CMS Pub. 100-22, ch. 1
(Rev. 82, 03-22-19)
90 - Confidential Feedback Reports 100 – Direct Mailings
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The Physician Quality Reporting System (formerly known as Physician Quality Reporting Initiative or PQRI) is a reporting program that provides a combination of incentive payments and payment adjustments to identified individual eligible professionals and group practices who satisfactorily report data on quality measures for covered professional services (defined below) furnished by eligible professionals during a specified reporting period.
The Physician Quality Reporting System was first implemented in 2007, then referred to as PQRI, as a result of section 101 of Division B – Medicare Improvements and Extension Act of 2006 of the Tax Relief and Health Care Act of 2006 (P.L. 109-432) (MIEA-TRHCA), which was enacted on December 20, 2006. Section 101(b) of the MIEA-TRHCA adds subsection (k) to section 1848 of the Social Security Act (the Act), which requires the establishment of a quality reporting system. Section 101(c) of the MIEA-TRHCA authorizes the Secretary to provide incentive payments to eligible professionals who satisfactorily report data on quality measures under the quality reporting system for covered professional services furnished to Medicare beneficiaries during the second half of 2007. CMS named the quality reporting system, the incentive payment, and the payment adjustment the Physician Quality Reporting System. Section 1848(k)(3)(A) of the Act defines “covered professional services” as services for which payment is made under, or is based on, the Medicare Part B Physician Fee Schedule (PFS) and which are furnished by an eligible professional.
Section 101(b)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173) (MMSEA), which was enacted on December 29, 2007, amends section 1848(k)(2)(B) of the Act (as added by the MIEA-TRHCA) and section 101(c) of the MIEA-TRHCA to extend the Physician Quality Reporting System through 2009 and to authorize the Secretary to make incentive payments for covered Medicare PFS services furnished to Medicare Part B fee-for-service (FFS) beneficiaries in 2008. In addition, the MMSEA amends section 101(c) of the MIEA-TRHCA by requiring the Secretary, for 2008 and 2009, to establish alternative reporting criteria and alternative reporting periods for reporting on measures groups, and for registry-based reporting.
Section 131 of the Medicare Improvements for Patients and Providers Act (P.L. 110-275) (MIPPA), which was enacted on July 15, 2008, makes the quality reporting system initially established under MIEA-TRHCA permanent. In addition, section 131(b)(2) of the MIPPA redesignates section 101(c) of the MIEA-TRHCA, as amended by MMSEA, as subsection (m) of section 1848 of the Act. Section 1848(m) of the Act, as redesignated and amended by the MIPPA, authorizes the Secretary to make Physician Quality Reporting System incentive payments for covered Medicare PFS services furnished to Medicare Part B FFS beneficiaries in 2009 and 2010.
The Affordable Care Act (ACA) makes further changes to the Physician Quality Reporting System, including the following: authorizing incentive payments until 2014; requiring payment adjustments beginning in 2015 for eligible professionals who do not satisfactorily report data on quality measures during the applicable reporting period for the year; requiring timely feedback to participating eligible professionals; requiring the establishment of an informal review process
whereby eligible professionals may seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures for purposes of qualifying for a Physician Quality Reporting System incentive payment; and making available an additional incentive payment for those eligible professionals satisfactorily reporting data on quality measures for a year and having such data submitted on their behalf through a Maintenance of Certification Program and participating in a Maintenance of Certification Program practice assessment more frequently than is required to qualify for or maintain board certification status.
The program requirements for the Physician Quality Reporting System are summarized in this chapter.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
As defined in section 1848(k)(3)(B) of the Act, eligible professional means any of the following:
1. Physicians
2. Practitioners
3. Therapists
Audiologists were added to the definition of “eligible professional” beginning with the 2009 Physician Quality Reporting System as required by section 131(b)(4) of the MIPPA.
All Medicare-enrolled professionals in these categories are eligible to participate in the Physician Quality Reporting System, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Some professionals who are included in the definition of “eligible professional” above, although listed as eligible to participate in the Physician Quality Reporting System, are not able to participate for one or more reasons described below.
Eligible professionals in certain settings in which Medicare PFS billing is processed by Medicare FIs/AB MACs. The FI/AB MAC claims processing systems for the following settings currently cannot accommodate billing at the individual eligible professional level:
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Providers and professionals not defined as eligible professionals are not eligible to participate in the Physician Quality Reporting System and do not qualify for an incentive. Services payable under fee schedules or methodologies other than the Medicare PFS are not included in the Physician Quality Reporting System (for example, services provided in federally qualified health centers, independent diagnostic testing facilities, portable x-ray suppliers, independent laboratories, hospitals [including critical access], rural health clinics, ambulance providers, and ambulatory surgery center facilities). In addition, suppliers of durable medical equipment (DME) are not eligible for the Physician Quality Reporting System since DME is not based on or paid under the Medicare PFS.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Prior to 2010, the Physician Quality Reporting System was limited to eligible professionals and the determination of whether an eligible professional satisfactorily reported quality data was
made at the individual professional level, based on the National Provider Identifier (NPI). No incentive payments were made to a group practice based on a determination that the group practice, as a whole, satisfactorily reported the Physician Quality Reporting System quality measure data. To the extent that individual eligible professionals (based on individuals' NPIs) are associated with more than one practice, or Tax Identification Number (TIN), the determination of whether an eligible professional satisfactorily reported the Physician Quality Reporting System quality measures data was made for each unique TIN/NPI combination. Therefore, the incentive payment amount was calculated for each unique TIN/NPI combination and payment was made to the holder of the applicable TIN (see §30 below).
As required by the MIPPA, group practices can qualify to earn a Physician Quality Reporting System incentive payment beginning with the 2010 Physician Quality Reporting System based on the determination that the group practice, as a whole, satisfactorily reports Physician Quality Reporting System quality measures data. The criteria for satisfactory reporting for group practices and the process for reporting by group practices under the Physician Quality Reporting System group practice reporting option (GPRO) are discussed in §70.3 below. In 2010, "group practice" was defined as a TIN with at least 200 individual eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN.
In 2011, the GPRO was expanded to include a second, smaller GPRO classification, GPRO II. Thus, whereas GPRO I consists of group practices comprised of a TIN with at least 200 individual eligible professionals, under GPRO II, a "group practice" is defined as a TIN with 2-199 eligible professionals. Therefore, in 2011, due to the addition of the GPRO II to the Physician Quality Reporting System, for purposes of this reporting option, "group practice" was defined as a TIN with at least 2 individual eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN.
In 2012, the definition of GPRO was further revised. First, the GPRO II option, along with its reporting requirements, was eliminated. In lieu of GPRO II, the GPRO (classified as GPRO I in 2011) was extended to group practices comprised of a TIN with at least 25 or more eligible professionals. Therefore, effective beginning January 1, 2012, "group practice" is defined as a TIN with at least 25 eligible professionals (as identified by NPIs) who have reassigned their billing rights to the TIN.
In order to participate in the Physician Quality Reporting System GPRO, group practices are required to complete a self-nomination process and to meet certain specified requirements, which include but are not limited to:
Have billed Medicare Part B during a specified timeframe;
Providing CMS with an electronic file (such as, a Microsoft® Excel file) with the self-nomination statement that includes the group practice's TIN and all rendering individual NPI numbers, and name of the group practice;
The specific self-nomination requirements for the Physician Quality Reporting System GPRO for a particular program year can be found in the Group Practice Reporting Option section of the CMS Physician Quality Reporting System website at http://www.cms.gov/PQRS.
CMS assesses whether the participation requirements are met by each self-nominated group practice and notifies group practices of a decision. Under section 1848(m)(3)(C)(iii) of the Act, an individual eligible professional who is a member of a group practice selected to participate in the Physician Quality Reporting System GPRO for a particular program year is not eligible to separately earn a Physician Quality Reporting System incentive payment as an individual eligible professional under that same TIN (that is, for the same TIN/NPI combination) for that year. Once a group practice (TIN) is selected to participate in the GPRO for a particular program year, this is the only Physician Quality Reporting System reporting option available to the group and all individual NPIs who bill Medicare under that group's TIN for that program year.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
A participating individual eligible professional or group practice (see §20 above) who satisfactorily reports data on Physician Quality Reporting System quality measures as described in §70 may earn an incentive payment equal to the applicable quality percent of the Secretary's estimate of allowed part B charges for covered professional services furnished by the eligible professional or group practice during a specified reporting period (see §40 below).
For 2007 and 2008, the applicable quality percent is 1.5% incentive.
For 2009, the applicable quality percent is 2.0%.
For 2010, the applicable quality percent is 2.0%.
For 2011, the applicable quality percent is 1.0%.
For 2012 through 2014, the applicable quality percent is 0.5%.
In addition, from 2011 through 2014, eligible professionals who are physicians may qualify to earn an additional Maintenance of Certification Program incentive (the applicable quality percent for each year is 0.5%). To earn this additional incentive payment, each year, a physician must:
For each year, the Physician Quality Reporting System incentive payment is calculated based on an eligible professional's a group practice's total estimated Medicare Part B PFS allowed charges for all covered professional services: (1) furnished during the applicable reporting period, (2) received into the CMS National Claims History (NCH) file by no later than 2 months after the end of the reporting period, and (3) paid under or based upon the Medicare PFS. Because claims processing times may vary by time of the year and Medicare Carrier/AB MAC, participating eligible professionals or group practices should submit claims from the end of a reporting period promptly, so that if, for example, the reporting period ends on December 31st of a particular year, claims from the end of the reporting period will reach the NCH file by February 28th of the following year. Physician Quality Reporting System incentive payments are paid as a lump sum. Physician Quality Reporting System incentive payments are generally made in the middle of the year following the year in which the reporting period falls. There is no beneficiary co-payment or notice to the beneficiary regarding the Physician Quality Reporting System incentive payments.
The Physician Quality Reporting System incentive payment amount is calculated using estimated allowed charges for all covered professional services under the Medicare Part B PFS, not just those charges associated with reported quality measures. The term "allowed charges" refers to total charges. Note that the amounts billed above the Medicare Part B PFS amounts for assigned and non-assigned claims do not apply to the incentive payment. The statute defines Physician Quality Reporting System covered professional services as those paid under or based upon the Medicare Part B PFS only, which includes technical components of diagnostic services and anesthesia services, as anesthesia services are considered fee schedule services though based on a different methodology.
Other Part B services and items that may be billed by eligible professionals but are not paid under or based upon the Medicare PFS do not apply to the Physician Quality Reporting System
incentive payment. In addition, any amounts owed to CMS, such as from overpayments or other withholds, are subtracted from the incentive payment amount.
The analysis of satisfactory reporting is performed at the individual eligible professional level using individual-level NPI data, and beginning in 2010, for group practices participating in the GPRO, the group practice level using TIN data. For both participating individual eligible professionals and group practices, CMS uses the TIN as the billing unit. Therefore, any Physician Quality Reporting System incentive payments earned are paid to the TIN holder of record. For individual eligible professional, Physician Quality Reporting System incentive payments are paid to the holder of the TIN, aggregating individual incentive payments for groups that bill under one TIN. For eligible professionals who submit claims under multiple TINs, CMS groups claims by TIN for payment purposes. As a result, a provider with multiple TINs who qualifies for the Physician Quality Reporting System incentive payment under more than one TIN would receive a separate Physician Quality Reporting System incentive payment associated with each TIN.
In situations where eligible professionals are employees or contractors who have assigned their payments to their employers or facilities, section 1848(m)(1)(A) of the Act specifies that any Physician Quality Reporting System incentive payment earned be paid to the employers or facilities.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2007 Physician Quality Reporting System, which was the first program year, the reporting period was July 1, 2007 through December 31, 2007, as required by section 1848(m)(6)(C)(i)(I) of the Act.
For 2008 and beyond, section 1848(m)(6)(C)(i)(II) of the Act defines “reporting period” to be the entire calendar year. Under section 1848(m)(6)(C)(ii) of the Act, however, for years after 2009, the Secretary is authorized to revise such reporting periods. In addition, section 1848(m)(5)(F) of the Act requires the Secretary to, beginning with the 2008 Physician Quality Reporting System, establish alternative reporting periods for reporting groups of measures, or measures groups, and for reporting using a medical registry.
Therefore, beginning with the 2008 Physician Quality Reporting System, there are 2 reporting periods for each program year: (1) a 12-month reporting period consisting of the entire calendar year and (2) a 6-month reporting period beginning July 1st and ending December 31st. Depending upon the particular program year, the second reporting period beginning July 1st may not apply to all of the Physician Quality Reporting System reporting options that are available for that program year (see §70 below for further details).
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Eligible professionals may choose to report quality measures data to CMS using one of the following established reporting mechanisms:
Beginning with the 2007 Physician Quality Reporting System, CMS implemented the claims-based reporting mechanism based on submission of quality measures data on Medicare Part B claims.
The registry-based reporting mechanism became available to eligible professionals beginning with the 2008 Physician Quality Reporting System. The registry-based reporting mechanism is available for reporting either individual Physician Quality Reporting System quality measures or Physician Quality Reporting System measures groups (see §60.1 and §60.2, respectively)
The EHR-based reporting mechanism became available to eligible professionals beginning with the 2010 Physician Quality Reporting System and is available for reporting on individual Physician Quality Reporting System quality measures only (see §60.1 below).
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Eligible professionals who choose to participate in Physician Quality Reporting System via the claims-based reporting mechanism do not have to enroll or register with CMS to begin reporting Physician Quality Reporting System quality measures data to CMS.
Participating eligible professionals whose Medicare patients fit the specifications of the Physician Quality Reporting System quality measures and/or measures groups will simply report on their claims the corresponding appropriate quality-data codes (QDCs), which are CPT Category II codes or G-codes (where CPT Category II codes are not yet available). CPT Category II codes and G-codes are Healthcare Common Procedure Coding System (HCPCS) codes for reporting quality data. Claims-based reporting may be via: (1) the paper-based CMS 1500 Claim form or (2) the equivalent electronic transaction claim, the 837-P.
(Rev. 82, Issued: 03-22-19, Effective: 04-22-19, Implementation: 04-22-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
The following principles apply to the reporting of QDCs for Physician Quality Reporting System measures:
Only final action claims will be analyzed for Physician Quality Reporting System. For Physician Quality Reporting System measure calculation purposes, claims will be combined based on the same beneficiary for the same date-of-service, for the same TIN/NPI and
analyzed as one claim. Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses or QDCs are not dropped.
Some measures require the submission of more than one QDC in order to properly report the measure. Eligible professionals may report each QDC as a separate line item, referencing one diagnosis and including the rendering provider NPI.
Use of CPT II modifiers (1P, 2P, 3P, 8P) is unique to CPT II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. Do not append CPT I modifiers to CPT II codes or vice versa.
QDCs shall be submitted to A/B MACs (B) either through:
Electronic submission, which is accomplished using the current version of the ASC X12 837 professional claim format.
CPT Category II and/or temporary G-codes should be submitted in the SV101-2 "Product/Service ID" Data Element on the SV1 "Professional Service" Segment of the 2400 "Service Line" Loop.
• In general for group billing, report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data elements NM109 (NM108=XX).
OR
Paper-based submission, which is accomplished by using the Form CMS-1500 claim (version 02-12). Relevant diagnosis codes are entered in Field 21. Service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers are entered in Field 24D with a single reference letter in the diagnosis pointer Field 24E that corresponds with the diagnosis letter in Field 21.
• For group billing, the National Provider Identifier (NPI) of the rendering provider is entered in Field 24J. • The Tax Identification Number (TIN) of the employer is entered in Field 25.
Group NPI Submission
When a group bills, the group's NPI is submitted at the claim level, therefore, the individual rendering physician's NPI must be placed on each line item, including all allowed charges and quality-data line items.
Individual NPI Submission
The individual NPI of the solo practitioner must be included on the claim line as is the normal billing process for submitting Medicare claims. For the Physician Quality Reporting System, the QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in Physician Quality Reporting System analysis.
Form CMS-1500 Claim Example
An example of a claim in CMS-1500 format that illustrates how to report several Physician Quality Reporting System measures is available in the Physician Quality Reporting System Implementation Guide, a downloadable document that is updated for each program year and posted on the CMS Physician Quality Reporting System website http://www.cms.hhs.gov/PQRS.
Satisfactorily Reporting Measures
Physician Quality Reporting System participants should also refer to the "How to Get Started" section of the Physician Quality Reporting System website, available at http://www.cms.gov/PQRS. This section provides helpful information on how to get started with reporting quality measures for the Physician Quality Reporting System.
Timeliness of Quality Data Submission
Claims processed by the A/B MAC (B) must reach the National Claims History (NCH) file by no later than 2 months after the end of the reporting period to be included in the analysis. For the 2010 Physician Quality Reporting System, for example, claims processed by the A/B MAC (B) must reach the NCH file by no later than February 28, 2011 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly.
Claims that are resubmitted only to add QDCs will not be included in the analysis for Physician Quality Reporting System.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Beginning in 2008, Individual eligible professionals may choose to participate in the Physician Quality Reporting System via the registry-based reporting mechanism. Eligible professionals who choose to participate in the Physician Quality Reporting System via the registry-based reporting mechanism do not have to enroll or register to begin registry-based reporting of Physician Quality Reporting System quality measures data to CMS. However, to report Physician Quality Reporting System quality measures data via the registry-based reporting mechanism, an eligible professional must select a registry qualified under the Physician Quality Reporting System for the program year and enter into and maintain an appropriate legal arrangement with the selected registry. Such arrangements should provide for the registry’s receipt of patient-specific data from the eligible professional and the registry’s disclosure of quality measures results and numerator and denominator data on Physician Quality Reporting System quality measures or measures groups on behalf of the eligible professional to CMS. An eligible professional choosing the registry-based reporting mechanism must submit information on Physician Quality Reporting System individual quality measures or measures groups to his or her selected registry in the form and manner and by the deadline specified by the registry. Thus the registry would act as a Health Insurance Portability and Accountability Act of 1996 (Pub. L.104-191) (HIPAA) Business Associate and agent of the eligible professional. Such agents are referred to as “data submission vendors.” The “data submission vendors” would have the requisite legal authority to provide clinical quality measures results and numerator and denominator data on individual quality measures or measures groups on behalf of the eligible professional for the Physician Quality Reporting System.
CMS qualifies registries to participate in each program year through a self-nomination process. Registries that were qualified to submit data on behalf of eligible professionals in a prior program year are not required to go through the qualification process again unless they were unsuccessful at submitting Physician Quality Reporting System data for the prior program year by the registry’s data submission deadline or CMS makes changes to the registry qualification requirements. The final list of qualified registries for a particular program year is made available on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS. The list is usually made available in the summer of the program year in question. For example, the list of qualified registries for the 2008 Physician Quality Reporting System was made available in the summer of 2008.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
To report Physician Quality Reporting System quality measures data via a direct EHR-based reporting mechanism, an eligible professional must select a qualified direct EHR product. For each program year, an eligible professional choosing the EHR-based reporting mechanism must:
CMS qualifies EHR vendors and their specific product(s) for use by eligible professionals to submit Physician Quality Reporting System quality measures data to CMS. The list of qualified EHR vendors and products for a specific program year are made available on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS. The list of qualified EHR vendors and products is generally posted before the start of program year or shortly thereafter. For example, the list of 2011 qualified EHR vendors and products was posted prior to January 2011.
To report Physician Quality Reporting System quality measures data via an EHR data submission vendor, an eligible professional must select a qualified EHR data submission vendor product.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
To qualify to earn the Physician Quality Reporting System incentive payment, an eligible professional must report data on quality measures. Beginning with the 2008 Physician Quality Reporting System, eligible professionals have the option of reporting data on individual quality measures or on measures groups. Physician Quality Reporting System measures groups are created by CMS by grouping 4 or more Physician Quality Reporting System measures that have a clinical condition or focus in common. The Physician Quality Reporting System measures that comprise a measures group share a common denominator specification and therefore differ in their specifications from that of individual measures.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
When the Physician Quality Reporting System was first implemented in 2007, the program consisted of 74 individual quality measures, all of which were reportable via the claims-based reporting mechanism only.
In 2008, CMS retired some of the 2007 measures but added new measures so that the total number of Physician Quality Reporting System individual quality measures expanded to 119.
The 2009 Physician Quality Reporting System included a total of 153 individual quality measures. Data on 53 of the 2009 Physician Quality Reporting System measures may only be reported through a qualified registry and may not be reported through claims-based reporting (see §50 above).
The 2010 Physician Quality Reporting System includes a total of 175 individual quality measures. Data on 10 of the 2010 Physician Quality Reporting System measures may be reported via a qualified EHR product, however, two of these may not be reported through claims-based reporting. In addition, data on 50 of the 2010 Physician Quality Reporting System measures may not be reported through claims-based reporting. Such data must be reported through a qualified registry, or if the measure is 1 of the 10 measures designated for EHR reporting, via a qualified EHR product.
The 2011 Physician Quality Reporting System included a total of 190 individual quality measures that may be reported via claims, registry, and/or EHR.
The 2012 Physician Quality Reporting System includes a total of 224 individual quality measures that may be reported via claims, registry, and/or EHR. Note that these are some limitations as to which measures may be reported via claims, registry and/or EHR.
A complete list of the individual Physician Quality Reporting System quality measures for a specific program year, as well as their detailed measure specifications and respective reporting requirements can be found on the CMS Physician Quality Reporting System website at http://www.cms.gov/PQRS. Measure specifications for the current or upcoming program year can be found on the Measures Codes page of the CMS Physician Quality Reporting System website. Measure specifications for prior program years are archived to the appropriate Physician Quality Reporting System Program page of the CMS Physician Quality Reporting System website.
When measures for a particular program year are selected from a prior year's measure set, the detailed measure specifications for such measures may have been updated or modified during the National Quality Forum endorsement process or for other reasons. The Physician Quality Reporting System quality measure specifications for any given measure selected for use in a specific program year may, therefore, be different from specifications for the same quality measure used for a prior program year. For example, the 2009 Physician Quality Reporting System specifications for a measure that was used in the 2008 Physician Quality Reporting System may be different from the 2008 Physician Quality Reporting System specifications for the same measure. Eligible professionals must ensure that they are using the published specifications for the correct program year.
For the 2008 Physician Quality Reporting System, CMS established 4 measures groups to address the following clinical topics:
(1) Diabetes Mellitus,
(2) Chronic Kidney Disease (CKD), (3) Preventive Care, and (4) End Stage Renal Disease (ESRD).
For the 2009 Physician Quality Reporting System, CMS removed the ESRD measures group, but added 4 additional measures for a total of 7 measures groups. The 2009 Physician Quality Reporting System measures groups address the following clinical topics:
(1) Diabetes Mellitus, (2) CKD, (3) Preventive Care, (4) Coronary Artery Bypass Graft (CABG) Surgery, (5) Rheumatoid Arthritis, (6) Perioperative Care, and (7) Back Pain.
For the 2010 Physician Quality Reporting System, CMS retained all of the 2009 Physician Quality Reporting System measures groups and added 6 new measures groups for a total of 13 measures groups. The 2010 Physician Quality Reporting System measures groups address the following clinical topics:
(1) Diabetes Mellitus, (2) CKD, (3) Preventive Care, (4) CABG Surgery, (5) Rheumatoid Arthritis, (6) Perioperative Care, (7) Back Pain, (8) Coronary Artery Disease (CAD), (9) Heart Failure, (10) Hepatitis C, (11) Ischemic Vascular Disease (IVD), (12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), and (13) Community-Acquired Pneumonia (CAP).
For the 2011 Physician Quality Reporting System, CMS retained all of the 2010 Physician Quality Reporting System measures groups and added 1 new measures group, for a total of 14 measures groups. The 2011 Physician Quality Reporting System measures groups address the following clinical topics:
(1) Diabetes Mellitus, (2) CKD, (3) Preventive Care, (4) CABG Surgery, (5) Rheumatoid Arthritis, (6) Perioperative Care,
(7) Back Pain, (8) Coronary Artery Disease (CAD), (9) Heart Failure, (10) Hepatitis C, (11) Ischemic Vascular Disease (IVD), (12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), and (13) Community-Acquired Pneumonia (CAP). (14) Asthma
For the 2012 Physician Quality Reporting System, CMS retained all of the 2011 Physician Quality Reporting System measures groups and added 8 new measures groups, for a total of 22 measures groups. The 2012 Physician Quality Reporting System measures groups address the following clinical topics:
(1) Diabetes Mellitus, (2) CKD, (3) Preventive Care, (4) CABG Surgery, (5) Rheumatoid Arthritis, (6) Perioperative Care, (7) Back Pain, (8) Coronary Artery Disease (CAD), (9) Heart Failure, (10) Hepatitis C, (11) Ischemic Vascular Disease (IVD), (12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), (13) Community-Acquired Pneumonia (CAP), (14) Asthma, (15) COPD, (16) IBD, (17) Sleep Apnea, (18) Dementia, (19) Parkinson's, (20) Elevated Blood Pressure, (21) Cardiovascular Prevention, and (22) Cataracts.
In addition, all measures contained in the following 2012 Physician Quality Reporting System measures groups are also reportable as individual measures:
(1) Diabetes Mellitus, (2) CKD, (3) Preventive Care, (4) CABG Surgery, (5) Rheumatoid Arthritis, (6) Perioperative Care,
(7) Coronary Artery Disease (CAD), (8) Heart Failure, (9) Hepatitis C, (10) Ischemic Vascular Disease (IVD), (11) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), (12) Community-Acquired Pneumonia (CAP), (13) Asthma, (14) COPD, and (15) Cardiovascular Prevention.
In addition, data on the CABG, CAD, Heart Failure, HIV/AIDS, IBD, Sleep Apnea, Dementia, Parkinson's, Elevated Blood Pressure, and Cataracts measures groups may only be reported through a qualified registry and may not be reported through claims-based reporting (see §50 above).
Measures groups specifications are different from the specifications for individually reported measures (if any measures in a measures group may be reported individually) that form the group. Therefore, the specifications, including the list of measures selected for inclusion in each of the Physician Quality Reporting System measures groups, and reporting instructions for the Physician Quality Reporting System measures groups are provided separately from the specifications for the individual Physician Quality Reporting System measures. The specifications manual for measures groups can be found on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS. Measures group specifications for the current or upcoming program year can be found on the Measures Codes page of the CMS PQRS website. Measures group specifications for prior program years are archived to the appropriate Physician Quality Reporting System Program page of the CMS Physician Quality Reporting System website.
To initiate claims-based reporting of measures groups, it is necessary that the eligible professionals indicate the intention to begin reporting a measures group by submitting a measures group-specific G-code on the patient claim. There is one defined measures group-specific G-code for each Physician Quality Reporting System measures group. It is not necessary to submit the measures group-specific G-code on more than one claim. If the measures group-specific G-code for a given group is submitted multiple times during the reporting period, only the submission with the earliest date of service will be included in the Physician Quality Reporting System analyses; subsequent submissions of that code will be ignored. It is not necessary to submit the measures-group specific G-code for registry-based submissions. In addition, beginning for the 2009 Physician Quality Reporting System, if all quality actions for the applicable measures in a measures group have been performed for the patient, one Physician Quality Reporting System composite G-code may be reported in lieu of the individual quality-data codes for each of the measures within the group. There is one defined composite G-code for each Physician Quality Reporting System measures group.
Similar to the specifications for individual Physician Quality Reporting System measures, when measures groups for a particular program year are selected from a prior year's measures group set, the detailed measures group specifications for such a measures group may have been updated or modified during the National Quality Forum endorsement process or for other reasons. In
addition, the individual measures that comprise a specific measures group may change from year to year. Therefore, the Physician Quality Reporting System measures group specifications for any given measures group selected for use in a specific program year may be different from specifications for the same measures group used for a prior program year. For example, the measures that form the Diabetes Mellitus and CKD measures groups for the 2009 Physician Quality Reporting System are different from the measures that were included in these measures groups for 2008.
Not only do eligible professionals need to ensure that they are using the measures groups specifications rather than the specifications for the individual Physician Quality Reporting System measures, but eligible professionals also must ensure that they are using the measures groups specifications for the correct program year.
In order to qualify to earn a Physician Quality Reporting System incentive payment, eligible professionals and group practices must meet the criteria for satisfactorily reporting data on Physician Quality Reporting System quality measures. The criteria that are applicable depend on whether participation is at the individual eligible professional level or at the group practice level and may differ from one program year to another.
For eligible professionals participating in the Physician Quality Reporting System at the individual eligible professional level, the criteria for satisfactory reporting differ depending on the reporting period an eligible professional chooses to report, the manner in which an eligible professional reports (whether the eligible professional chooses the claims-based, registry-based, or EHR-based reporting mechanism), and whether an eligible professional chooses to report on individual quality measures or on measures groups.
For the 2007 Physician Quality Reporting System, there was only 1 reporting option and a single reporting period that an eligible professional could use to attempt to satisfactorily report quality measures. There was no option of reporting on measures groups, or reporting through a qualified registry or qualified EHR.
In 2008, with the introduction of registry-based reporting, reporting on measures groups, and alternative reporting periods for the Physician Quality Reporting System, multiple reporting options became available.
For the 2008 Physician Quality Reporting System, there were a total of 9 reporting options. For the 2009 Physician Quality Reporting System, 9 reporting options were also available but there were some differences between the 2008 Physician Quality Reporting System reporting options and the 2009 Physician Quality Reporting System reporting options.
For the 2010 Physician Quality Reporting System, 11 reporting options are available.
For the 2011 Physician Quality Reporting System, there were still 11 reporting options available. However, there are some differences between the 2010 Physician Quality Reporting System reporting options and the 2011 Physician Quality Reporting System reporting options. To qualify for a Physician Quality Reporting System incentive payment for a particular program year, each eligible professional must ensure that he or she meets the criteria for satisfactory reporting for the relevant reporting period, relevant reporting mechanism, and for reporting either individual measures or measures groups, as appropriate.
For the 2012 Physician Quality Reporting System, there are a total of 9 reporting options that an individual eligible professional could use to attempt to satisfactorily report quality measures. The change in the number of reporting options from 11 in 2011 to 9 in 2012 is due to the following factors: (1) the elimination of the 6-month reporting period, except for reporting on measures groups via registry and (2) adoption of an additional reporting option for EHR-based reporting that aligns with the criteria for meeting the clinical quality measure objective for achieving meaningful use under the Medicare EHR Incentive Program in 2012.
Although there are multiple reporting options for satisfactory reporting, an eligible professional only needs to satisfactorily report under one option for a specific program year to qualify for the incentive payment applicable to a reporting period for the program year. An eligible professional who qualifies for more than one reporting period for a particular program year will receive the incentive payment for the longest reporting period for which the professional qualifies for that program year. Only one incentive payment per program year may be obtained regardless of how many reporting options the eligible professional chooses.
For purposes of determining satisfactory reporting, if an eligible professional attempts to submit data for a quality measure or measures group at least once, then the measure or measures group is presumed to be applicable to the eligible professional. Eligible professionals are responsible for selecting the quality measures and/or measures groups that are applicable to their practices.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
As discussed in §60 above, eligible professionals have the option of reporting on individual quality measures or on measures groups. The criteria for determining whether an eligible professional satisfactorily reports data on Physician Quality Reporting System quality measures for reporting individual quality measures are different from the criteria for satisfactory reporting of measures groups.
To qualify for a Physician Quality Reporting System incentive payment through claims-based reporting of individual measures prior to the 2011 program year, each eligible professional must meet the following criteria for satisfactory reporting during the applicable reporting period:
For years prior to the 2011 Physician Quality Reporting System, if an eligible professional reports less than 3 measures, the eligible professional must:
The eligible professional may also be subject to a Measure Applicability Validation (MAV) process, which would allow CMS to determine whether an eligible professional should have reported QDCs for additional measures.
For the 2007 Physician Quality Reporting System, these criteria applied to the 6-month reporting period beginning July 1st only.
For the 2008 and 2009 Physician Quality Reporting System, these criteria applied to the 12-month reporting period beginning January 1st only.
For the 2010 Physician Quality Reporting System, these criteria apply to both the 12-month reporting period beginning January 1st and the 6-month reporting period beginning July 1st for claims-based reporting of individual measures. This results in a total of 2 reporting options for claims-based reporting of individual measures for the 2010 Physician Quality Reporting System.
The 2011 Physician Quality Reporting System retained the 2 reporting options established in the 2010 Physician Quality Reporting System. However, the 2011 Physician Quality Reporting System reduced the percentage of instances eligible professionals must report per measure. Eligible professionals need only report on 50% instead of 80% of the Medicare Part B FFS patients to whom each measure applies.
The 2012 Physician Quality Reporting System retains 1 of the 2 reporting options established in the 2011 Physician Quality Reporting System. The reporting option established for a 6-month reporting period was eliminated. In addition, under all 2012 claims-based reporting options for the 2012 Physician Quality Reporting System, measures reported with a zero percent performance rate will not be counted.
The 2012 Physician Quality Reporting System criteria for satisfactorily reporting individual quality measures through claims-based reporting that each eligible professional must meet under these 2 reporting options are summarized in Table 1 below along with the relevant reporting period for each reporting option.
Table 1: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through Claims
| Reporting Criteria | Reporting Period |
|---|---|
| - Report at least 3 Physician Quality Reporting System measures, or - 1-2 measures if less than 3 measures apply to an EP; and - Report each measure for at least 50% of Medicare Part B FFS patients to whom the measure applies. If reporting less than 3 measures, the eligible professional must: - Report on all measures that apply to the services furnished by the professional, and - Report each measure for at least 50% of the eligible professional's Medicare Part B PFS patients for whom services were furnished during the reporting period to which the measure(s) applies. - May also be subject to a MAV process | January 1, 2012–December 31, 2012 |
Eligible professionals who report on fewer than three individual Physician Quality Reporting System individual quality measures may be subject to a two-step measure-applicability validation (MAV) process. The purpose of the MAV is to determine whether the eligible professional should have submitted quality-data codes for additional measures. If CMS finds that eligible professionals who have reported fewer than three quality measures have not reported additional measures that are also applicable to the services they furnished during the reporting period, then those eligible professionals cannot earn the incentive payment. More information on the MAV process for a specific program year is available in the Analysis and Payment section of the CMS PQRS website at http://www.cms.hhs.gov/PQRS.
When claims-based reporting of measures groups was introduced in the 2008 Physician Quality Reporting System program, the only reporting period available for claims-based reporting of measures groups was the 6-month reporting period beginning July 1, 2008. However, there were 2 reporting options for claims-based reporting of measures groups for 2008. The first reporting option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting System consisted of the following criteria for satisfactory reporting:
The term “consecutive” refers to the manner in which the patients are seen by the eligible professional and are selected for inclusion in the eligible professional’s patient sample. The patient sample must consist of at least 15 unique Medicare Part B FFS patients seen consecutively, or in order, by date of service, by the eligible professional.
The second reporting option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting System consisted of the following criteria for satisfactory reporting:
Beginning with the 2009 Physician Quality Reporting System, CMS implemented two reporting periods for claims-based reporting of measures groups: a 12-month reporting period beginning January 1st and a 6-month reporting period beginning July 1st.
For the 2009 Physician Quality Reporting System, there were 3 reporting options for claims-based submission of measures groups. Whereas for the 2008 Physician Quality Reporting System only the 6-month reporting period was available for claims-based submission of measures groups, both the 12-month and the 6-month reporting periods are available for claims-based submission of measures groups for the 2009 Physician Quality Reporting System. In addition, CMS eliminated the option of reporting on at least one measures group on 15 consecutive patients for the 6-month reporting period but added the option of reporting on at least 30 consecutive Medicare Part B FFS patients during the 12-month reporting period instead. We also added a minimum sample size requirement for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients. Eligible professionals reporting on 80% of applicable Medicare Part B FFS patients for the 12-month reporting period must have at least 30 applicable patients. Eligible professionals reporting on 80% of applicable Medicare Part B FFS patients for the 6-month reporting period must have at least 15 applicable patients.
CMS implemented the following changes to the 2009 Physician Quality Reporting System for the 2010 Physician Quality Reporting System: (1) eliminated the requirement that the 30 patients be seen consecutively to allow an eligible professional to report on any 30 patients seen at any time during the reporting period; and (2) reduced the minimum patient sample size threshold for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively.
With respect to the reporting options for claims-based submission of measures groups, the 2011 Physician Quality Reporting System is largely identical to the 2010 Physician Quality Reporting System. However, CMS implemented the following change in 2011: eligible professionals need only report at least 50% (instead of the 80% that was required in the 2010 Physician Quality Reporting System) of their Medicare Part B FFS patients seen during the reporting period to which the measures group applies.
For the 2012 Physician Quality Reporting System, CMS retained the two 2011 reporting options for the 12-month reporting period. However, CMS implemented the following change for 2012: measures within a measures group with a zero percent performance rate will not be counted. Therefore, the 2012 Physician Quality Reporting System criteria for satisfactorily reporting measures groups through claims-based reporting that each eligible professional must meet under
these 2 reporting options are summarized in Table 2 below along with the relevant reporting period for each reporting option.
Table 2: 2012 Criteria for Satisfactory Reporting of Measures Groups through Claims
| Reporting Criteria | Reporting Period |
|---|---|
| - Report at least one measures group; and - Report each measure within the measures group for at least 30 Medicare Part B FFS patients to whom the measures group apply - Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
| - Report at least one measures group; and - Report each measure within the measures group for at least 50% of Medicare Part B FFS patients to whom the measures in the measures group apply; but - Report each measures group on at least 15 patients during the reporting period for which the measures group applies. - Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012– December 31, 2012 |
Eligible professionals choosing to participate in the Physician Quality Reporting System through the claims-based reporting mechanism, regardless of whether they choose to report on individual measures or measures groups, must have their own individual-level NPI and must consistently use their individual NPI to correctly identify their services, procedures, and QDCs for an accurate determination of satisfactory reporting. As stated in §30 above, the analysis of whether an eligible professional has satisfactorily reported is performed at the individual eligible professional level using the individual-level NPI. The eligible professional’s individual NPI must be listed correctly along with the HCPCS codes for services, procedures, and QDCs on the claim. More information on reporting options for a specific program year is available on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In addition to the option of reporting on individual quality measures or on measures groups, eligible professionals, beginning with the 2008 Physician Quality Reporting System, also have the option of reporting Physician Quality Reporting System quality measures information to CMS via a qualified registry instead of submitting the quality measures data on claims (see §50).
The criteria for determining whether an eligible professional satisfactorily reports data on Physician Quality Reporting System quality measures for reporting via a registry are different from the criteria for satisfactory reporting via claims.
When registry-based reporting of Physician Quality Reporting System quality measures data was introduced in the 2008 Physician Quality Reporting System, there were two reporting periods available for registry-based reporting of individual measures: the 12-month reporting period beginning January 1, 2008 and the 6-month reporting period beginning July 1, 2008. To qualify to earn a 2008 Physician Quality Reporting System incentive payment through registry-based reporting of individual measures, each eligible professional had to meet the following criteria for satisfactory reporting:
These criteria were applicable to both 2008 reporting periods for registry-based reporting. Consequently, there were 2 reporting options for registry-based reporting of individual measures.
No changes have been made to the criteria for registry-based reporting of individual measures until the 2011 program year. For the 2011 Physician Quality Reporting System, measures with a zero percent performance rate will not be counted. That is, if the recommended clinical quality action is not performed on at least 1 patient for a particular measure or measures group reported by the eligible professional via a registry or EHR, we will not count the measure (or measures groups) as a measure (or measures group) reported by an eligible professional.
The 2012 Physician Quality Reporting System retained the 2011 reporting criteria for the 12-month reporting period. The reporting options continue for registry-based reporting for the 2012 Physician Quality Reporting System of individual measures are summarized in Table 3 below.
Table 3: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through Registries
| Reporting Criteria | Reporting Period |
|---|---|
| - Report at least 3 Physician Quality Reporting System measures; and - Report each measure for at least 80% of Medicare Part B FFS patients to whom the measure applies. - Measures with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
For registry-based reporting of measures groups, there were 2 reporting periods available when registry-based reporting of measures groups was first introduced in the Physician Quality Reporting System for 2008: the 12-month reporting period beginning January 1, 2008 and the 6-month reporting period beginning July 1, 2008.
For the 2008 Physician Quality Reporting System, there were 2 reporting options available for registry-based reporting of measures groups for the 12-month reporting period. An eligible professional could either:
For the 2008 Physician Quality Reporting System, there were 2 reporting options available for registry-based reporting of measures groups for the 6-month reporting period. An eligible professional could either:
There are 2 differences between the 2008 criteria for registry-based reporting of measures groups and the 2009 criteria. The first difference is the elimination of the reporting option based on reporting for at least 15 consecutive patients for the 6-month reporting period. The second difference is the addition of a minimum sample size requirement for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients. Identical to the 2009 criteria for claims-based submission of measures groups discussed in §70.1.1 above, eligible professionals reporting in 2009 on 80% of applicable Medicare Part B FFS patients for the 12-month reporting period were required to have at least 30 applicable patients. Eligible professionals reporting in 2009 on 80% of applicable Medicare Part B FFS patients for the 6-month reporting period were required to have at least 15 applicable patients.
The 2010 criteria for registry-based reporting of measures groups are similar to the 2009 criteria except for 2 differences. First, CMS eliminated the requirement that the 30 patients be seen consecutively to allow an eligible professional to report on any 30 patients seen during the reporting period. The second difference is that CMS reduced the minimum sample size requirement for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively.
For the 2011 Physician Quality Reporting System, measures within a measures group with a zero percent performance rate will not be counted. Furthermore, in registry-based reporting, in contrast to prior program years, the minimum patient numbers or percentages must be met by Medicare Part B FFS patients exclusively and not non-Medicare Part B FFS patients.
For reporting measures groups via registry under the 2012 Physician Quality Reporting System, CMS retained all 3 of the 2011 reporting options for the 6 and 12-month reporting periods described above. Therefore, the 2012 Physician Quality Reporting System criteria for satisfactory reporting that each eligible professional must meet to qualify to earn an incentive payment through registry-based reporting of measures groups in 2012 are summarized in Table 4 below.
Table 4: 2012 Criteria for Satisfactory Reporting of Measures Groups through Registries
| Reporting Criteria | Reporting Period |
|---|---|
| - Report at least one measures group (measures groups with a zero percent performance rate will not be counted); and - Report each measures group for at least 30 patients Medicare Part B FFS patients to whom the measures in the measures group apply. Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
| - Report at least one measures group (measures with a zero percent performance rate will not be counted); and - Report each measures groups for at least 80 % of Medicare Part B FFS patients to whom the measures in the measures group applies; but - Report each measures group on at least 15 Medicare Part B FFS patients during the reporting period to which the measures group applies. - Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
| - Report at least one measures group; and - Report each measures group for at least 80 % of Medicare Part B FFS patients to whom the measures in the measures group applies; but - Report each measures group on no less than 8 Medicare Part B FFS patients seen during the reporting period to which the measure group applies. - Measures within a measures group with a zero percent performance rate will not be counted. | July 1, 2012 – December 31, 2012 |
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Beginning with the 2010 Physician Quality Reporting System, an individual eligible professional who chooses to report on individual Physician Quality Reporting System quality measures rather than measures groups has the additional option of reporting on the individual Physician Quality Reporting System quality measures via a qualified EHR product in lieu of submitting the quality measures data on claims or via a qualified registry (see §50).
For 2010 and 2011, the criteria for determining whether an eligible professional satisfactorily reports data on individual Physician Quality Reporting System quality measures for reporting via an EHR was identical to the criteria for satisfactory reporting of individual Physician Quality Reporting System quality measures via a qualified registry. However, there was only one reporting period available for EHR-based reporting of individual measures: the 12-month
reporting period beginning January 1st. Consequently, there is only one reporting option for EHR-based reporting of individual measures for the 2010 and 2011 Physician Quality Reporting System. To qualify to earn a 2010 and 2011 Physician Quality Reporting System incentive payment through EHR-based reporting of individual measures, each eligible professional must meet the following criteria for satisfactory reporting:
The following changes to the EHR-based reporting option were introduced for the 2012 Physician Quality Reporting System: (1) allowing EHR-based reporting via a qualified direct EHR product or a qualified EHR data submission vendor, and (2) adding criteria under EHR-based reporting that are identical to the criteria for meeting the clinical quality measure objective of achieving meaningful use under the Medicare EHR Incentive Program. The reporting options for satisfactory reporting via the EHR-based reporting mechanism in 2012 are summarized in Table 5 below.
Table 5: Criteria for Satisfactory Reporting of Individual Measures through EHR
| Reporting Mechanism | Reporting Criteria | Reporting Period |
|---|---|---|
| Qualified Direct EHR Product | - Report at least 3 individual Physician Quality Reporting System EHR measures; and - Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the measure applies. - Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
| Qualified EHR Data Submission Vendor | - Report at least 3 individual Physician Quality Reporting System EHR measures; and - Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the measure applies. - Measures within a measures group with a zero percent performance rate will not be counted. | January 1, 2012 – December 31, 2012 |
| Direct EHR Technology that is both “qualified” for the Physician Quality Reporting System and Certified EHR Technology | - Report on ALL three Medicare EHR Incentive Program core measures. - If the denominator for one or more of the Medicare EHR Incentive Program core measures is zero, report on up to three Medicare EHR Incentive Program alternate core measures; and - Report on three (of the 38) additional measures available for the Medicare EHR Incentive Program. | January 1, 2012 – December 31, 2012 |
| EHR Data Submission Vendor Technology that is both “qualified” for the Physician Quality Reporting System and Certified EHR Technology | - Report on ALL three Medicare EHR Incentive Program core measures. - If the denominator for one or more of the Medicare EHR Incentive Program core measures is zero, report on up to three Medicare EHR Incentive Program alternate core measures; and - Report on three (of the 38) additional measures available for the Medicare EHR Incentive Program. | January 1, 2012 – December 31, 2012 |
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In accordance with section 1848(m)(3)(C)(i) of the Act, we established, beginning with the 2010 Physician Quality Reporting System, a new process whereby group practices can qualify to earn
a Physician Quality Reporting System incentive based on a determination that the practice satisfactorily reports data on Physician Quality Reporting System quality measures.
For 2010, group practice is defined under the Physician Quality Reporting System as 200 or more individual eligible professionals.
For 2011, group practice is defined under the Physician Quality Reporting System as 2 or more individual eligible professionals and there are two group practice reporting options (GPRO). Group practices with 200 or more eligible professionals participate in the GPRO option named GPRO I, whereas group practices comprised of 2-199 eligible professionals participate in the GPRO option named GPRO II.
Effective January 1, 2012, group practice is defined under the Physician Quality Reporting System as 25 or more individual eligible professionals. CMS eliminated the GPRO II classification. As in prior years, realizing the size of a group practice may vary throughout the reporting period, for purposes of determining a group practice's reporting requirements under the Physician Quality Reporting System, the size of the group is determined at the time the group's participation in one of the 2012 GPRO options is approved by CMS. However, please note that the group practice must, at all time, have at least the minimum number of eligible professionals required under the definition of group practice (i.e., 25 eligible professionals for 2012) in order to participate in the GPRO.
Each group practice selected to participate in the Physician Quality Reporting System GPRO (see §20.3 for discussion of how a group practice can qualify to participate in the Physician Quality Reporting System GPRO) must complete a data collection web-interface that pre-populated with an assigned sample of patients and those patients' demographic and utilization information. The group practice is required to populate the remaining data fields necessary for capturing quality measure information on each of the consecutively assigned Medicare beneficiaries with respect to services furnished during the relevant Physician Quality Reporting System reporting period. The selected group practices are provided access to the pre-populated web-interface no later than the first quarter of the year following the program year in which the practice is participating in the Physician Quality Reporting System GPRO. For example, if the group practice is participating in the 2011 Physician Quality Reporting System GPRO, the practice would be provided access to the pre-populated web-interface no later than the first quarter of 2012. Upon receiving access to this pre-populated data collection web-interface, the practice must complete the remaining data elements for a specified number of patients and return the completed web-interface to CMS.
For purposes of determining whether a group practice satisfactorily submits Physician Quality Reporting System quality measures data for a particular program year, each selected group practice is required to complete this data collection web-interface for a specified number of quality measures. The quality measures are grouped into disease modules plus a series of patient care measures. Data from the January 1st through October 29th NCH file for the program year (10 months) is used by CMS to randomly assign Medicare beneficiaries to each physician group practice TIN. Medicare beneficiaries are retrospectively assigned to the TIN based on a determination by CMS that the group practice provided the plurality of office or other outpatient services to the beneficiary (with a minimum of at least two visits) in the 10-month period.
Furthermore, part-year and managed care patients are not considered since CMS would have incomplete claims data for these beneficiaries and group practices may not have had sufficient time to impact the quality of their care.
For each disease module or patient care measure, depending on the group’s size, the selected Physician Quality Reporting System GPRO practice must complete the data collection web-interface for the first 218 (for groups comprised of 25-99 eligible professionals) or 411 (for groups comprised of 100+eligible professionals) consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the primary payer. If the pool of eligible assigned beneficiaries is less than 218 or 411 for any module/measure, then the group practice must report on 100% (all) of the assigned beneficiaries for that module/measure to satisfactorily participate in the Physician Quality Reporting System GPRO.
For purposes of determining whether a group practice satisfactorily submits Physician Quality Reporting System quality measures data for a particular program year, each selected group practice is required to complete this data collection web-interface for a specified number of quality measures. The quality measures are grouped into disease modules plus a series of patient care measures. Data from the January 1st through October 29th NCH file for the program year (10 months) is used by CMS to randomly assign Medicare beneficiaries to each physician group practice TIN. Medicare beneficiaries are retrospectively assigned to the TIN based on a determination by CMS that the group practice provided the plurality of office or other outpatient services to the beneficiary (with a minimum of at least two visits) in the 10-month period. Furthermore, part-year and managed care patients are not considered since CMS would have incomplete claims data for these beneficiaries and group practices may not have had sufficient time to impact the quality of their care.
In 2011, for each disease module or patient care measure, the selected Physician Quality Reporting System GPRO I practice was required to complete the data collection web-interface for the first 411 consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the primary payer. If the pool of eligible assigned beneficiaries was less than 411 for any module/measure, then the group practice was required to report on 100% (all) of the assigned beneficiaries for that module/measure to satisfactorily participate in the Physician Quality Reporting System GPRO I. The reporting mechanism, reporting period, and criteria for satisfactory reporting under the GPRO I for 2011 are summarized in the Table 6 below.
Table 6: 2011 Physician Quality Reporting System Process for Physician Group Practices to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on Quality Measures by Group Practices for GPRO I
| Reporting Mechanism | Reporting Criteria | Reporting Period |
|---|---|---|
| A pre-populated data collection web-interface provided by CMS | - Report on all measures included in the data collection web-interface (26 measures); and - Complete the web-interface for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each disease module or patient care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries. | January 1, 2011–December 31, 2011 |
In addition, for 2011, GPRO II groups were required to report on a specified number of individual measures and measures groups depending on the group practice’s size. For individual measures reporting, GPRO II groups were required to report on a specified percentage of patients. To satisfactorily report measures groups for the 2011 Physician Quality Reporting System GPRO II, the group practice need only report on the minimum number of patients specified in Table 9 for their group size. In addition, since we did not have the ability to determine whether the registries can ensure that only unique patients are counted, GPRO II groups were required to report the 2011 Physician Quality Reporting System data via claims unless the only measures groups that apply to the practice are one of the four registry-only measures groups. Group practices that must report on one of the four registry-only measures groups in order to meet the criteria for satisfactory reporting were able to use the registry-reporting mechanism to submit all of their 2011 Physician Quality Reporting System data via the registry reporting mechanism. The reporting mechanism, reporting period, and criteria for satisfactory reporting under the GPRO II for 2011 are summarized in the Table 7 below.
Table 7: 2011 Physician Quality Reporting System Process for Physician Group Practices to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on Quality Measures by Group Practices for GPRO II
| Group size (number of eligible professionals) | Number of measures groups required to be reported | Minimum number of Medicare Part B patients in denominator for satisfactory reporting of measures groups | Number of individual measures required to be reported | Percent of Medicare Part B patients in denominator for satisfactory reporting of individual measures via claims (%) | Percent of Medicare Part B patients in denominator for satisfactory reporting of individual measures via registries (%) |
|---|---|---|---|---|---|
| 2-10 | 1 | 35 | 3 | 50 | 80 |
| 11-25 | 1 | 50 | 3 | 50 | 80 |
| 26-50 | 2 | 50 | 4 | 50 | 80 |
| 51-100 | 3 | 60 | 5 | 50 | 80 |
| 101-199 | 4 | 100 | 6 | 50 | 80 |
In 2012, the GPRO II reporting option was eliminated, leaving a single GPRO reporting option. However, CMS finalized two different satisfactory reporting criteria under the GPRO for groups comprised of 25-99 eligible professionals and groups comprised of 100+ eligible professionals. With respect to the criteria for satisfactory reporting for groups comprised of 25-99 eligible professionals, for each disease module or patient care measure, the selected Physician Quality Reporting System GPRO practice must complete the data collection web-interface for the first 218 consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the primary payer. If the pool of eligible assigned beneficiaries was less than 218 for any module/measure, then the group practice is required to report on 100% (all) of the assigned beneficiaries for that module/measure to satisfactorily participate in the Physician Quality Reporting System GPRO.
With respect to the criteria for satisfactory reporting for groups comprised of 100+ eligible professionals, for each disease module or patient care measure, the selected Physician Quality Reporting System GPRO practice must complete the data collection web-interface for the first 411 consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the primary payer. If the pool of eligible assigned beneficiaries was less than 411 for any module/measure, then the group practice was required to report on 100% (all) of the assigned beneficiaries for that module/measure to satisfactorily participate in the Physician Quality Reporting System GPRO.
The reporting mechanism, reporting period, and criteria for satisfactory reporting under the GPRO for 2012 are summarized in the Table 8 below.
Table 8: 2012 Criteria for Satisfactory Reporting of Data on Quality Measures by Group Practices for theGPRO
| Group Size | Reporting Mechanism | Reporting Criteria | Reporting Period |
|---|---|---|---|
| 25-99 eligible professionals | A submission web interface provided by CMS | - Report on all measures included in the web-interface (29 measures); and - Populate the data field for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample (with an over-sampler of 327) for each disease module or patient care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100% of assigned beneficiaries. | January 1, 2012–December 31, 2012 |
| 100+ eligible professionals | A submission web interface provided by CMS | - Report on all measures included in the web-interface (29 measures); and - Populate the date fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample (with an over-sample of 616) for each disease module or patient care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries. | January 1, 2012–December 31, 2012 |
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Section 1848(m)(5)(E) of the Act, except for the informal review process noted below, there is no administrative or judicial review or otherwise of the determination of: (1) the determination of quality measures applicable to services furnished by eligible professionals, (2) the determination of satisfactory reporting, or (3) the determination of any incentive payment.
However, section 1848(m)(5)(I) of the Act, as added by the Affordable Care Act, requires the establishment of an informal review process by January 1, 2011. As such, beginning with the 2011 Physician Quality Reporting System, eligible professionals may seek an informal review of the determination that an eligible professional or group practice did not satisfactorily submit data on quality measures under the Physician Quality Reporting System. To request an informal review, an eligible professional or group practice must submit a written request to CMS within
90 days of the release of the applicable year's feedback reports. The request must state the eligible professional's or group practice's reasons for requesting an informal review which may include information to assist in the review. CMS will provide a final, written response to the request within 60 days of the receipt of the original request. With respect to an informal review request received in 2012 based on 2011 data, CMS will provide a final, written response to the request within 60 days of the receipt of the original request. With respect to an informal review request received in 2013 based on 2012 data and subsequent years, CMS will provide a final, written response to the request within 90 days of the receipt of the original request. All decisions are final and are not subject to further review.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In accordance with section 1848(m)(5)(H) of the Act, CMS provides confidential annual feedback reports on Physician Quality Reporting System reporting to participating eligible professionals at or near the time that the lump sum incentive payments for a particular payment year are made. Feedback reports for the 2009 Physician Quality Reporting System, for example, would be provided in 2010.
In addition to confidential annual feedback reports, beginning 2012, CMS will provide confidential interim feedback reports on Physician Quality Reporting System reporting.
Access to confidential feedback reports may require eligible professionals to complete an identity-verification process. However, receipt of a report is not required to participate in the Physician Quality Reporting System or to receive an incentive payment.
Feedback reports are available for every TIN under which at least one eligible professional (identified by his or her National Provider Identifier, or NPI) submitting Medicare Part B FFS claims reported at least one valid Physician Quality Reporting System measure a minimum of once during the reporting period. Thus, to receive a feedback report the eligible professional must have had at least one valid Physician Quality Reporting System submission. A valid submission is defined as receipt by CMS of the correct numerator, denominator codes, age and gender (where applicable) as listed in the applicable Physician Quality Reporting System quality measure specifications manual. The Physician Quality Reporting System quality measure specifications are subject to change for each program year. The Physician Quality Reporting System quality measure specifications manual for the current or an upcoming program year is posted on the Measures Codes page at http://www.cms.gov/PQRS. Physician Quality Reporting System measure specifications for prior program years are archived on the appropriate Physician Quality Reporting System Program page of the CMS Physician Quality Reporting System website at http://www.cms.gov/PQRS.
In addition, section 1848(m)(5)(G) of the Act requires CMS to post on the CMS website, in an easily understandable format, a list of the names of the eligible professionals who satisfactorily submitted data on quality measures under Physician Quality Reporting System. Therefore, beginning with the 2009 Physician Quality Reporting System, the names of eligible professionals and group practices who satisfactorily submit data on quality measures for the Physician Quality Reporting System will be posted on http://www.medicare.gov. The names of eligible
professionals (and group practices) who satisfactorily submit data on quality measures for a particular year are publicly posted after the lump sum incentive payments for that program year are made in the following year.
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
At the request of CMS, contractors shall print and distribute hardcopy mailings to all or a subset of their active providers related to the Physician Quality Reporting System. Mailings shall be sent to the best address to reach the provider, not the billing agency used by the provider. As such, contractors should consider using the correspondence address in PECOS if it is available.
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R82QRI | 03/22/2019 | Update to Publication 100-22 to Provide Language-Only Changes for the New Medicare Card Project | 04/22/2019 | 11166 |
| R31QRI | 08/29/2014 | Language-Only Changes for Updating ICD-10 and ASC X12 Language in Pub 100-22, Chapters 1 and 2 | 09/30/2014 | 8787 |
| R10QRI | 07/27/2012 | Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program | 10/29/2012 | 7879 |
| R1QRI | 06/11/2010 | Physician Quality Reporting Initiative (PQRI) and E-Prescribing (eRx) Medicare Quality Reporting Incentive Programs Manual | 09/13/2010 | 6935 |