and may be required to report on Measures 182: Functional Outcome Assessment. MSN will evaluate your MAV risk
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How is MSN protecting your practice?

MSN actively reviews each provider’s documentation to ensure PQRS compliance. MSN provides this feedback monthly during the new client start-up phase and quarterly or as needed thereafter. MSN also provides feedback to its coding team to make sure the PQRS CPT II codes are correctly added and submitted to CMS.
Utilizing its Billing Intelligence software program, MSN verifies the accuracy of PQRS submission to CMS by cross-referencing eligible CPTs and the PQRS CPT II codes submitted. In this way, MSN ensures that the 50% compliance threshold is met.
MSN also verifies that PQRS CPT II codes are being received by CMS by verifying the electronic remittance advice received from CMS. Remark codes N-620 or CO 246 N572 need to be received on the remittance advice to verify that CMS is properly adjudicating the PQRS CPT II codes. Please see your client services representative for more information.