PQRS for LCSWs
Laura W. Groshong, LICSW
Director, Government Relations
April 26, 2014, 12-1 pm EDT
Disclaimer
CSWA has done its best to collect accurate information on
the information provided in this webinar. There will
undoubtedly be changes to the Physician Quality Reporting
System going forward, which will modify the information
presented here in the future. CSWA will provide additional
information as it becomes available.
Get Ready for a Wild Ride
 Learning about the new concepts which will anchor mental
health and health care reimbursement will revise many
concepts we have worked by for decades
Areas to be Covered
 Business Plans for LCSWs as Context
 Physician Quality Record Systems
(PQRS)
 Changes to Health Care
The End of the World
as We Know It?
 Therapists considering dropping out of solo practice to join
groups: “The increasing complexity of running a practice has
meant more therapists are taking down their shingles or
forming groups with other therapists to share the burden,
executives at national mental health groups say. Others have
joined large medical groups that offer mental health services
as part of comprehensive care.” (NPR.org, 10/24/13)
http://www.npr.org/blogs/health/2013/10/24/234737302/therapistsexplore-dropping-solo-practices-to-joingroups?goback=%2Egde_4267431_member_5799134027814297601#%21
Biggest Health Care
Changes
 Massive changes in health care delivery
 ‘Out of network’ reimbursement likely to end in next 5
years; instead in-network, new risk sharing systems (ACOs,
health homes) or private pay
 In 5-10 years LCSWs working with third-party payers are
likely to be required to do record keeping through
interoperable electronic systems
Impact of Affordable Care Act and
Mental Health Parity Act
 “Integrated care” in ACA likely to lead to LCSWs working in
virtual clinic-like organizations in capitated systems
 Cost of hiring billers and/or buying EHRs may make joining
groups more appealing to cover administrative costs
 Parity will make mental health more integrated into medical
care, but up to LCSWs to explain what mental health
treatment needed
 More marketing necessary for clinicians who want to remain
in private pay system
From FFS to P4P –
Underlying Goal
 Medicare goal to end fee-for-service (FFS) payment, go to
pay for performance (P4P) – likely to be adopted by private
insurers
 Less treatment and better outcomes lead to higher
reimbursement rates
 Role of insurers unclear as ACOs/health homes roll out
 For now, LCSWs need to learn how to explain mental health
treatment needs, esp. long-term
LCSWs and Overall Changes to
Health Care Reimbursement
We feel that we are being locked into systems which are at
odds with being in control of our own practices
Unlock the Changes:
New Business Plans for LCSWs
 Business plan good base for all new health service delivery
changes
 Courses offered by SAMHSA: Strategic Business Planning;
Third-party Billing and Compliance; Eligibility and
Enrollment; Third-party Contract Negotiation; and
Meaningful Use of Healthcare Technology (not for clinicians
at this time)
 Go to http://bhbusiness.org/Special-pages/Home.aspx to
register!
New Business Plans for
LCSWs
(cont.)
 Another option for learning to navigate new business models:
 Behavioral Health First Aid at
http://bhbusiness.org/Special-pages/Home.aspx
Consultants on Clinical
Business Practices
 Rob Reinhardt, LPC – EHRs – www.tameyourpractice.com
 Steve Walfish, PsyD – business practices - Financial Success in
Mental Health Practice: Essential Tools and Strategies for
Practitioners (2008); Earning a Living Outside of Managed Mental
Health Care: 50Ways to ExpandYour Practice (2010) http://thepracticeinstitute.com/the-tpi-team
On to Physician Quality Reporting
System (PQRS)
Climbing the PQRS mountains…..
PQRS is Part of Medicare
 LCSWs are automatically part of the Medicare provider
network
HOWEVER
 To become eligible for reimbursement, LCSWs must “opt in”
through the Internet-based Provider Enrollment, Chain and
Ownership System (PECOS) for Provider and Supplier
Organizations
 http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-NetworkMLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderS
up_FactSheet_ICN903767.pdf
LCSWs Can Opt Out of Medicare
 If an LCSW decides not to become part of the Medicare
provider network, the LCSW must do two things:
- The LCSW must send an “Opt Out Form” to the Medicare
Administrative Center (MAC) that oversees the LCSW’s
region (see CSWA website)
- The LCSW must send an exact copy of the “Medicare Private
Contract” that the LCSW will use with any Medicare
beneficiary to guarantee that no claims will be submitted by
the LCSW or the beneficiary for the LCSW’s services
LCSWs Can Opt Out of Medicare
 No templates of Opt Out Form or Private Medicare
Contract provided by CMS
 Editable templates of the Opt Out Form and the Private
Medicare Contract can be found in the Members Only
Section of the CSWA website:
(www.clinicalsocialworkassociation.org)
 Go to CSWA Templates to download
 Can join CSWA on website and access Templates
(cont.)
Physician Quality Reporting System
(PQRS)
 Started as Physician Quality Reporting Initiative in 2007
 Changed to PQRS in 2010
 PQRS which will provide ‘incentive’ (bonus) for data
submitted in 2013 and 2014 two years later, i.e., 2015 and
2016 of .5%
 PQRS will also provide ‘payment adjustment’ (penalties) if
reporting threshold is not met
CMS Guidelines for PQRS
 “We urge solo practitioners and physicians in smaller groups
to participate in the PQRS now, because we will propose in
future rulemaking to apply the value-based payment modifier
to smaller groups and solo practitioners. (CMS, 2012)”
http://www.ama-assn.org/amednews/2012/11/12/gvsa1112.htm
 Translation: clinicians do not use PQRS measures by 2015
will see increasing penalties in payments
CMS Contact Information on PQRS
 Telephone: 866-288-8912, x3
 Email: qnetsupport@sdps.org
‘Eligible’ Mental Health
Professionals for PQRS
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1. Medicare physicians
Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic
 2. Practitioners
 Physician Assistant
 Nurse Practitioner
 Clinical Nurse Specialist
 Certified Registered Nurse
 Anesthetist (and Anesthesiologist
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Assistant)
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologists
 3.Therapists
 Physical Therapist
 Occupational Therapist
 Qualified Speech-Language Therapist
“Eligibility” for PQRS
 “Eligibility” actually misnomer – requirement for all “eligible”
groups or will have reimbursements penalized
 Will have “eligibility” for bonus in 2015 and 2016 – in 2017
will be only penalty (1.5 in 2015 for 2013 data; 2% for 2016
for 2014 data)
 Starting in 2017 will only be penalties of 2% per year if
PQRS data not submitted
Reason for PQRS
 PQRS designed to reduce costs of most expensive disorders,
e.g., diabetes, congestive heart failure, major depressive disorder,
chemical dependency, to provide assessments and preventive
care
HOWEVER:
 PQRS not lined up with DSM/ICD codes – must be creative
to implement as mental health clinicians (see below)
PQRS and Mental Health
 PQRS is not easily applied to chronic disorders, including
mental health, more for assessment
 PQRS concept started in Medicare but likely be used by all
insurers/health care delivery systems within next 5 years
 Most important general document for finding PQRS data
that applies to LCSWs: 2013 Physician Quality Reporting
System (PQRS) Claims/Registry Measure Specifications Manual
(637 pp.)
Mental Health Diagnoses
and PQRS
 Remember: DSM/ICD Diagnoses not linked to PQRS
Measures!
 Mainly assessment and prevention measures for LCSW
patients, i.e., depression assessment, suicide risk
assessment, smoking assessment, substance use
assessment, etc., regardless of actual ICD-9 diagnoses
 List of codes for LCSWs to follow
PQRS Effect on
Medicare Payments
 PQRS will affect Medicare reimbursement rates with bonus
(.5% in 2015 and 2016) or penalty (1.5% in 2015, 2% in
2016) for 2015 and 2016 claims
 PQRS bonuses end in 2016, then only penalties
 Must have three QDCs for 50% of Medicare patients
to be eligible for PQRS bonus in 2016 (from 2014 data
submitted) and be MAV compliant
Six Areas of PQRS Usage
 Denominator and Numerator – information that must
be included to be PQRS compliant
 Measures – 350 areas that are ‘measured’ by Medicare as
Denominator and Numerator (9 for LCSWs)
 Quality Data Codes (QDCs) – codes entered on CMS-
1500 representing the use of a measure
Six Areas of PQRS Usage
cont.
 Domains – 11 areas that assess the overall reason for
including a given measure
 Medicare-Applicability Validation (MAV) – validates
that there are less than 9 measures available to the provider
(applies to LCSWs) and leads to
 Clusters – 27 ‘clusters’ of CPT codes that should be
included if one is used
PQRS ‘Denominator’
 Denominator= patient group/encounter/dx, i.e., CPT
and ICD Codes, treatment location, i.e., what LCSWs already
submit
 ICD-9 Codes for mental health disorders, especially major
depressive disorder, AND
 CPT Codes for LCSWs: 90791, 90832, 90834, 90837,
90839, 90845, 90846, 90847, 90849, 90853
PQRS ‘Numerator’
 Numerator = treatment according to Quality Data Codes
(QDCs) using new G-codes and F-codes for measures
 Can be submitted if new ‘episode’, i.e., patient not
treated for diagnosed condition for at least 4 months
 Go to Clinical Social Work Association link for complete
list of connected G-codes and F-codes:
http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20%20PQRS%20Options%20for%20LCSWs%20(revised)%20-%209-24-13%20(2).pdf
PQRS Domains
 Six general areas which are used to describe underlying goal
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of measure:
Efficiency and Cost Reduction (ECR)
Effective Clinical Care (ECC)
Community/Population Health (CPH)
Patient Safety (PS)
Communication and Care Coordination (CCC)
Person/Caregiver-Centered Outcomes (PCCO)
Use as many as possible!
PQRS Measures Purpose
 PQRS Measures created to ‘measure’ most expensive
diagnostic categories and contain costs
 Measures reported on CMS-1500 forms as Quality Data
Codes once a year for most Measures used by LCSWs
 Exception: Measure #130, Documentation of All
Medication, must be submitted for each session
List of PQRS Measures
 Go to http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-AssessmentInstruments/PQRS/index.html?redirect=/pqrs
 Then go to “Educational Resources” (left side)
 Then go to
http://www.cms.gov/2014_PQRS_MeasuresList_1213
2013.pdf
 Change every year!
PQRS Quality Data Codes
 PQRS Measures are like general categories, i.e., depression
 PQRS Quality Data Codes (QDCs) are like specific
categories, i.e., a new specific code
 Again, QDCs get reported on CMS-1500!
PQRS Clusters (MAV)
 Medicare-Applicability Validation (MAV)
 Automatically used when less than 9 measures available, as
with LCSWs
 27 ‘Clusters’ to make sure all possible measures reported on
PQRS Clusters (MAV)
cont.
 Based on CPT codes, e.g., 90791, 90834, 90837
 If any CPT code used by LCSW in a cluster, all other
measures must be reported if in scope of practice
 Three clusters for LCSWs: #1 (General Preventive Care);
#11 (Depression); #22 (Substance Use Disorders)
PQRS Clusters (MAV)
cont.
 Cluster 1 (General Preventive Care) = Measures #130
(Medications), #226 (Tobacco Use)
 Cluster 11 (Depression) = Measures #106 (Depression
Screening), #107 (Suicide Assessment), #134 (Follow Up
Plan), #226 (Tobacco Use)
 Cluster 22 (Substance Use Disorders) = Measures #130
(Medications), #226 (Tobacco Use), #247 (Treatment for
Alcohol Dependence), #248 (Treatment for Depression with
Substance Dependence)
Measures Used by LCSWs
 The next 9 slides summarize the QDC, Domain, Cluster, and
reporting schedule for each measure used by LCSWs
PQRS Measures =
Major Depression Evaluation
 #106 Adult Major Depressive Disorder Comprehensive
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Depression Evaluation: Diagnosis and Severity
Domain: ECC
QDC: G8930 (for assessment of depression severity at the
initial evaluation)
Clusters: #11
Report: Once a year or every new episode (must be four
months since end of last treatment for MDD)
PQRS Measures = Suicide Risk
 #107 (Suicide Risk Assessment)
 Domain: ECC
 QDC: G8932 for suicide risk assessed at the initial
evaluation; 3092F for major depressive disorder in remission;
or G8933 for suicide risk not assessed at the initial evaluation
 Clusters: #11
 Report: Once a year or every new episode (must be four
months since end of last treatment)
PQRs Measures - Medications
 #130 (Medication Documentation)
 Domain: PS
 QDC: G8427: Current Medications Documented;
G8430: Current Medications not Documented
 Clusters: #1 and #22
 Report: EVERY SESSION
PQRS Measures – Depression
Treatment Plan
 #134 Preventive Care and Screening: Screening for Clinical
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Depression and Follow-Up Plan
Domain: CPH
QDC: G8431: Positive screen, documented follow-up plan;
G8510: Negative screen, follow-up not required;
G8433: Screening not done, patient not eligible
Clusters: #11
Report: Once a year or every new episode (must be four
months since end of last treatment)
PQRS Measures –
Unhealthy Alcohol Use
 #173 Preventive Care and Screening: Unhealthy Alcohol Use
 Domain: CPH
 QDC: 3016F: Patient screened for unhealthy alcohol use
using a systematic screening method
3016F-1P: unhealthy alcohol use screening not performed,
 Clusters: #22
 Report: Once a year or every new episode (must be four
months since end of last treatment)
PQRS Measures –
Elder Maltreatment
 #181 Elder Maltreatment Screen and Follow-Up Plan
 Domain: PS
 QDC: G8733: Documentation of a positive elder
maltreatment screen and follow-up plan
G8734: Elder maltreatment screen documented as negative
 Clusters: None
 Report: Once a year
PQRS Measures – Tobacco Use
 #226 Preventive Care and Screening: Tobacco Use: Screening
and Cessation Intervention
 Domain: CPH
 QDC: 4004F: Patient screened for tobacco use AND
received tobacco cessation intervention (counseling,
pharmacotherapy, or both), if identified as a tobacco user
1036F: Current tobacco non-user; patient screened for
tobacco use and Identified as a non-user of tobacco
 Clusters: #1, #22
 Report: Once a year
PQRS Measures –
Alcohol Dependence
 #247 Substance Use Disorders: Counseling Regarding
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Psychosocial and Pharmacologic Treatment Options for
Alcohol Dependence
Domain: ECC
QDC: 4320F: assessment of psychosocial and pharmacologic
treatment options for alcohol dependence
Clusters: #22
Report: Once a year
PQRS Measures – Depression and
Substance Dependence
 #248 Substance Use Disorders: Screening for Depression
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among Patients with Substance Abuse or Dependence
Domain: ECC
QDC: 1220F: screening for depression among patients with
substance abuse or dependence
1220F-1P: screening for depression among patients with
substance abuse or dependence not completed for medical
reasons, documentation required.
Clusters: #22
Report: Once a year
Two Ways to Submit PQRS
 Claims reporting – through CMS-1500 – most practical way
for private practitioners
 Must be submitted once a quarter for most QDCs
 Easiest way to submit QDCs every time bill
 Registries – will collate PQRS information – to use must have
80% of all Medicare cases with 3 measures reported OR a 20
patient sample
PQRS Claims Reporting –
CMS-1500 Details
 Put G-codes into 24D - right under CPT codes
 Put in ‘pointer’ for each DSM/ICD diagnosis in 24E
 Be sure to add $.01 in 24F for each G-code
 For more information on CMS-1500 go to:
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c26.pdf
 For sample new CMS-1500 form (02/12), go to:
http://www.clinicalsocialworkassociation.org/sites/default/files/CSWA%20%20CMS-1500%20Changes%20-%203-14.pdf
Reactions to Past 20 Slides
PQRS and EHRs
 PQRS will be automatically loaded into approved programs
 LCSWs not required to use EHRs by 2015, as physicians are,
but may be required after 2015 to avoid payment penalties or
to even receive third-party reimbursement
 No incentives or meaningful use requirements at this time
 Important to become ‘literate’ in EHR systems for future
Considerations in Choosing an EHR
 EHRs have 18 areas which should be reviewed to make
best decision – not all LCSWs will want all functions,
which include:
 Record keeping (see below)
 Billing
 Outcomes tools
 Interoperable system
Considerations in Choosing an EHR
(cont.)
 Business Associate Agreement
 Website Integration
 Client ‘Portal’ for Record
 Client Forms
 View appointments
 Schedule Appointments
 Encrypted Messaging/Emails
Considerations in Choosing an EHR
(cont.)
 Data Portability
 Bill Paying Option
 Graphic User Interface
 User Experience
 Tablet Friendly
 Server Support
 Reliability
Problems with EHRs
 EHRs were designed to prevent fraud but not successful so
far
 Privacy still issue – no required auditing of who logs on to
records and encryption – breaches exploding
(http://www.healthcareitnews.com/news/cms-called-out-ehr-fraudfailings?goback=.gde_4172177_member_5828467181918134276#!)
 HHS and CMS trying to address
Online Billing Systems
 Hard to find online billing system that is as reliable as direct
payment
 Currently Paypal, Square, and Intuit most widely used
 Be prudent when choosing online billing/payment system
The Future in Mental Health
 There are no absolutes, but here are some likely changes that
LCSWs can expect:
The Future:
Personal Health Records (PHR)
 http://www.cms.gov/Medicare/E-
Health/PerHealthRecords/downloads/SummaryofPerso
nalHealthRecord.pdf
 Designed to give patients control of health records but
not as robust as CMS hoped
 May become record model over next 10 years
The Future:
Integrated Care
 Medicare goal - 'integrated care' systems, i.e., care provided in
health homes and ACOs which operate on capitated cost
management
 Integrated care systems will promote communication
between medical professionals working with a patient
 LCSWs may see better communication with other health
care professionals
The Future:
New Medicare Rate Formula
 Sustainable Growth Rate (SGR) ties Medicare
reimbursement to Consumer Price Index, long been seen as
flawed
 Implementation has been delayed 17 times since it was
established in 1996, as potential cuts rose to 27%
 Congress delays at last minute (currently delayed until March
31, 2015)
 New formula for reimbursement needed to replace ‘doc fix’
The Future:
Health (Medical) Homes
 New systems which provide capitated funding for integrated
care
 Mainly connected to Medicaid in Affordable Care Act
 Require balancing mental health costs with medical costs
The Future:
Accountable Care Organizations
 Accountable Care Organizations – identify high cost
conditions and assure that steps are taken to treat conditions
early
 Must be approved by the Office of National Certification
(ONC) and oversee 5000 Medicare or Medicaid beneficiaries
– currently @200 ACOs
The Future: ACOs
 Will seek clinicians in next 2-5 years
 ACOs will look something like Cleveland Clinic, except will have
capitation, profit-sharing/loss-sharing
 Go to http://www.cms.gov/Outreach-and-
Education/Outreach/NPC/Downloads/2013-04-09-MSSPNPC.pdf to get information on becoming a provider for ACOs
The Future: Outcome Tools
 Outcome Tools (2-5 years)
 PQRS data tip of the iceberg in terms of required outcome
data of all kinds
 Provide a baseline for what kinds of treatment work with
what kinds of treatment goals
 CSWA hopes to offer guidance about the way to integrate
outcome tools into our practices in the near future.
Many Questions
 How do we choose our practice model, private practitioner
or group practice?
 How do we choose to have a private pay or third-party pay?
 What is the right way forward for each LCSW?
Difficult But Necessary Choices –
Time Frame
 All choices likely to be necessary in next five years
 Mental health world different from today
 Possible changes will be:
- inclusion of LMHCs and LMFTs in Medicare;
- national licensure standards (already true in military);
- decisions about working in ‘clinic’ systems and/or privately
Difficult But Necessary Choices PQRS
 If we choose to work in Medicare after 2015, LCSWs will
need to incorporate PQRS and EHRs into our practices to
avoid reimbursement penalties
 May be necessary for private insurers as well
 ACOs/health homes may be a useful option in terms of
administering the new requirements for health care
reimbursement
Difficult But Necessary Choices –
Interoperable Record-Keeping
 Interoperable electronic record keeping systems will be
required for third-party reimbursement
 May be provided by ‘clinic’ systems which pay ‘salary’ based
on outcomes, possible bonus/penalty
 Systems must be certified by ONC
Difficult But Necessary Choices –
Practice Only Record-Keeping
 If private practice, may only use practice electronic systems
or stay with paper record keeping
 Must still have dual record-keeping if want to keep
psychotherapy notes private
 Probably need to do more branding and marketing to build
practice privately
Difficult But Necessary Choices –
Health Care Systems
 Move from 3rd party fee-for-service to pay-for-performance
 Role of insurers as exist today unclear for reimbursement
 In-network systems only – Out-of-network likely to be
eliminated in next five years
Difficult But Necessary Choices –
Health Care Systems
 For future 3rd party payments, will need to join one or more
of following:
- Health/Medical Homes
- Accountable Care Organizations
- Medicare
- Independent Practice Organizations
Be Prepared to Educate
 LCSWs will need to explain to other health care
professionals why mental health treatment needed as follows:
1) treatment needed for chronic mental health conditions,
especially ones like personality disorders and substance abuse,
that for decades have been given short shrift in terms of
coverage
2) the importance of integrating psychotherapy with medication
as a primary treatment, rather than medication alone as a
primary intervention
Thanks for Participating!
CSWA hopes that this information will make navigating the
new health care delivery changes easier.
Clinical Social Work Association
P.O. Box 10
Garrisonville, VA 22463
1-703-522-3866
www.clinicalsocialworkassociation.org