PQRS – Understanding the “WHY”, not the how

21 May PQRS – Understanding the “WHY”, not the how

The triple aim: Better care. Better health. Lower costs.

You’ve read the implementation guides, followed the guidance of your EHR vendor and mapped all of the requirements to collect data. You’ve attended webinars, listened to live chats and completed all trainings related to program incentives and penalties. Workflows have been observed and reworked. Redesign strategies are in place. All requisite data fields are enabled and your staff is trained. Early gap analyses reflect that your blood, sweat and tears to transition to an electronic environment, comply with governmental directives and your Medicare payments will continue to flow without sanction. Let the clicking begin.

But, do you really have an understanding of the big picture?

Do you really “get it?”

Does it make sense?

Do you have a feel for how each of those clicks affects the big picture, how each of those clicks can possibly affect patient outcomes?

Why are you doing all of this?

How does this all really tie together, to achieve the coveted “triple aim?”

Let’s take a look at the big picture.

Currently…a patient is seen for an office visit, a diagnosis for a certain condition has been determined, documentation for the visit is complete, and a claim is prepared and filed with Medicare, using appropriate CPT codes. Medicare pays for your service never really knowing if the service provided, either helped, hindered or…made any difference whatsoever to improve the health of the patient. The same patient is seen in routine follow up visit for the same diagnosis. The process is repeated. Can the success or failure of the previous treatment really be determined?

As the adage goes, “if you don’t measure it, you can’t improve it.”


PQRS is the tool that will measure the success of treatment efforts. Applying PQRS strategies will allow measurement of, adjustment of, and treatment modifications, should outcomes indicate that an alternative treatment option may support a better outcome.

Here’s how it works. Preliminary back office selection and mapping of clinical quality measures has been completed, per scope of practice preference, by your office. Measures appropriate to provider scope of practice are in place so that workflows can efficiently capture quality actions performed during an office visit, real time, as the medical record is created during the office visit.

The provider sees a patient and determines a diagnosis. Upon completion of the visit and supporting documentation, the medical record is embedded with diagnosis related quality actions selected and a treatment plan is determined. Post visit, the data saved into the electronic medical record is entered into the billing system and is linked to the appropriate CPT code that supports the service provided.  The claim is then electronically submitted to CMS for analysis and payment.

The claim is analyzed for diagnosis related quality actions. If the metrics of the measure have been satisfied, the data for this claim are included in the PQRS program denominator and the numerator. If not, they do not qualify, and are not added to either. The provider has now successfully determined a diagnosis, selected an appropriate CPT code, attached related quality metrics performed to support the diagnosis and sent the claim for payment. Quality metrics are stored at the CMS level per diagnosis and outcomes tracked for future reference. Outcomes tracked through measure statistics affect better outcomes in the future.

Once this process is completed, it is possible to statistically verify that Patient X with a diagnosis code XXX and related quality actions XXX & XYZ were performed for Patient A. These findings, when associated with a CPT code on date XX/XX/XXXX, either did or did not improve the condition as a result of the quality treatment decisions attributed to that visit.

A provider can now use the statistics from previous visit plans to analyze outcomes for a specific diagnosis, as a barometer as to what worked and what did not. Through this analysis, treatment plans may be adjusted based on statistical results.

The process equation is simple: CPT code + diagnosis code + quality measures = measurable outcome metrics for ensuring optimal improved health for this patient in the future. And by the way, you’ve also successfully included this patient’s quality metrics into your PQRS requirements.

PQRS does not have to be a mystery when you take a look at the equation that pulls the overall concept of each program together. As a result, you will be compliant with the PQRS program and stave off ill financial consequences.

Now, as you run through your mental checklist of required “clicks”, the reason that you select and apply each metric should make the understanding of the process more clear. Know that you are laying the groundwork for the highest level of care for your patient based on objective clinical measurement. Future treatments will now be a direct reflection of measured actions as you begin to exam and use the data that you trend.

Happy clicking!

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Peggy Losey

Manager of Ambulatory Incentive Programs at eHealthcare Consulting Inc.
Our Central and West Coast Outpatient Meaningful Use (MU) and PQRS Services Manager, brings 19 years of clinic operational expertise to the “family” and brings a true passion to her work as an avid patient and physician advocate. Her background includes supporting all aspects of physician practice EHR implementations and her recent work as a EHR Clinical Implementation Specialist working for a Regional Extension Center (REC) enables her to provide service offerings that many physician practices are in need of today.
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