I am going to describe the process by which CMS calculates Quality and Resource Use and then show you data from my own Quality and Resource Use Report (QRUR). Warning: there is math involved, and there is no possible way to make this topic interesting. However, it is vitally important. “Resource use” is a major part of the Value-Based Modifier, which is a major component of the Merit-Based Incentive Payment System (MIPS), which determines what percentage of a provider’s Medicare billing they get to keep. In other words, how you score on your QRUR determines whether your Medicare payments are adjusted upwards, downwards, or not at all. Most importantly, wound care clinicians might score very badly on the QRUR through no fault of their own. Keep reading to find out why. However, if you understand how the QRUR works, you can avoid being totally burned by your QRUR score. Seeing my QRUR may help you understand what you need to do in 2016.
Episodes of Care and the “Most Responsible” Provider
The QRUR [report] is distributed to all medical group practices and solo practitioners who had at least one 2014 QRUR “episode.” The data comes from Medicare fee-for-service patients only and contain a total of 64 reported episode types comprised of both acute conditions and procedure-based episodes. We are going to hear the phrase “episode-based” more and more as outpatient reimbursement starts to look and feel more like inpatient reimbursement (with rates set by diagnosis), except that QRUR “episodes” can include both inpatient and outpatient services bundled together AND they can be linked to OUTCOMES (at least, that is the idea). The “episode of care” for the QRUR has a “trigger event” identified by a certain procedure or diagnosis code (e.g. a knee replacement). Some episodes include services and procedures occurring a few days prior to the trigger event, as well as complications of the condition or the treatment, diagnostic tests, and post-acute care including LTAC care, hospice and a variety of outpatient services.
Table 1 below lists the 64 episodes that CMS used to create the QRUR. There are 20 Acute Episode types and 44 Procedural Episode types (including some subtypes of each). Subtypes were chosen to help providers understand how their care for specific subsets of the episode may differ, the idea being that in looking at the details of charges, clinicians might learn something about their practice patterns. There is at least 1 category with subtypes relevant to a wound care clinician. The category of “Cellulitis” has the following 3 subtypes: 1) Cellulitis in Diabetics, 2) Cellulitis in Patients with Wound, non-Diabetic, and 3) Cellulitis in Obese Patients, non-Diabetic without Wound.
CMS then assigns the identified episode to the practitioner determined to be the “most responsible” for the patient’s care (read “the most responsible for charges generated”). Practitioners are identified by their Medicare-enrolled tax identification number (TIN). For Acute Condition episodes, the most responsible clinician is the one who billed at least 30% of the inpatient Evaluation and Management (E&M) visits during the trigger event. The “lead” eligible professionals are the 3 clinicians who billed the largest share of inpatient E&Ms during the trigger event. For Procedural episodes, the “responsible clinician” is the clinician whose TIN is listed on the claim as having performed the specified procedure. In trying to figure out how this relates to my own QRUR report, note that all the Procedures in Table 1 (items 21- 64) are major surgical procedures. Surgeons (especially vascular and plastics) who practice wound care but who perform any of the following procedures should take special note because these patients are likely to end up on their QRUR: aortic aneurysm repair, valvular heart surgery, coronary bypass surgery, hip replacement or repair, knee replacement, or any type of breast cancer surgery or breast reconstruction. The rest of us are likely to be identified from activities related to participation in the cases of patients hospitalized for things on the Acute Conditions list (items 1 – 20, Table 1). Remember that the patients from whom your cost data will be derived are not going to be the same patients for whom you have reported quality data.
Stay tuned for the continuation next week “Cost Calculations”
Caroline Fife, MD
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