It’s a new year, and you know what that means: a new PQRS reporting period. Many WebPT Members have already started reporting PQRS data—and that’s great. The sooner you begin reporting, the sooner you’ll reach the minimum reporting requirements and thus ensure you avoid the 2% penalty.
As you might recall from this blog post, you have a few different options when it comes to satisfactory PQRS reporting. For those practitioners who treat a large population of Medicare patients with back pain, we recommended reporting on the back pain measures group, as it is by far the easiest way to not only avoid the penalty, but also earn the 0.5% incentive payment that is available to those who report to the highest possible degree.
Initial Visit vs. Episode
However, the wording Medicare used to explain the requirements for the back pain measures group was a bit confusing, and we’ve received several requests for clarification. According to Medicare’s specifications for this measure (Measure #148: Back Pain: Initial Visit), eligible patients must have a qualifying back pain diagnosis and must not have been “seen or treated for back pain by any practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back pain.”
At first glance, that stipulation may appear to exclude patients who initially saw a physician before being referred to physical therapy. Thankfully, that is not the case. Medicare is merely targeting a more chronic pain patient population who has procrastinated—as many do—before seeking medical attention. In other words, the date of injury or pain onset must be at least four months prior to the patient’s first visit with any medical professional. Although it’s not immediately clear in the above excerpt, you can report on a patient who has already seen another provider—such as a physician or chiropractor—during a particular episode as long as the patient experienced back pain for at least four months prior to seeking any type of medical treatment. Upon seeking treatment for back pain—whether it’s a recurrence of prior pain or an onset of new pain—the first visit to any medical professional triggers the start of a new episode. But if the patient sees both a primary care physician and a specialist (e.g., a PT), both visits are considered the initial visit for each clinician, and both clinicians can report on the back pain measures group for that patient, even though they are treating within the same episode. In fact, further down in the measure specification document, Medicare provides this direction: “If a patient has a four-month period without treatment, and then sees both a primary care physician and a specialist, both visits are considered the initial visit with that clinician.”
Another common scenario involves returning patients (i.e., those who discontinued therapy for their back pain but later returned for further treatment). In such cases, the key factor in patients’ eligibility for the back pain measures group is the amount of time that has elapsed since the patient’s last date of treatment. If at least four months have passed during which the patient sought no medical treatment for his or her back pain (from any medical professional, not just you or another physical therapist), then the patient would enter a new episode and therefore would qualify for back pain reporting. Per CMS: “A new episode can either be a recurrence for a patient with prior back pain or a patient with a new onset of back pain. The first clinical encounter after the four months without being seen or treated for back pain is considered the beginning of the new episode.”
Speaking of first encounters, please remember that to satisfactorily report on the back pain measures group, you must report at the initial visit for each qualifying patient. This means that if the patient’s initial visit for an episode of back pain occurred prior to the beginning of the reporting period (i.e., before January 1, 2014) this patient will not count toward the required 20-patient sample.
Also, please note that if—and this is a big “if”—the patient is receiving therapy post-surgery, that patient does not qualify for the back pain measures group unless it has been four months since surgery and he or she has not received any other treatment over the course of that four-month period (which is a highly unlikely scenario).
Still, I feel strongly that a physical therapy practice with a steady volume of Medicare back pain patients can meet the reporting requirements for the back pain measures group, especially if that practice has a back specialty program. From what I can surmise, the purpose of the back pain measures group is to collect data related to chronic back pain. I know four months without treatment may seem like a long period of time, but during my time as a practicing therapist, I frequently treated lower back pain on patients who experienced pain for years without seeking medical attention. They were simply waiting for the pain to become unbearable. Those patients would absolutely qualify for this measure. Thus, when assessing whether the back pain measures group would be a sound reporting option for your practice, you should consider how many chronic back pain patients you see and treat.