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AAO Logo (PRNewsFoto/American Academy of Ophthalmology)

Academy’s Effort to Secure More Accurate Quality Benchmarks Benefits Retina Specialists
Ophthalmologists using EHRs can more easily avoid value-based modifier penalties

In a 2016 quality-benchmarks report released last month, the Centers for Medicare & Medicaid Services confirmed that it will use lower value-based modifier benchmarks for physicians using electronic health records and IRIS® Registry participants with integrated EHRs. CMS will score these physicians against lower benchmarks than those who reported for the Physician Quality Reporting System manually or through claims-based data.

CMS calculates 2018 value-based modifier adjustments based on 2016 PQRS performance. This is the first time CMS will score EHR-based reporters, including IRIS Registry-EHR integration, differently than those who report manually or using claims. The Academy advocated for this change, which will result in a fairer comparison for the value-based modifier. This can help you avoid penalties.

CMS uses quality benchmarks to assess a physician’s 2016 PQRS measures to determine any value-based modifier payment adjustments for 2018.

Historically, physicians in any specialty reporting via EHR typically score worse against quality benchmarks than do physicians using claims reporting or using a manual clinical data registry reporting method. This does not mean these physicians have lower success rates. In fact, there are several reasons why performance rates may be lower for EHR-based reporters.

For example:

  • CMS requires very exact documentation when reporting through an EHR.
  • Some EHR systems do not collect all the information needed for successful submission for every measure.
  • Cloud-based systems, because of the data transfer process, sometimes submit data to IRIS Registry that is different than what the practice “sees” in the EHR system – unlike non-cloud based systems.

Good news! The new benchmarks mean that providers using an EHR system or the IRIS Registry-EHR integration option to report PQRS in 2016 will have a greater likelihood at successfully avoiding penalties under the 2018 value-based modifier than in past years. Further, the published benchmarks confirm that perfect or very high performance is not required to avoid penalties, as long as physicians’ 2016 performance fall within the accepted benchmark range.

To illustrate, some electronic clinical quality measures retina specialists frequently report on are included in the chart below. Performances higher than the average quality range would be considered “high quality”; below the average quality range would be considered “low quality.”

CMS Electronic Clinical Quality Measure Benchmarks:

  • PQRS measure number 374: Closing the Referral Loop:  Receipt of Specialist report
    Benchmark: 22.97%
  • PQRS measure number 19: DR: Communication with Physician Managing Diabetes Care
    Benchmark: 45.41%
  • PQRS measure number 236: Hypertension: Controlling High BP
    Benchmark: 62.92%
  • PQRS measure number 18: DR: Documentation of ME and Level of Severity
    Benchmark: 59.85%
  • PQRS measure number 117: Diabetes Mellitus: Dilated Eye Exam
    Benchmark: 57.80%

As in previous years, CMS compares those who report by claims or via the manual-entry IRIS Registry web portal against higher benchmarks. Therefore, these physicians will likely receive average quality scores. However, as with the EHR reporters, having a performance rate that is less than perfect does not mean that CMS will necessarily identify you as low quality or penalize you.

Further, under the value-based modifier, CMS analyzes your quality performance across the National Quality Strategy domains. Even if you perform below the accepted performance range for one measure, if you perform well on other measures in the same quality domain, you may still avoid the low quality score.

In a nutshell, if you report through the IRIS Registry with your integrated EHR system, you will be judged against lower benchmarks. This makes it easier to avoid a penalty.