American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

CMS Approves MBSAQIP Data Registry as a QCDR

The MBSAQIP is proud to announce that on April 29, 2014 the Centers for Medicare and Medicaid Services (CMS) approved the MBSAQIP Data Registry as a Qualified Clinical Data Registry (QCDR) for the 2014 Physician Quality Reporting System (PQRS) reporting mechanism. MBSAQIP is one of only over 30 other organizations to receive this approval.

What Is PQRS?

The Physician Quality Reporting System (PQRS) is a CMS reporting program that uses incentive payments and penalties to promote reporting of quality information by eligible professionals (EPs). The PQRS provides a 0.5% incentive payment of the total allowed charges through 2014 to individual physicians or group of physicians for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period. PQRS, however, is transitioning from an incentive payment for participation to a payment penalty for non-participation. Penalties for non-participation in PQRS reporting will begin in 2015. Penalties are applied to EPs two years following the current calendar year (see Table 2 below).

What Is a QCDR?

A QCDR is a CMS-approved entity (registry) that collects clinical data for the purpose of patient and disease tracking to improve quality of care provided to patients in a particular population.

There are several ways for a physician to report PQRS measures (claims-based, registry-based, or EHR-based reporting); however, starting in 2014 the QCDR provides a new option for individual Eligible Professionals (EPs) to meet PQRS requirements. Most importantly, the QCDR reporting option allows MBSAQIP to develop its own quality measures thereby allowing bariatric surgeons to choose what is reported to CMS. These measures can be more relevant, clinically appropriate, and actionable for metabolic and bariatric surgeons when compared to traditional PQRS measures.

Physicians may satisfactorily participate in PQRS through a QCDR and (see Table 2 below):

  • Earn the 2014 incentive payment (+0.5%)
  • Avoid the 2016 payment adjustment (-2.0%)

How Do Metabolic and Bariatric Surgeons Participate in the MBSAQIP QCDR?

MBSAQIP participants (U.S. surgeons who accept Medicare and have valid NPIs) will have the opportunity to voluntarily elect that their MBSAQIP QCDR quality measures results be submitted to CMS for PQRS participation. Physicians will be provided with reports of their results of the QCDR measures to track their performance throughout the year. The MBSAQIP will submit approved measures during the first quarter of 2015 on behalf of MBSAQIP participants only if individual surgeons choose to have their data submitted to CMS. The choice is up to the physician—if qualified, they can choose to submit their MBSAQIP data, or choose to submit using other reporting options to satisfy the PQRS requirements. One benefit of using the MBSAQIP is that this data is already being collected as part of participation in the MBSAQIP.

To earn the PQRS incentive by using a QCDR in 2014, an EP must successfully report at least 9 individual measures including at least one outcome measure, covering at least 3 National Quality Strategy (NQS) domains, and report each measure for at least 50 percent of provider’s applicable patients seen during the reporting period to which the measure applies. Participation in the MBSAQIP will satisfy all these requirements. Penalties are applied to EPs two years following the current calendar year (see Table 2 below).To avoid a payment penalty in 2016 and not earn an incentive payment, an EP must successfully report in 2014 at least 3 individual measures covering at least 1 NQS domain. Measures with a 0 percent performance rate will not count.

Table 1: The 2014 MBSAQIP QCDR nine measures and NQS domains

MBSAQIP Measure Title NQS Domain
1. Risk standardized rate of patients who experienced a postoperative complication within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Effective Clinical Care
2. Risk standardized rate of patients who experienced a readmission (likely related to the initial operation) to any hospital within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Efficiency and Cost Reduction
3. Risk standardized rate of patients who experienced a reoperation (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Efficiency and Cost Reduction
4. Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Effective Clinical Care
5. Risk standardized rate of patients who experienced a bleeding/hemorrhage event requiring transfusion, intervention/operation, or readmission within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Effective Clinical Care
6. Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) (superficial incisional, deep incisional, or organ/space SSI) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Effective Clinical Care
7. Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Effective Clinical Care
8. Risk standardized rate of patients who experienced extended length of stay (> 7 days) following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary procedure Patient Safety
9. Percentage of patients who had complete 30 day follow-up following any metabolic and bariatric procedure Communication and Care Coordination

Value-Based Payment Modifier (VM)

Participation in PQRS will also impact the physician value-based payment modifier (VM), which will be implemented starting in 2015. The VM provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based on the quality of care furnished compared to cost during a performance period. The VM will be phased in over three years, applying first to physicians in groups of 100 or more EPs in 2015, then to physicians in groups of 10 or more EPs in 2016, and to all physicians in 2017. Physicians who are successful PQRS reporters will be eligible for VM bonuses, and those who are not successful PQRS reporters will be subject to penalties under the VM.

Table 2: PQRS and VM payment incentives and penalties

Calendar Year (CY) PQRS Incentive PQRS Penalty VM Incentive VM Penalty Total Penalties
2014 +0.50% -2.00%





Applied in CY 2016
Range of incentives, with maximum of+2.00%


Applied in CY 2016 to physicians in groups of 10+ EPs
Range of penalties, with maximum of-2.00%


Applied in CY 2016 to physicians in groups of 10+EPs
-4.00%
2015 N/A -2.00%




Applied in CY 2017
Range of incentives, maximum currently unknown

Applied in CY 2017 to all physicians
Range of penalties, maximum currently unknown

Applied in CY 2017 to all physicians
TBD
2016 N/A -2.00%




Applied in CY 2018
Range of incentives, maximum currently unknown

Applied in CY 2018 to all physicians
Range of penalties, maximum currently unknown

Applied in CY 2018 to all physicians
TBD

This is an excellent opportunity for metabolic and bariatric surgeons to participate in quality initiatives. Through participation in the MBSAQIP, surgeons could fulfill Part IV of the American Board of Surgery Maintenance of Certification (MOC) program, meet PQRS reporting requirements, avoid PQRS penalties and potentially earn incentives under PQRS and the VM program.

The Agreement/Consent Form will be available soon and more information regarding the MBSAQIP QCDR will be posted to the MBSAQIP website and shared via email. In the interim, should you have any questions, please contact mbsaqip@facs.org.

Specifications of the approved QCDR MBSAQIP quality measures are available here.

A list of CMS-designated QCDRs is available on the CMS PQRS website at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html

More information about PQRS reporting in 2014: http://bulletin.facs.org/2014/03/pqrs-reporting-in-2014/