Quality Reporting for 2015: The ED Is Now A Site for Screening for Hypertension

By Ron Stunz, MD, FACEP

The Physician Quality Reporting System (PQRS) has undergone some dramatic changes beginning this reporting year. First, unlike in the past, successful reporting will no longer result in the payment of a bonus. Secondly, failure to successfully participate in PQRS in 2015 will result in significant “negative adjustments” (read: Penalties) in 2017 to the tune of a 2% docking of total Medicare Revenue. Third, PQRS reporting is directly linked to payment adjustments in the context of the Value Based Modifier program for 2017; here, failure to successfully report PQRS in 2015 triggers an additional 4% loss of Medicare revenues. Thus, failure to meet PQRS reporting obligations in 2015 could cost every ED provider as much as 6% of total Medicare revenues in 2017, and the need to successfully participate in the program now has a fiscally more palpable importance than the payment of small bonuses in prior years.

Several structural changes within the specialty of Emergency Medicine have also occurred which impact our reporting methodologies for the PQRS program. Claims-based reporting, our only pathway for reporting in past years, will continue for 2015, however, claims-based reporting is widely seen as being phased out entirely by CMS as soon as 2016. An added disincentive to claims-based reporting in 2015 is that to be successful, the provider must either report on nine claims-based measures or, if reporting on fewer than nine measures, have his claims subjected to what is known as the Measure Applicability Validation (MAV) process in which CMS evaluates all potentially available cases to determine whether the provider availed himself of every reporting possibility. And, unfortunately, for Emergency Medicine only eight claims-based measures are available for reporting, meaning any attempt at standard claims-based reporting in 2015 will automatically subject the provider to the uncertainties of the MAV process.

A second development of importance for reporting is the establishment, by National ACEP, of a formal relationship with a Registry. Registries effectively function as a clearinghouse for PQRS reporting, and this option opens up the ability to report on seven additional PQRS measures that are Registry-only reportable measures. For a fee of about $170 per provider (depending on the size of the ED group) a total of fifteen measures can be reported through the Registry. Full reporting via this channel would eliminate the prospect of going through the MAV process.

The third, and most favorable development for 2015 reporting, is the creation by CMS of a smaller Emergency Medicine “cluster” allowing successful PQRS reporting by the submission of only four measures: EKG for chest pain patients (Measure #54); ultrasound determination of location of pregnancy for pregnant patients with abdominal pain (Measure #254); Rh immunoglobulin (Rhogam) for Rh-negative pregnant women at risk for fetal blood exposure (Measure #255); and a fourth, “cross-cutting” measure, Measure #317, screening for high blood pressure and follow up documented. While the performance of an EKG for patients over forty with non-traumatic chest pain is relatively speaking a matter of routine, and the two pregnancy measures have a low incidence among Medicare beneficiaries, the cross-cut screening for high blood pressure has substantive implications for how Emergency Physicians practice and how they must now document. For, although claims-based reporting of the ED “cluster” obviates the need for Registry signup and fees, the “cluster” reporting will still be subjected to the MAV record review process, and the sweeping scope of Measure 317 presents some challenges.

Measure 317, as a “cross-cutting” measure, will be reported by a number of medical specialty fields and certainly has obvious value in bringing to diagnosis and treatment a potentially significant number of patients with an otherwise unrecognized treatable medical condition. However, some of the requirements of successful reporting of this measure require some retooling of the Emergency Medicine patient record. In the first place, Measure 317 must be reported for all Medicare patients seen in the ED regardless of the nature of their presenting problem. Thus, a 65 year old who comes to the ED with a cough and is discharged with a diagnosis of bronchitis must not only have a blood pressure reading recorded (again, a matter of routine), but the ED physician must then comment on and categorize by severity the level of blood pressure abnormality and then further make specific arrangements for follow up care in function of the level of BP abnormality. So, not only will ED providers be obliged to comment on blood pressure readings in clinical circumstances where they may have nothing to do with the reason for the patient’s visit, but, as bolded and underlined in the Measure specifications for the numerator, “and a recommended follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or hypertensive.”

The “as indicated” requirement noted in the Measure specifications refers to the following table, itself a component of the Measure definitions:

Recommended Blood Pressure Follow-Up Table
BP Classification
Systolic BP mmHg
Diastolic BP mmHg
Recommended Follow-Up
(must include all indicated actions for each BP Classification)

Normal BP Reading < 120 AND < 80
• No Follow-Up required

Pre-Hypertensive BP Reading ≥ 120 AND ≤ 139
OR ≥ 80 AND ≤ 89
• Rescreen BP within a minimum of 1 year

AND Recommend Lifestyle Modifications
• Referral to Alternative/Primary Care Provider

First Hypertensive BP Reading ≥ 140 OR ≥ 90
• Rescreen BP within a minimum of ≥ 1 day and ≤ 4 weeks AND Recommend Lifestyle Modifications

• Referral to Alternative/Primary Care Provider

Second Hypertensive BP Reading ≥ 140 OR ≥ 90
• Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions (see definitions)

• Referral to Alternative/Primary Care Provider

Since it is unlikely that significant “lifestyle modifications” counseling will occur in the ED for an unrelated problem, and even more unlikely that follow-up would occur with the ED provider himself, the alternative of referral to the primary care provider would be the follow-up outcome in almost all cases. But, it’s important to note, the recommended follow-up must be documented in every case if the positive element of the Measure is to be met.

The only exceptions to the need to report Measure 317 on every Medicare case are the following situations categorized as “not eligible”:

  • Patient has an active diagnosis of hypertension
    • Patient refuses blood pressure measurement
    • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
  • This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.

    Duly noting these exclusions, it remains a fact that the vast majority of Medicare patients presenting to the ED will require documentation specific to Measure 317 if a substantial negative payment adjustment in 2017 is to be avoided. Further, since the reporting of this cross-cutting measure is also required in Registry reporting or if reporting only on 8 standard measures via claims-based reporting, there is no getting around the requirement to address the specifics of Measure 317 in every Medicare patient record. Reporting on Measure 317 is obligatory for all PQRS submissions in 2015.

    How best to tackle this challenge is the responsibility of every Emergency Department director and will obviously vary somewhat in function of local practice patterns and the malleability of the Electronic Health Record or other documentation tool in place. One suggestion is to build the Table from Measure 317 into the discharge instructions of every patient whose insurance information indicates they are Medicare beneficiaries over the age of 18. The physician needs to indicate which of the four categories the patient falls into based on BP reading, and make the appropriate follow up recommendation. Alternatively, if the flexibility of the EHR allows for this, an algorithmic default could be built in such that every Medicare insurance sign in automatically generates the documentation parameters of Measure 317 directly into the body of the clinical note, allowing the provider to complete the Measure requirements as part of the clinical record itself.

    It is worth noting that, like all PQRS measures, Measure 317 includes the ability to not document the BP or the recommended follow up and provides codes for these “negative” documentation standards and, at present at least, there is a “no harm/no foul” approach on the part of CMS: the Measure has been “reported” albeit unmet in its positive aspects. Going forward however it seems likely that excessive use of these “negative” reporting codes may eventually have negative performance and reimbursement consequences.

    Finally, successful reporting via the cluster/MAV pathway requires that only fifty percent of eligible cases be reported. Thus, there is still ample time in 2015 to educate providers, ramp up the health care record to accommodate the requisite new information and still achieve the 50% reporting threshold.

    So, welcome to the new world of the ED as a hypertension screening center!

    Ron Stunz, MD, FACEP is the Co-Chairman of the PACEP Emergency Medicine Practice and Medical Economics Committee. Nationally he serves on ACEP Committees for Reimbursement and the Coding Nomenclature Advisory Committee. He is the Medical Director for Zotec Partners.