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P h y s

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Physician Quality
Reporting System
Published February 2012
Part B
  IMPORTANT  
The information provided in this manual was current as of
January 2012. Any changes or new information superseding
the information in this manual, provided in MLN Matters®
articles, eBulletins, listserv notices, Local Coverage
Determinations (LCDs) or CMS Internet-Only Manuals with
publication dates after January 2012, are available at:
http://www.trailblazerhealth.com/Medicare.aspx
© CPT codes, descriptions, and other data only are copyright 2011 American Medical
Association. All rights reserved. Applicable FARS/DFARS clauses apply. © CDT codes and
descriptions are copyright 2011 American Dental Association. All rights reserved. Applicable
FARS/DFARS clauses apply.
Provider Outreach and Education
SV
© 2012 TrailBlazer Health Enterprises®/TrailBlazer®. All rights reserved.
  IMPORTANT  
MEDICARE PART B
Physician Quality Reporting System
Table of Contents
PHYSICIAN QUALITY REPORTING SYSTEM (FORMERLY KNOWN AS PHYSICIAN
QUALITY REPORTING INITIATIVE (PQRI)) BACKGROUND ...................................... 1
PHYSICIAN QUALITY REPORTING – WHAT IS IT? .................................................... 5
PHYSICIAN QUALITY REPORTING – HOW DOES IT WORK? ................................... 6
PHYSICIAN QUALITY REPORTING – WHO IS ELIGIBLE? ......................................... 7
Eligible Professionals................................................................................................... 7
PHYSICIAN QUALITY REPORTING QUALITY MEASURES........................................ 9
CPT II Modifiers ........................................................................................................... 9
Reporting Frequency ................................................................................................. 10
How Is Age Calculated? ............................................................................................ 10
WHERE TO START ...................................................................................................... 11
INDIVIDUAL MEASURES ............................................................................................ 12
MEASURES GROUPS ................................................................................................. 13
PHYSICIAN QUALITY REPORTING – REPORTING CRITERIA/REPORTING
OPTIONS ...................................................................................................................... 14
Claims-Based Reporting............................................................................................ 14
Registry-Based Reporting Criteria ............................................................................. 17
Electronic Health Record (EHR) Criteria.................................................................... 21
Group Practice Reporting Criteria.............................................................................. 24
Maintenance of Certification Program Criteria ........................................................... 26
PHYSICIAN QUALITY REPORTING OVERVIEW........................................................ 35
2012 Physician Quality Reporting System................................................................. 35
MEASURES OVERVIEW.............................................................................................. 36
Individual Measure Overview..................................................................................... 36
Common Claims-Based Reporting Errors.................................................................. 41
Measures Group Overview ........................................................................................ 42
Measures Groups Intent to Report ‘G’ Codes............................................................ 47
Measures Groups Composite ‘G’ Codes ................................................................... 48
EHR-Based Overview................................................................................................ 50
Steps for Successful EHR Reporting ......................................................................... 57
Group Practice Reporting Option for 2012................................................................. 58
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Contents
MEDICARE PART B
Steps for Successful GPRO Reporting ...................................................................... 62
MEASURE-APPLICABILITY VALIDATION PROCESS............................................... 63
FUTURE PAYMENT ADJUSTMENTS FOR NON-PARTICIPATION ........................... 65
CMS PHYSICIAN QUALITY REPORTING RESOURCES ........................................... 66
The 2012 Physician Quality Reporting Measures List ............................................... 67
2012 Physician Quality Reporting Measures Groups Specifications Manual............. 70
FEEDBACK REPORTS ................................................................................................ 71
Original/Group TIN Process....................................................................................... 71
Individuals Authorized Access to CMS Computer Services (IACS) ........................... 72
Steps to Access Feedback Reports........................................................................... 73
Obtaining Feedback Reports ..................................................................................... 73
INCENTIVE CALCULATIONS ...................................................................................... 76
Physician Quality Reporting Online Resources ......................................................... 76
Help Desk Support..................................................................................................... 76
Physician Quality Reporting Portal User Guide ......................................................... 77
REVISION HISTORY .................................................................................................... 78
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Contents
MEDICARE PART B
PHYSICIAN QUALITY REPORTING SYSTEM (FORMERLY KNOWN AS
PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)) BACKGROUND
On December 20, 2006, the President signed the Tax Relief and Health Care Act of
2006 (TRHCA). Section 101 under Title I required the establishment of a physician
quality reporting system, including an incentive payment for eligible professionals who
satisfactorily report data on quality measures for covered professional services
furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting
period). CMS named this program the Physician Quality Reporting Initiative (PQRI).
PQRI was further modified as a result of the Medicare, Medicaid and SCHIP Extension
Act of 2007 (MMSEA) (Pub. L. 110-275) and the Medicare Improvements for Patients
and Providers Act of 2008 (MIPPA) (Pub. L. 110-275).
Note: For 2011, the Physician Quality Reporting Initiative (PQRI) was renamed and
should now be referred to as the Physician Quality Reporting System or Physician
Quality Reporting.
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2007 PQRI:
○ There were 74 unique measures.
○ A financial incentive of 1.5 percent, which was subject to a cap.
○ Reporting period: July 1, 2007 – December 31, 2007.
2008 PQRI:
○ There were a total of 119 measures available.
○ There were four measures groups.
○ A 1.5 percent financial incentive.
○ Claims-based individual measures reporting period: January 1, 2008 –
December 31, 2008.
○ Claims-based measures group reporting periods: January 1, 2008 –
December 31, 2008, or July 1, 2008 – December 31, 2008.
○ Registry reporting periods: January 1, 2008 – December 31, 2008, or July 1,
2008 – December 31, 2008.
Note: Individual measures could not be reported if the eligible provider
started in July.
2009 PQRI:
○ There were 153 measures available.
○ There were seven measures groups.
○ A 2 percent financial incentive.
○ Claims-based individual measures reporting period: January 1, 2009 –
December 31, 2009.
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(Formerly PQRI) Background
MEDICARE PART B
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○ Claims-based measures group reporting periods: January 1, 2009 –
December 31, 2009, or July 1, 2009 – December 31, 2009.
○ Registry reporting periods (either by individual measures or by measures
group): January 1, 2009 – December 31, 2009, or July 1, 2009 – December
31, 2009.
2010 PQRI:
○ There are 179 quality measures available.
○ There are 13 measures groups.
○ Reporting options:
 Claims-based.
 Registry-based.
 Electronic Health Record (EHR).
 Group Practice Reporting Option (GPRO).
○ Reporting methods:
 Individual measures:
 Claims-based submission.
 Registry-based submission.
 EHR-based submission.
 Measures groups:
 Registry-based:
 The data must be submitted directly to the registry.
 GPRO.
 A special data collection tool sent directly to CMS.
○ There are two reporting periods:
 January 1, 2010 – December 31, 2010.
 July 1, 2010 – December 31, 2010.
2011 Physician Quality Reporting:
 Claims-based.
 Registry-based.
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MEDICARE PART B
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 Group Practice Reporting Options (GPRO) I and II.
 Registry-based:
 GPRO I and GPRO II.
 July 1, 2011 – December 31, 2011.
2012 Physician Quality Reporting:
○ There are 51 EHR measures for EHR-based reporting.
○ There are 29 group reporting practice measures.
○ A 0.5 percent financial incentive.
 Claims-based.
 Registry-based.
 Group Practice Reporting Options (GPRO).
 Registry-based:
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MEDICARE PART B
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GPRO I and GPRO II.
 July 1, 2012 – December 31, 2012. (For 2012 the six-month reporting
period can only be used for reporting on measures groups via registry.)
In 2012, physicians will have the opportunity to earn an additional incentive of 0.5
percent by working with a Maintenance of Certification entity and by completing the
following:
 Satisfactorily submitting data, without regard to method, on quality measures
under Physician Quality Reporting, for a 12-month reporting period either as an
individual physician or as a member of a selected group practice.
And,
 More frequently than is required to qualify for or maintain board certification:
○ Participate in a Maintenance of Certification Program.
And,
o Successfully complete a qualified Maintenance of Certification Program
practice assessment.
Future incentive amounts:
 2013: 0.5 percent.
 2014: 0.5 percent.
Future claim payment adjustment amounts for non-participation in the Physician
Quality Reporting System program:
 2015: 1.5 percent.
 2016 and each subsequent year: 2.0 percent.
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MEDICARE PART B
PHYSICIAN QUALITY REPORTING – WHAT IS IT?
The Physician Quality Reporting System is a voluntary individual reporting program that
provides an incentive payment to identified eligible professionals who satisfactorily
report data on quality measures for covered Physician Fee Schedule (PFS) services
furnished to Medicare Part B beneficiaries (including Railroad Retirement Board and
Medicare Secondary Payer).
Note: Eligible professionals do not have to sign up or pre-register to participate in
the Physician Quality Reporting program.
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Physician Quality Reporting –
What Is It?
MEDICARE PART B
PHYSICIAN QUALITY REPORTING – HOW DOES IT WORK?
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Eligible professionals review the current year’s published measures and select
from listed measures those that are applicable to their practice.
Eligible professionals systematically (for every applicable patient) determine if the
service being measured was provided.
Eligible professionals report the performance of the applicable measure(s).
Neither CMS nor TrailBlazer can tell a provider which measures codes are appropriate
for their practice.
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How Does It Work?
MEDICARE PART B
PHYSICIAN QUALITY REPORTING – WHO IS ELIGIBLE?
Under Physician Quality Reporting, covered professional services are those paid based
on the Medicare Physician Fee Schedule (PFS). To the extent eligible professionals are
providing services that get paid under the Medicare PFS, those services are eligible for
Physician Quality Reporting.
Eligible professionals are encouraged to contact their professional organizations for
measures code information that may facilitate participation in Physician Quality
Reporting.
Eligible professionals who plan to participate in the program should familiarize
themselves and their office staffs with the Physician Quality Reporting measures that
appear to apply to their patients. Under TRHCA, Section 101, “eligible professionals”
are specifically defined and can be found on the CMS Web site at:
http://www.cms.gov/PQRS//Downloads/EligibleProfessionals.pdf
Eligible Professionals
The following professionals are eligible to participate in the Physician Quality Reporting
program:
Medicare physicians:
 Doctor of Medicine.
 Doctor of Osteopathy.
 Doctor of Podiatric Medicine.
 Doctor of Optometry.
 Doctor of Oral Surgery.
 Doctor of Dental Medicine.
 Doctor of Chiropractic.
Practitioner:
 Physician Assistant.
 Nurse Practitioner.
 Clinical Nurse Specialist.
 Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant).
 Certified Nurse Midwife.
 Clinical Social Worker.
 Clinical Psychologist.
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Who Is Eligible?
MEDICARE PART B
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Registered Dietician.
Nutrition Professional.
Audiologists (as of January 1, 2009).
Therapists:
 Physical Therapist.
 Occupational Therapist.
 Qualified Speech-Language Therapist (as of July 1, 2009).
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Who Is Eligible?
MEDICARE PART B
PHYSICIAN QUALITY REPORTING QUALITY MEASURES
Each measure is assigned a unique number. Due to annual program updates, some
measures and the measure numbers have been retired. The numbering system will be
sequential but not all-inclusive.
Measures consist of two major components:
 Denominator – Describes the eligible cases for a measure (the eligible patient
population associated with a measure’s numerator):
○ Physician Quality Reporting-eligible CPT category I codes.
○ Physician Quality Reporting-eligible HCPCS codes.
○ ICD-9-CM (if applicable).
○ Patient demographics (age, gender, etc.).
 Numerator – Describes the clinical action required by the measure for reporting
and performance:
○ Quality-Data Codes (QDCs) are non-payable HCPCS codes comprising
specified CPT category II codes and/or “G” codes that describe the clinical
action required by a measure’s numerator. The CPT II codes are not
modified/updated during the reporting period and are valid for the program
year specified within the specific measure.
Each component is defined by specific codes described in each measure specification
along with reporting instructions and use of modifiers.
CPT II Modifiers
Performance Measure Exclusion Modifiers
Performance measure exclusion modifiers indicate that an action specified in the
measure was not provided due to medical, patient or system reason(s) documented in
the medical record. Not all measures allow for performance exclusions. It is important to
read the measure in its entirety and only append a performance modifier if the measure
denotes the use.
Performance measure exclusion modifiers fall into one of three categories:
 1P – Performance measure exclusion modifier is used due to medical reasons:
○ Not indicated (absence of organ/limb, already received/performed, other).
○ Contraindicated (patient allergic history, potential adverse drug interaction,
other).
○ Other medical reasons.
 2P – Performance measure exclusion modifier is used due to patient reasons:
○ Patient declined.
○ Economic, social, or religious reasons.
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Physician Quality Reporting
Quality Measures
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○ Other patient reasons.
3P – Performance measure exclusion modifier is used due to system reasons:
○ Resources to perform the services not available (e.g., equipment, supplies).
○ Insurance coverage or payer-related limitations.
○ Other reasons attributable to health care delivery system.
8 – Performance measure exclusion modifiers are used with CPT II codes only.
One or more exclusions may be applicable for a given measure. Certain
measures have no applicable exclusion modifiers. Refer to the measure
specifications to determine the appropriate exclusion modifiers.
Performance Measure Reporting Modifier
The performance measure reporting modifier facilitates reporting a case when the
patient is eligible but an action described in a measure is not performed and the reason
is not specified or documented.
 8P – Performance measure reporting modifier – Action not performed, reason not
otherwise specified. Using this modifier will allow credit for satisfactorily reporting
but the provider will not receive credit for performance.
Note: The above modifiers should not be appended to the Physician Quality Reporting
measure unless the measure lists a specific modifier based on the patient meeting the
measure specifications.
Reporting Frequency
Each measure has a reporting frequency requirement for each eligible patient seen
during the reporting period, (for example, report one time only, once for each procedure
performed, once for each acute episode, per each eligible patient). The frequency will
be specified within the individual measure.
Note: Some measures also include specific performance time frames related to the
clinical action in the numerator that may be distinct from the measure’s reporting
frequency requirement. (For example, performance time frames may be stated as
“within 12 months” or “most recent.”)
How Is Age Calculated?
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Age is determined based on the Date of Service (DOS).
If the patient is of the proper age for a measure any time during the reporting
period and you are reporting using the 80 percent of a measures group option,
that patient would count in the 80 percent cohort for the measures group.
If you are reporting using the consecutive patient option, the patient’s age at the
time it appears in the consecutive patient sequence is the age used to determine
if it should count as one of the consecutive patients.
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Quality Measures
MEDICARE PART B
WHERE TO START
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Determine if the provider is eligible to participate.
Providers should review the measures and determine which measures apply to
the manner in which the physician/provider practices medicine and the types of
Medicare patients treated in the practice. Select the appropriate number of
measures to report based on program guidelines.
The various reporting options should also be reviewed to determine which would
best fit the practice. Based on the reporting option, the reporting period could be
different.
Processes should be implemented within the office to capture the HCPCS code
and any modifier for correct reporting to Medicare or the applicable requirement
(e.g., registry).
Begin reporting Physician Quality Reporting and verify on the Medicare
Remittance Advice (MRA) that the message N365 is listed. This message
indicates that the claim was processed with the measure and was posted to the
National Claims History (NCH) records, where CMS will evaluate the following
year for bonus consideration.
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Where to Start
MEDICARE PART B
INDIVIDUAL MEASURES
Each year CMS publishes a listing of the individual measures specific for claims and
registry reporting. Each measure consists of a numerator and a denominator, which
permits the calculation of the percentage of a defined patient population that receives a
particular process of care or achieves a particular outcome. The measure also consists
of specific instructions regarding CPT category 1 modifiers, place of service codes and
other detailed information. Providers should review each measure carefully to determine
what measures are appropriate for an eligible professional and what measure meets the
patient population. The individual measures can be viewed on the Physician Quality
Reporting Web site at: http://www.cms.gov/PQRS/15_MeasuresCodes.asp.
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Individual Measures
MEDICARE PART B
MEASURES GROUPS
Each year CMS publishes a list of the measures groups specific for claims and registry
reporting. Each group is a subset of four or more individual measures that have been
grouped together by a particular clinical condition or focus. Each measures group
specifies the individual measures that make up the respective group. Each measures
group has specific reporting instructions and the denominator coding has been modified
from the individual measures that are published.
 A measures group is a group of measures covering patients with a particular
condition or preventive services.
 Each of the applicable measures in a measures group must be reported for each
patient in the measures group.
 A single set of codes (CPT I and/or ICD-9-CM) as well as specific age ranges
comprise the denominator for each measures group.
The measures group specifications can be viewed on the Physician Quality Reporting
Web site at:
http://www.cms.gov/PQRS/15_MeasuresCodes.asp.
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Measures Groups
MEDICARE PART B
PHYSICIAN QUALITY REPORTING – REPORTING
CRITERIA/REPORTING OPTIONS
Note: Providers should review all of the different reporting options and select the best
option for the practice. The 2012 Physician Quality Reporting System Measure List and
Implementation Guide provides a Physician Quality Reporting Participation Tree,
included within this document as Appendix C, that will assist in the reporting option
selection and can be found at: http://www.cms.gov/PQRS/15_MeasuresCodes.asp.
There are four reporting options available for providers to choose from:
 Claims-based:
○ Individual measures.
○ Measures groups.
 Registry-based.
 Electronic Health Record (EHR).
 Group Practice Reporting Options (GPRO).
Claims-Based Reporting
There are 210 individual quality measures and 22 measures groups for providers to
review and choose from. A complete listing of the 2012 Physician Quality Reporting
System measures can be found on the CMS Web site at:
2012 Criteria for Reporting Claims-Based Via Individual Measures
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Reporting period: January 1, 2012 – December 31, 2012.
Report at least three Physician Quality Reporting System measures.
Report each measure for at least 50 percent of the eligible professional’s
Medicare Part B physician fee schedule patients seen during the reporting period
to which the measure applies.
Measures with a zero percent rate will not be counted.
Providers reporting fewer than three measures during the reporting period could
be subject to measure-applicability validation.
Eligible providers selecting this reporting option must:
 Select the CPT category II code, which supplies the numerator. The CPT
category II code must be reported on the same claim as the payment CPT
category I codes and ICD-9-CM (measure specific – if applicable), which supply
the denominator of the measures.
○ Note: Multiple CPT category II codes can be reported on the same claim, as
long as the corresponding denominator codes are also on the claim.
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Reporting Criteria/Reporting Options
MEDICARE PART B
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Indicate the individual National Provider Identifier (NPI) of the participating
professional properly on the claim.
○ Note: Multiple eligible professionals with their NPIs may be reported on the
same claim with each Quality-Data Code (QDC) line item corresponding to
the services rendered by the professional for that encounter.
Report the correct numerator on at least 50 percent of eligible claims for each
selected measure or measures group.
Indicate the patient’s ICD-9-CM diagnosis and the CPT category I encounter
code on the claim. These should match the diagnosis and encounter codes listed
in the denominator criteria of the selected measure specification.
Remember that the submitted charge field cannot be blank.
Populate the line item charge as $0.00.
○ If a system does not allow $0.00 line item charge, use a small amount like
$0.01.
○ Remember that claims with a zero charge will be rejected.
File claims timely. Claims must reach the National Claims History (NCH) file by
the last day of February following the reporting year to be included in the
analysis.
Understand that once the claim has processed, the QDC line items will be denied
for payment but then passed through to the NCH file for Physician Quality
Reporting analysis.
Follow up. Eligible professionals should check their Remittance Advice (RA) for a
denial code (e.g., N365) for the measure’s specific code, confirming that the code
passed through their carrier/Medicare Administrative Contractor (MAC) to the
NCH file.
○ The N365 denial indicates that the code is not payable and is used for
reporting/informational purposes only.
2012 Criteria for Reporting for Claims-Based Via Group Measures
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Report at least one Physician Quality Reporting System measures group.
Report each measure for at least 30 of the eligible professional’s Medicare Part B
physician fee schedule patients seen during the reporting period to which the
measure applies.
Measures groups with a zero percent rate will not be counted.
Or,
Report at least one Physician Quality Reporting System measures group.
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MEDICARE PART B
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to which the measure applies (minimum of 15 patients).
Or,
Report each measure for at least 30 applicable Medicare Part B physician fee
schedule patients for a measures group.
Measures groups with a zero percent rate will not be counted.
Eligible providers selecting this reporting option must:
 Report on all applicable measures within the selected measures group. If all the
measures within the group were performed during the patient’s encounter, report
the respective group measure code on the claim along with the patient encounter
(numerator).
○ If the patient encounter did not include all of the applicable measures within
the group, each individual measure codes must be included on the claim
along with the applicable CPT II modifier to indicate the reason the individual
measure was not performed.
○ Note: Multiple CPT category II codes can be reported on the same claim, as
long as the corresponding denominator codes are also on the claim.
 Indicate the individual NPI of the participating professional properly on the claim.
○ Note: Multiple eligible professionals with their NPIs may be reported on the
same claim with each QDC line item corresponding to the services rendered
by the professional for that encounter.
 Initial reporting of the measures group will require the claim to include the “I
intend to report” specific intent “G” code. The intent “G” code must be reported to
indicate the eligible professional’s selection of the measures group and that the
professional intends to report the respective measure. The intent “G” code only
needs to be reported once.
 Indicate the patient’s ICD-9-CM diagnosis and the CPT category I encounter
code on the claim. These should match the diagnosis and encounter codes listed
in the denominator criteria of the selected measure specification.
 Remember that the submitted charge field cannot be blank.
 Populate the line item charge as $0.00.
 If a system does not allow $0.00 line item charge, use a small amount like $0.01.
○ Remember that the patient is not responsible for the small amount billed;
make sure to properly adjust off any amount billed in this instance.
 File claims timely. Claims must reach the NCH file by the last day of February
following the reporting year to be included in the analysis.
 Understand that once the claim has processed, the QDC line items will be denied
for payment but then passed through to the NCH file for Physician Quality
Reporting analysis.
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MEDICARE PART B
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Follow up. Eligible professionals should check their RA for a denial code (e.g.,
N365) for the measure’s specific code, confirming that the code passed through
their carrier/MAC to the NCH file.
○ The N365 denial indicates that the code is not payable and is used for
reporting/informational purposes only.
Registry-Based Reporting Criteria
In 2011, providers could select from 97 qualified registries and 27 qualified EHR
vendors. At this time, a 2012 qualified registry listing is not available and providers
should continue to check the CMS Web site for the listing. Registry-based reporting is
an alternative to reporting measures either by claims-based or EHR reporting methods.
To be eligible and report through a registry, that registry must be one that has been
preapproved by CMS. CMS selects qualified registries annually, all of which must go
through a thorough vetting process. While the registries published on the CMS Web site
have completed the vetting process, CMS cannot guarantee that any or all of the
registries will be successful in providing the required information on behalf of the eligible
professionals for the possible payment incentive.
There are several methods by which a selected registry can collect the Physician
Quality Reporting System measure information:
 Copy of claims.
 Web site portal.
 Practice management software data mining.
 EHR.
Qualified registries must:
 Have been in existence as of January 1, 2011.
 Have at least 25 participants by January 1, 2011.
 Provide at least one feedback report per year to participating eligible
professionals.
 Not be owned or managed by an individual locally-owned single-specialty group;
in other words, single-specialty practices with only one practice location or solo
practitioner practices would be prohibited from self-nominating to become a
qualified Physician Quality Reporting registry.
 Participate in ongoing 2011 Physician Quality Reporting mandatory support
conference calls hosted by CMS. (Approximately one call per month, including an
in-person registry kickoff meeting to be held at CMS headquarters in Baltimore,
Maryland. Registries who miss more than one meeting will be precluded from
submitting Physician Quality Reporting data for the 2011 reporting year.)
 Be able to collect all needed data elements and transmit to CMS the data at the
Tax Identification Number (TIN)/National Provider Identifier (NPI) level for eligible
professionals for at least three measures in the 2011 Physician Quality Reporting
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MEDICARE PART B
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System (according to the posted 2011 Physician Quality Reporting Quality
Measure Specifications).
Be able to calculate and submit measure-level reporting rates or the data
elements needed to calculate the reporting rates at the TIN/NPI level.
Be able to calculate and submit, by TIN/NPI for eligible professionals, a
performance rate (that is, the percentage of a defined population who receive a
particular process of care or achieve a particular outcome) for each measure or
measures group on which the eligible professional reports or the data elements
needed to calculate the reporting rates.
Be able to separate out and report on Medicare Fee-for-Service (FFS) Part B
patients.
Provide the name of the registry.
Provide the reporting period start date the registry will cover.
Provide the reporting period end date the registry will cover.
Provide the measure numbers for the Physician Quality Reporting System quality
measures for which the registry is reporting.
Provide the measure title for the Physician Quality Reporting System quality
measures for which the registry is reporting.
Report the number of eligible instances (reporting denominator).
Report the number of instances of quality service performed (numerator).
Report the number of performance exclusions.
Report the number of reported instances, performance not met (eligible
professional receives credit for reporting, not for performance).
Be able to transmit this data in a CMS-approved XML format.
Comply with a CMS-specified secure method for data submission, such as
submitting registry’s data in an XML file through an identity management system
specified by CMS or another approved method such as over the National Health
Information Network (NHIN) if technically feasible.
Submit an acceptable “validation strategy” to CMS by March 31, 2011. A
validation strategy ascertains whether eligible professionals have submitted
accurately and on at least the minimum number (80 percent) of their eligible
patients, visits, procedures or episodes for a given measure. Acceptable
validation strategies often include such provisions as the registry being able to
conduct random sampling of their participants’ data, but may also be based on
other credible means of verifying the accuracy of data content and completeness
of reporting or adherence to a required sampling method.
Perform the validation outlined in the strategy and send the results to CMS by
June 30, 2012, for the 2011 reporting year’s data.
Enter into and maintain with its participating professionals an appropriate
business associate arrangement that provides for the registry's receipt of patient-
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specific data from eligible professionals, as well as the registry's disclosure of
quality measure results and numerator and denominator data on behalf of eligible
professionals who wish to participate in the Physician Quality Reporting System.
Obtain and keep on file signed documentation that each holder of an NPI whose
data are submitted to the registry has authorized the registry to submit quality
measures results and numerator and denominator data to CMS for the purpose
of Physician Quality Reporting System participation. This documentation must be
obtained at the time the eligible professional signs up with the registry to submit
Physician Quality Reporting System quality measures data to the registry and
must meet any applicable laws, regulations and contractual business associate
agreements.
Provide CMS access (if requested for validation purposes) to review the
Medicare beneficiary data on which 2011 Physician Quality Reporting System
registry-based submissions are founded or provide to CMS a copy of the actual
data (if requested).
Indicate the reporting options the registry seeks to submit on behalf of its users in
addition to individual measures (measures groups, GPRO II, Electronic
Prescribing (eRx) for individuals, eRx for GPROs, six-month and 12-month
reporting periods).
Provide the reporting option(s) (reporting period and reporting criteria) that the
eligible professional has satisfied or chosen.
Provide CMS a signed, written attestation statement via mail or e-mail that states
the quality measure results and any and all data, including numerator and
denominator data provided to CMS, are accurate and complete.
In addition to the above, registries (both new and previously qualified) that intend to
report on 2011 Physician Quality Reporting System measures must:
 Indicate the reporting period selected for each eligible professional who chooses
to submit data on measures groups.
 Base reported information for measures groups only on patients to whom
services were furnished during the 12-month reporting period of January 1, 2011,
through December 31, 2011, or the six-month reporting period of July 1, 2011,
through December 31, 2011.
 Agree that the registry’s data may be inspected or a copy requested by CMS and
provided to CMS under CMS oversight authority.
 Be able to report data on all applicable measures in a given measures group on
either 30 patients or more Medicare Part B FFS patients from January 1, 2011,
through December 31, 2011, or on 80 percent of applicable Medicare Part B FFS
patients for each eligible professional (with a minimum of 15 patients during the
January 1, 2011, through December 31, 2011, reporting period or a minimum of
eight patients during the July 1, 2011, through December 31, 2011, reporting
period).
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MEDICARE PART B
Registries are no longer permitted to included non-Medicare patients for measures
group(s) reporting. Additionally, in an effort to reduce the variation in measures results
across registries and better allow eligible professional comparisons, all current and
future registries must meet the following new requirements:
 Use Physician Quality Reporting System measure specifications and a standard
set of measure calculation logic provided by CMS to calculate reporting rates or
performance rates unless otherwise stated.
 Provide a calculated result using the CMS-supplied logic and XML file for each
measure that the registry intends to calculate. The registries will be required to
show that they can calculate the proper measure results (that is, reporting and
performance rates) using the CMS-supplied logic and send the calculated data
back to CMS in the specified format.
 Provide the individual data elements used to calculate the measures if so
requested by CMS for validation purposes. Registries that are subject to
validation will be asked to send discrete data elements for a measure
(determined by CMS) in the required data format for us to recalculate the
registries’ reported results. Validation will be conducted for several measures at a
randomly selected sample of registries in order to validate their data
submissions.
Eligible professionals who wish to participate in Physician Quality Reporting using one
of the registry-based options should check with the specific registry they are using or
intend to use to verify which measures, reporting periods and options the registry
intends to report to CMS on their behalf.
A list of names and contact information of the “qualified” registries that may submit
quality data on behalf of eligible professionals for a possible incentive can be found on
the CMS Physician Quality Reporting Web site at:
http://www.cms.gov/PQRS/Downloads/2011_Qualified_Registries_Posting_11-302011.pdf
Future registry information will be published on the CMS Web site as information
becomes available.
To determine what measures can be submitted through a registry, review the 2012
Physician Quality Reporting Specifications Manual for Claims and Registry Reporting of
Individual Measures, which is located on the CMS Web site at:
http://www.cms.gov/PQRS/15_MeasuresCodes.asp
2012 Criteria for Reporting on Individual Measures Via Registry

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MEDICARE PART B



Report at least three Physician Quality Reporting System measures.
And,
to which the measure applies.
Measures with a zero percent rate will not be counted.
2012 Criteria for Reporting on Measures Group Via Registry
 Reporting period: January 1, 2012 – December 31, 2012.
○ Report one measures group.
○ Report the measures group for at least 30 applicable Medicare Part B
physician fee schedule patients for a measures group.
○ Measures groups with a zero percent performance rate on a measure will not
be counted.
Or,
○ Report the measures group for at least 80 percent of applicable Medicare
Part B physician fee schedule patients for a measures group (minimum of 15
patients).
be counted.
Or,
 Reporting period: July 1, 2012 – December 31, 2012.
○ Report the measures group for at least 80 percent of applicable Medicare
Part B physician fee schedule patients for a measures group (minimum of
eight patients).
be counted.
No additional specific billing details can be provided for providers billing the registrybased option. The eligible professional must contact the registry directly and work with
the registry for detailed reporting requirements. The measure(s) selected must also be
followed in conjunction with the registry reporting requirements for an eligible
professional to be considered successful at the end of the respective reporting period.
Electronic Health Record (EHR) Criteria
Eligible professionals may participate in Physician Quality Reporting by quality
measures data being extracted from a qualified EHR product. For 2012, there are 51
measures that qualify under EHR. An EHR is a systematic collection of electronic health
Rev. 02/2012
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MEDICARE PART B
information about individual patients or populations.
CMS selects qualified EHR vendors annually and publishes the current list of the
preapproved qualified vendors on the CMS Web site. Each of the EHR vendors goes
through a thorough vetting process to qualify. While the listed vendors and their
qualified systems and product(s) have successfully completed the vetting process, CMS
cannot guarantee that any other product or version of software, other than what is listed
in the EHR documents, will be compatible for EHR-based submission for the Physician
Quality Reporting System Incentive Program.
Providers selecting this method of reporting must register for an Individuals Authorized
Access to the CMS Computer Services (IACS) account. If the provider has an account
established, the IACS profile must be updated to include the EHR submitter role.
Eligible professionals wishing to report these measures using a “qualified” EHR system
should access the CMS documents concerning the 51 measures submission found
under the Downloads section of the Alternative Reporting Mechanisms page of the CMS
Physician Quality Reporting Web page at:
http://www.cms.gov/PQRS//20_AlternativeReportingMechanisms.asp
2012 Criteria for Direct EHR-Based Reporting
 The EHR product must be deemed qualified by CMS and be on the CMS
approved vendors list, which is located on the CMS Web site at:
http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp.
 Report at least three EHR individual measures. The 2012 EHR Documents for
Eligible Professionals can be found on the CMS Web site at:
 Report the individual measures on at least 80 percent of the applicable Medicare
Part B physician fee schedule patients.
 Measures with a zero percent performance rate will not be counted.
Or,
 Report a total of three Health Information Technology for Economic and Clinical
Health (HITECH) core or alternate core measures.
And,
 Report three additional HITECH measures.
Reminder:
 Three core and three alternate core measures must be submitted, even if the
measures have a zero denominator value.
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
Successful submission of HITECH data will qualify eligible professionals for the
Physician Quality Reporting System incentive and demonstrate meaningful use
of the CQM component of the EHR Incentive Program.
2012 Criteria for Vendor EHR Data Submission Reporting








The EHR product must be deemed qualified by CMS and be on the CMSapproved vendors list, which is located on the CMS Web site at:
Report at least three EHR individual measures. The 2012 EHR Documents for
Eligible Professionals can be found on the CMS Web site at:
The EHR submits data on at least 80 percent of the applicable Medicare Part B
physician fee schedule patients.
Measures with a zero percent performance rate will not be counted.
Or,
Report a total of three HITECH core or alternate core measures.
And,
Report three additional HITECH measures.
Reminder:
 Three core and three alternate core measures must be submitted, even if the
measures have a zero denominator value.
 Successful submission of HITECH data will qualify eligible professionals for the
Physician Quality Reporting System incentive and demonstrate meaningful use
of the CQM component of the EHR Incentive Program.
This reporting option is completed with the cooperation of approved EHR vendors. An
eligible professional reporting through a qualified/approved vendor could earn a
Physician Quality Reporting incentive payment beginning in January 2011. Qualification
will be based on the provider using one of the EHR products that CMS has deemed
“qualified” and the qualified vendor is listed on the approved vendor list from the CMS
Web site.
Each approved EHR vendor has gone through a thorough vetting process for the
product and version listed including checking their capability to provide the required
Physician Quality Reporting data elements for EHR Physician Quality Reporting
measures.
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The most recent approved EHR approved vendor list can be found on the CMS Web
site at:
http://www.cms.gov/PQRS//Downloads/QualifiedEHRVendorsRvsd10282010.pdf
While these vendors have been successful and approved, CMS cannot guarantee that
any other product or version of software from the listed vendors will be compatible for
EHR-based submission for Physician Quality Reporting.
The requirements for EHR vendors for the 2012 Physician Quality Reporting System
can be found on the CMS Web site at:
http://www.cms.gov/PQRS/Downloads/2012EHRVendorRequirements_12-082010_Final.pdf
The current list of EHR measure specifications can be found at:
http://www.cms.gov/PQRS//Downloads/2010_EHR_Measure_Specifications_rev05-252010.pdf
Group Practice Reporting Criteria
In accordance with Section 1848(m)(3)(C) of the Social Security Act, CMS created a
new Group Practice Reporting Option (GPRO) for 2010. Group practices that
satisfactorily report data on Physician Quality Reporting System measures for a
particular reporting period are eligible to earn a Physician Quality Reporting System
incentive payment equal to a specified percentage of the group practice’s total
estimated Medicare Part B physician fee schedule allowed charges for covered
professional services furnished during the reporting period.
To participate in the 2012 GPRO, practices are required to complete a self-nomination
process and meet certain technical and other requirements.
To qualify for GPRO, a “group practice” consists of a physician group practice as
defined by a TIN with at least 25 or more individual eligible professionals who have
reassigned their billing rights to the group TIN.
There are 29 quality measures for GPRO that target high-cost chronic conditions and
preventive care.
The measure specifications are grouped into seven disease modules and preventive
care:
 Care Coordination/Patient Safety (Care) – two measures.
 Chronic Obstructive Pulmonary Disease (COPD) – one measure.
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MEDICARE PART B






Coronary Artery Disease (CAD) – three measures.
Diabetes Mellitus (DM) – eight measures.
Heart Failure (HF) – five measures.
Hypertension (HTN) – one measure.
Ischemic Vascular Disease (IVD) – two measures.
Preventive Care (Prev) – seven measures.
The 2012 Physician Quality Reporting GPRO Narrative Measure Specifications can be
found on the CMS Web site at:
http://www.cms.gov/PQRS/22_Group_Practice_Reporting_Option.asp
Group practices will submit data to CMS via a database that has pre-populated with an
assigned beneficiary sample, plus the quality measures. The database will be provided
once CMS has approved the group for participation. The collected data will be based on
services furnished during the reporting period from January 1, 2012, through December
31, 2012.
Group practices that satisfactorily submit data on quality measures via GPRO are
eligible to earn an incentive of 0.5 percent of the group practice’s total estimated
Medicare Part B physician fee schedule allowed charges for covered professional
services for 2012. This incentive is in lieu of Physician Quality Reporting under the
individual NPI’s incentive payments.
Once providers have submitted the self-nomination and the group has been selected to
participate using the GPRO option, detailed information is provided.
2012 Criteria GPRO-Based Reporting








Report using Web interface by CMS.
Provider group size: 25–99.
Self-nominate between January 3, 2012 – January 31, 2012.
Must have confirmation of acceptance by CMS to participate.
Report on all measures included in Web interface (CMS beneficiary database) for
a pre-populated beneficiary sample.
Report consecutive, confirmed and completed beneficiaries for each disease
module.
Report preventive care measures.
Or,
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






Report using Web interface by CMS.
Provider group size: 100 or more.
Self-nominate between January 3, 2012 – January 31, 2012.
Must have confirmation of acceptance by CMS to participate.
Report on all measures included in Web interface (CMS beneficiary database) for
a pre-populated beneficiary sample.
Report consecutive, confirmed and completed beneficiaries for each disease
module.
Report preventive care measures.
Additional information related to group reporting can be found on the CMS Web site
under the Group Practice Reporting Option Web page at:
http://www.cms.gov/PQRS//22_Group_Practice_Reporting_Option.asp
Maintenance of Certification Program Criteria
In accordance with Section 1848(m)(7) of the Social Security Act (“Additional Incentive
Payment”), CMS is continuing the Maintenance of Certification Program Incentive that
began in January 2011. Eligible professionals who are incentive eligible for the
Physician Quality Reporting System (formerly known as the Physician Quality Reporting
Initiative, or PQRI) could receive an additional 0.5 percent incentive payment when
Maintenance of Certification Program Incentive requirements have also been met.
Providers may qualify for an additional 0.5 percent incentive for the 2012 Physician
Quality Reporting System based on the 12-month reporting period (January 1 through
December 31).
The eligible professional must:
 Satisfactorily submit data, without regard to method, on quality measures under
Physician Quality Reporting, for a 12-month reporting period either as an
individual physician or as a member of a selected group practice and have such
data submitted:
○ On their behalf through a Maintenance of Certification Program that meets the
criteria for a registry under the Physician Quality Reporting System.
Or,
○ In an alternative form and manner determined appropriate by the Secretary.
And,
○ More frequently than is required to qualify for or maintain board certification
status.
 Participate in such Maintenance of Certification Program for a year and:.
○ Successfully complete a qualified Maintenance of Certification Program
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MEDICARE PART B

practice assessment for such year. If the board does not have assessment
modules in place, the eligible professionals will not be eligible for the 0.5
percent incentive.
○ Practice assessment must include a survey of patient experience with care as
part of the practice assessment. This data must be available to CMS for
validation purposes upon request.
And,
The Maintenance of Certification Program will need to submit the following
information to CMS on behalf of the eligible professional:
○ In a form and manner specified by the Secretary, that the eligible
professional, more frequently than is required to qualify for or maintain board
certification status, participates in the Maintenance of Certification Program
for a year and successfully completes a qualified Maintenance of Certification
Program practice assessment for such year.
○ Upon request by the Secretary, information on the survey of patient
experience with care.
And,
○ As the Secretary may require, on the methods, measures and data used
under the Maintenance of Certification Program and the qualified
Maintenance of Certification Program practice assessment.
Definition of a Maintenance of Certification Program
A Maintenance of Certification Program is defined as a continuous assessment program
that advances quality and the lifelong learning and self-assessment of board-certified
specialty physicians by focusing on the competencies of patient care, medical
knowledge, practice-based learning, interpersonal and communication skills, and
professionalism. To qualify for the bonus, eligible professionals will be required to
participate more frequently than is required in at least one of the following three parts of
the Maintenance of Certification Program, as well as “more frequent” successful
completion of a qualified maintenance of certification program practice assessment.
 Maintain a valid, unrestricted medical license in the United States.
○ Physicians simply need to maintain a valid unrestricted license in the United
States to meet the requirement for “more frequent” participation.
 Participate in educational and self-assessment programs that require an
assessment of what was learned.
 Demonstrate through a formalized, secure examination that the physician has the
fundamental diagnostic skills, medical knowledge and clinical judgment to
provide quality care in his respective specialty.
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MEDICARE PART B
Definition of a Qualified Maintenance of Certification Program Practice
Assessment
A qualified Maintenance of Certification Program practice assessment includes an initial
assessment of an eligible professional’s practice that:
 Demonstrates the physician’s use of evidence-based medicine.
 Includes a survey of patient experience with care.
 Requires the physician to implement a quality improvement intervention to
address a practice weakness identified in the initial assessment.
 The practice assessment must also require the practice to reassess performance
improvement after the intervention.
Definition of ‘More Frequently’
This could be interpreted differently by different Maintenance of Certification Programs.
CMS expects to see an attestation from a Maintenance of Certification Program entity
that both the Maintenance of Certification Program and the practice assessment are
completed once more by a physician than is required by a specific Maintenance of
Certification Program.
Self-Nomination
New and previously approved Maintenance of Certification Program entities wishing to
enable their members to be eligible for the additional incentive must complete the selfnomination process by January 31, 2012. Maintenance of Certification Program entities
will need to be approved for participation by CMS. Qualified Maintenance of Certification
Program entities will then be able to submit on the physicians’ behalf. For consideration,
Maintenance of Certification Program entities must submit the following by a mailed
letter to CMS:
 Detailed information regarding the Maintenance of Certification Program with
reference to the statutory requirements.
 Indicate the organization sponsoring the Maintenance of Certification Program,
and whether the Maintenance of Certification Program is sponsored by an
American Board of Medical Specialties (ABMS). If not an ABMS, indicate
whether the program is substantially equivalent to the ABMS Maintenance of
Certification Program process.
 Confirmation that the program is in existence as of January 1, 2012.
 Indicate that the program has at least one active participant.
 The frequency of a cycle of Maintenance of Certification for the specific
Maintenance of Certification Program of the sponsoring organization, including
what constitutes "more frequently" for both the Maintenance of Certification
Program itself and the practice assessment for the specific Maintenance of
Certification Program of the sponsoring organization.
 Confirmation that the practice assessment will occur and be completed in the
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MEDICARE PART B





year the physician is participating in the Maintenance of Certification Program
Incentive.
What was, is or will be the first year of availability of the Maintenance of
Certification Program practice assessment for completion by an eligible
professional.
What data is collected under the patient experience of care survey and how this
information would be provided to CMS.
How the Maintenance of Certification program monitors that an eligible
professional has implemented a quality improvement process for their practice.
Describe the methods and data used under the Maintenance of Certification
Program and provide a list of all measures used in the Maintenance of
Certification Program for 2011 and to be used for 2012, including the title and
descriptions of each measure, the owner of the measure, whether the measure is
endorsed by the National Quality Forum (NQF), and a link to a Web site
containing the detailed specifications of the measures or an electronic file
containing the detailed specifications of the measures.
Previously approved Maintenance of Certification Programs should also note any
updates to the program.
New Maintenance of Certification Program entities will be interviewed as part of the
vetting process. Existing Maintenance of Certification Program entities will not be
required to participate in a second interview.
Sponsoring organizations that desire to participate as a Maintenance of Certification
Program must provide CMS the following information in a CMS-specified file format via
a secure method by March 31, 2013:
 The name of the eligible professional who would like to participate in the
Maintenance of Certification Program Incentive for 2012.
 The individual NPI (not the group NPI).
 The applicable TIN(s) or Social Security number used to bill and receive
Medicare reimbursement.
 Attestation from the board that the information provided to CMS is accurate and
complete.
 Maintenance of Certification Program entity has signed documentation from
eligible professional(s) that he wishes to have the information released to CMS.
 Information from the patient experience of care (patient satisfaction) survey.
 Information certifying the eligible professional has participated in a Maintenance
of Certification Program for a year, “more frequently” than is required to qualify
for or maintain board certification status, including the year the physician met the
board certification requirements for the Maintenance of Certification Program and
the year the eligible professional participated in the Maintenance of Certification
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MEDICARE PART B

Program “more frequently” than is required to maintain or qualify for board
certification.
Information certifying the eligible professional has completed the Maintenance of
Certification Program practice assessment at least one time each year the
eligible professional participates in the Maintenance of Certification Program
Incentive.
CMS anticipates completing the qualification process by mid-2012 and will post the final
list of Qualified Maintenance of Certification Program entities on the Physician Quality
Reporting System section of the CMS Web site at that time.
Physician(s) desiring to be considered for the 2012 Maintenance of Certification
Program incentive should review the documents referenced above for the qualified
Maintenance of Certification Program entities. The Maintenance of Certification
Program incentive is applicable for physicians participating in the Physician Quality
Reporting System via individual and group practice reporting (GPRO). Eligible providers
will need to work with their selected Maintenance of Certification Program entity to
ensure successful completion of the Maintenance of Certification Program Incentive
participation requirements. The Maintenance of Certification Program incentive payment
will be paid at the same time as the Physician Quality Reporting incentive payment for
2012 for those physicians that qualify. It will be a separately identifiable payment on the
Physician Quality Reporting feedback report for 2012. The 2012 Physician Quality
Reporting will calculate the Maintenance of Certification Program incentive payment of
0.5 percent based on allowed Medicare Part physician fee schedule charges for
covered professional services furnished between January 1, 2012, and December 31,
2012. Physicians cannot receive more than one additional 0.5 percent incentive even if
they complete a Maintenance of Certification Program in more than one specialty. The
Maintenance of Certification Program incentive will not be awarded to physicians who
have not qualified for the Physician Quality Reporting incentive.
The Maintenance of Certification Program self-nomination letters are required each year
the Maintenance of Certification Program intends to participate in the Physician Quality
Reporting System Maintenance Program.
Self nominations should be sent via a mailed letter to:
2012 Physician Quality Reporting System Maintenance of Certification Program
Incentive Self-Nomination
Centers for Medicare & Medicaid Services
Office of Clinical Standards and Quality
Quality Measurement & Health Assessment Group
7500 Security Boulevard
Mail Stop S3-02-01
Baltimore, MD 21244-1850
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MEDICARE PART B
The letter must be received no later than 5 p.m. ET on January 31, 2012. Providers
should allow two weeks for mail processing.
Specialty boards that also wish to send Physician Quality Reporting System information
to CMS on behalf of eligible professionals must meet the requirements for registry data
submission and should follow the directions for self-nomination to become a qualified
registry. (Refer to the Registry Requirements for additional information.)
Boards may also participate as registries for Physician Quality Reporting System data
provided that they meet the registry requirements. As an alternative to requiring boards
to either operate a qualified Physician Quality Reporting System or to self-nominate to
submit Maintenance of Certification Program data to CMS on behalf of their members,
CMS will continue to allow the various boards to submit Maintenance of Certification
Program data to the ABMS and have the ABMS submit the information on behalf of the
various boards and their member-eligible professionals to CMS.
A sample self-nomination letter is provided by CMS and can be found on the CMS Web
site at:
http://www.cms.gov/PQRS/Downloads/2012_Maintenance_of_Certification_Requireme
nts_2.pdf
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MEDICARE PART B
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MEDICARE PART B
CMS lists the 2011 conditionally qualified Maintenance of Certification Program
Incentive entities on its Web site at:
http://www.cms.gov/PQRS/Downloads/Conditionally_Qualified_MOC_ap_mm_508_rvsd
info.pdf
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MEDICARE PART B
Below is a snapshot of the most recent listing of qualified Maintenance of Certification
program entities for 2011. Reminder: Periodically check the CMS Web site for any
updates to this list.
Additional program information for Maintenance of Certification can be found on the
CMS Web site at:
http://www.cms.gov/PQRS/23_Maintenance_of_Certification_Program_Incentive.asp
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MEDICARE PART B
PHYSICIAN QUALITY REPORTING OVERVIEW
2012 Physician Quality Reporting System
The 2012 Physician Quality Reporting program was finalized in the 2012 PFS Final
Rule. The final regulation can be found in the Federal Register dated November 1,
2011. The final rule with comment period may be viewed at:
http://www.cms.gov/PQRS/05_StatuteRegulationsProgramInstructions.asp
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Physician Quality Reporting Overview
MEDICARE PART B
MEASURES OVERVIEW
Physician Quality Reporting measures are formatted based on:
 Measure title.
 Reporting option available (claims-based or registry).
 Measure description.
 Instructions on reporting (frequency, time frames and applicability).
 Denominator statement and coding.
 Numerator statement and coding options.
 Definitions of terms where applicable.
 Rationale statement for measure.
 Clinical recommendations or evidence forming the basis for supporting criteria for
measure.
Individual Measure Overview
The individual measure provided below, Measure #1 Diabetes Mellitus: Hemoglobin A1c
Poor Control in Diabetes Mellitus is provided as an educational example. The measure
has been dissected to point out key elements to assist in successful reporting.
The measure was taken from the CMS Web site’s 2012 Physician Quality Reporting
Measure Specifications and is intended to detail the individual measure, section by
section, as an educational tool.

Reporting: The measure title is listed in the example above along with the
applicable reporting options available. This measure can be reported by claims-
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Measures Overview
MEDICARE PART B


based or through a qualified registry.
Description: The measure describes age restrictions along with lab result
requirements. Patients between the ages of 18 and 75 with a recent hemoglobin
A1c greater than 9.0 percent qualify for this measure.
Instruction: The measure details the frequency of billing the measure. This
measure should be reported a minimum of once per reporting period.
Included in the measure instructions are details relating to measure reporting. The
example above indicates the requirements when the measure is reported on the
Medicare Part B claims as well as reported through a qualified registry. Additional
coding information is included to further explain the coding when the 8P modifier is
used.
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Measures Overview
MEDICARE PART B
The denominator is the patient population and is defined by certain ICD-9-CM and CPT
category I codes specified in the measure that are submitted as part of a claim for
Medicare physician fee schedule services by eligible professionals. This section
restates the age requirements of 18 through 75 years of age. The patient’s diagnosis
must be one listed within the denominator section and must be submitted on the
Medicare claim. The denominator section also provides a listing of CPT/HCPCS codes;
one must be submitted to reflect the patient encounter that was performed on the date
the patient was seen. Note: The denominator must be submitted on the same claim as
the numerator to be considered for the incentive. Claims submitted without the
appropriate CPT/HPCS and the appropriate numerator cannot be appealed. There are
no appeal rights to this policy. The initial claim must be submitted correctly to count
toward successful billing.
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Measures Overview
MEDICARE PART B
The numerator section provides the CPT category II code(s)/ “G” code(s) to report the
physician’s performance of the measure. The “G” code can be billed with or without a
modifier, depending on the reason for the patient’s visit and the outcome. Selection of
the “G” code is dependent on the patient’s most recent A1c level. The appropriate “G”
code must be reported on the claim to indicate the measure was met for the individual
patient on the specified date of service. The numerator is the CPT procedure code that
reflects the patient and the patient’s lab results. The appropriate code should be
selected based on the patient’s recent lab results. Claims submitted without the
appropriate CPT/HCPCS and the appropriate numerator cannot be appealed. There are
no appeal rights to this policy. The initial claim must be submitted correctly to count
toward successful billing.
The rationale is the “logic” of maintaining the A1c level used when determining the
measure specifications. The diabetes rationale states intensive therapy of glycosylated
hemoglobin reduces the risk of microvascular complications.
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Measures Overview
MEDICARE PART B
Clinical recommendation statements are provided at the end of the measures and detail
the “clinical logic” that was used during the measure development. These clinical
statements are outside expert clinical medical recommendations/statements to provide
additional medical clarification after measure development.
Below is an example of an individual measure billed under the claims-based reporting
option. This example is provided as a guide for correct Physician Quality Reporting
measures code/modifier placement and claim submission.
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Measures Overview
MEDICARE PART B
Claim reminders:
 The patient’s diagnosis code(s) and the procedure code(s) performed on the date
of service should be reflective of the measure selected.
 Any modifier (taken from the measure) should be entered on the claim if some
type of circumstance prevented the measure from being performed. Remember,
one of the CPT II modifiers should only be applied to the claim if it is listed as an
option within the measure. The CPT II modifier should reflect the reason the
measure was not performed.
 A zero charge should be entered on the charge field. If zero cannot be entered,
enter a small monetary amount and providers should make necessary
adjustments to the patient’s account after the claim has processed.
 The performing provider’s NPI and/or the rendering provider’s NPI number must
be submitted on the claim. Use of these fields is dependent on the type of
provider (solo or group) billing.
Common Claims-Based Reporting Errors
CMS’ data indicates the following errors associated with Physician Quality Reporting
System claim-based reporting:
 The patient’s age and/or gender mismatch to the measure reported.
 Incorrect diagnosis and/or HCPCS code mismatch to the measure reported.
 Measure reported without an eligible encounter.
 No quality-data code submitted on an eligible claim.
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Physician Quality Reporting System error reports are available on the CMS Web site to
assist eligible professionals and their staff on common errors identified during data
analysis. The error reports are available on the CMS Web site at:
http://www.cms.gov/PQRS/25_AnalysisAndPayment.asp
Measures Group Overview
The example below is taken from the 2012 Physician Quality Reporting Measures
Group listing and refers to the Diabetes Mellitus Measures Group. This measure has
been dissected to point out key elements to assist in successful reporting.
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This measures group can be reported either through claims-based or registrybased.
The Diabetes Mellitus Measures Group is composed of six individual measures:
measure numbers 1, 2, 3, 117, 119 and 163.
To report this measures group, all six of the individual measures have to be
performed during the patient encounter.
Each of the six measures within this measures group must be reviewed and
considered during the patient’s encounter.
If any of the six measures could not be performed during the patient encounter,
the appropriate CPT II modifier should be included on the claim to indicate why
the patient’s visit did not meet the measure specifications.
Providers must report their intention to bill for a particular measures group. This
can be done by selecting the appropriate “I intend to report G code” on one claim
on the earliest date of service for the reporting period selected. It is not
necessary to submit the measures group intent “G” code on more than one claim;
subsequent submissions of that code will be ignored.
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The above example is an excerpt from the claim-based reporting intent “G” code list,
which was taken from the Physician Quality Reporting System Measures Groups
Specifications Manual located on the CMS Web site at:
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The appropriate intent “G” code should be selected. Selection of this code must
also include the manner in which the eligible professional will report the
measures group: claim-based reporting or registry-only reporting.
Using the example of diabetes mellitus from above, G8485 would be reported on
an early claim within the respective reporting period to indicate the diabetes
measures group.
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The patient’s diagnosis would need to be one that is listed within the diabetes
measures group.
The encounter for the date of service would need to be one that is listed within
the diabetes measures group.
If the eligible professional was able to complete all six of the measure
requirements for that patient during the encounter, the diabetes mellitus
composite “G” code can be submitted. The composite “G” code for the diabetes
measures group is G8494. This code indicates that all quality actions for the
applicable measures in the Diabetes Mellitus Measures Group have been
performed for this patient.
If one or more of the six measures within the Diabetes Mellitus Measures Group
could not be performed during the patient’s encounter, the claim should reflect
each quality-data measure code (six measure codes would need to be reported
on the claim) along with the respective CPT II code to explain why that particular
measure was not met for that patient.
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The two examples below are for the Diabetes Mellitus Measures Group.
Example 1: Patient meets all elements within the Diabetes Mellitus Measures Group.
Example 1 Recap:
 If the patient’s encounter was inclusive of all six Diabetes Mellitus measure
requirements, the claim should include the patient encounter code (e.g., 99214)
as well as the “I intend to report” code for the diabetes measures group (G8485)
and the diabetes measures group composite code (G8494).
 Once the “I intend to report” code has been billed, it is not necessary to bill that
code again during the reporting period.
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Example 2: Patient does not meet all of the elements within the Diabetes Mellitus
Measures Group.
Example 2 Recap:
 If the patient’s encounter did not meet the requirements of all six measure
requirements, the composite code cannot be submitted.
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The claim should be filed with the patient encounter code (e.g,. 99214) along with
the “I intend to report” code for the diabetes measures group (G8485) plus a
specific numerator from each measure that was met as well as the specific
numerator from the measures that were not met during the encounter and any
CPT II modifier that describes why that measure was not performed.
In the example above, the provider completed all of the required measures within
the measures group with the exception of Measure #163. The patient had a
previous double foot amputation so the diabetes foot exam could not be
performed. By selecting the appropriate CPT II procedure code (2028F: Foot
exam not performed for medical reason) and adding the 1P CPT II modifier
(documentation of medical reason for not performing foot exam), the billing of this
measures group would be complete.
Measures Groups Intent to Report ‘G’ Codes
Eligible professionals identify their intent to report a measures group by submitting a
measures group-specific “G” code on a claim for covered professional services
furnished to a patient enrolled in Medicare Part B Fee-for-Service (FFS).
 It is not necessary to submit the measures group-specific “G” code on more than
one claim.
 If the “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 analyses; subsequent submissions of that code will
be ignored.
 It is not necessary to submit the measures group-specific “G” code for registrybased submissions.
The following is a listing of the 2012 Physician Quality Reporting intend to report
measures group codes:
Claims and Registry ‘G’ Codes
G8485:
G8487:
G8486:
G8490:
G8492:
G8493:
G8545:
G8547:
G8546:
G8645:
G8898:
I intend to report the Diabetes Mellitus Measures Group
I intend to report the Chronic Kidney Disease (CKD) Measures Group
I intend to report the Preventive Care Measures Group
I intend to report the Rheumatoid Arthritis Measures Group
I intend to report the Perioperative Care Measures Group
I intend to report the Back Pain Measures Group
I intend to report the Hepatitis C Measures Group
I intend to report the Ischemic Vascular Disease (IVD) Measures Group
I intend to report the Community-Acquired Pneumonia (CAP) Measures Group
I intend to report the Asthma Measures Group
I intend to report the Chronic Obstructive Pulmonary Disease (COPD)
Measures Group
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G8905: I intend to report the Cardiovascular Prevention Measures Group
Registry-Only ‘G’ Codes
G8544:
G8548:
G8489:
G8491:
G8899:
G8900:
G8902:
G8903:
G8904:
G8906:
I intend to report the Coronary Artery Bypass Graft (CABG) Measures Group
I intend to report the Heart Failure (HF) Measures Group
I intend to report the Coronary Artery Disease (CAD) Measures Group
I intend to report the HIV/AIDS Measures Group
I intend to report the Inflammatory Bowel Disease (IBD) Measures Group
I intend to report the Sleep Apnea Measures Group
I intend to report the Dementia Measures Group
I intend to report the Parkinson’s Disease Measures Group
I intend to report the Hypertension (HTN) Measures Group
I intend to report the Cataracts Measures Group
It is not necessary to submit the measures group-specific intent “G” code for registrybased submissions. However, the measures group-specific intent “G” codes have been
created for registry-only measures groups for use by registries that utilize claims data.
Measures Groups Composite ‘G’ Codes
If all quality actions for the patient have been performed for the measures group, a
composite “G” code may be reported in lieu of the individual QDCs for each of the
measures within the group.
 G8494: All quality actions for the applicable measures in the Diabetes Mellitus
Measures Group have been performed for this patient.
 G8495: All quality actions for the applicable measures in the CKD Measures
Group have been performed for this patient.
 G8496: All quality actions for the applicable measures in the Preventive Care
 G8497: All quality actions for the applicable measures in the Coronary Artery
Bypass Graft (CABG) Measures Group have been performed for this patient.
 G8498: All quality actions for the applicable measures in the Coronary Artery
Disease (CAD) Measures Group have been performed for this patient.
 G8499: All quality actions for the applicable measures in the Rheumatoid Arthritis
 G8500: All quality actions for the applicable measures in the HIV/AIDS Measures
 G8501: All quality actions for the applicable measures in the Perioperative Care
 G8502: All quality actions for the applicable measures in the Back Pain
 G8549: All quality actions for the applicable measures in the Hepatitis C
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G8551: All quality actions for the applicable measures in the Heart Failure (HF)
G8552: All quality actions for the applicable measures in the Ischemic Vascular
Disease (IVD) Measures Group have been performed for this patient.
G8550: All quality actions for the applicable measures in the CommunityAcquired Pneumonia (CAP) Measures Group have been performed for this
patient.
G8646: All quality actions for the applicable measures in the Asthma Measures
G8757: All quality actions for the applicable measures in the Chronic Obstructive
Pulmonary Disease (COPD) Measures Group have been performed for this
patient.
G8758: All quality actions for the applicable measures in the Inflammatory Bowel
Disease (IBD) Measures Group have been performed for this patient.
G8759: All quality actions for the applicable measures in the Sleep Apnea
G8761: All quality actions for the applicable measures in the Dementia Measures
G8762: All quality actions for the applicable measures in the Parkinson’s Disease
G8763: All quality actions for the applicable measures in the Hypertension
G8764: All quality actions for the applicable measures in the Cardiovascular
Prevention Measures Group have been performed for this patient.
G8765: All quality actions for the applicable measures in the Cataracts Measures
Note: Verify the measures group to ensure that it can be billed under the reporting
option that has been selected by the eligible provider: registry or claims-based.
Claim reminders:
 Submission of the “G code I intend to report” must be submitted once during the
reporting period. The intended “G” code initiates the count during the 12-month
reporting period with either of the two options: the 30 Medicare patients sample
or the 50 percent of Medicare patients sample method with a minimum of 15
patients.
 The patient’s diagnosis code and patient encounter code should reflect the
measure selected and performed during the patient encounter.
 A zero charge should be entered on the charge field. If zero cannot be entered,
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enter a small monetary amount and adjust that amount from the patient’s balance
after the claim has processed.
The performing provider’s NPI and/or the rendering provider’s NPI must be
submitted on the claim. Use of these fields is dependent on the type of provider
(solo or group) billing.
If the patient does not meet all of the individual measures that make up the
measures group, the composite “G” code should not be billed. Each individual
measures code within the measures group would need to be billed on the claim.
Any measure that was not accomplished would need to reflect the appropriate
CPT II modifier to indicate why the measure was not performed.
Verify on the Medicare Remittance Advice (MRA) that the message N365 is
listed. This message indicates that the claim was processed with the measure
and was posted to the NCH records where CMS will evaluate the following year
for bonus consideration.
EHR-Based Overview
CMS will accept quality measures data extracted from a qualified EHR product for a
limited subset of Physician Quality Reporting quality measures.
Some EHRs are also capable of reporting the electronic prescribing measure. In
addition to capturing the required data elements for the measure calculation, these
“qualified” EHR products can also transmit the required information in the requested file
format. Eligible professionals who choose this option will report the quality information
directly from their EHR.
The 2012 EHR Measure Specifications Manual will provide clinical practice guidelines
and standards. This manual should be reviewed to determine which measure should be
selected for any one office as well as program guidelines. This manual is located under
the 2012 EHR Documents for Eligible Professionals file on the CMS Web site at:
https://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp
While the listed EHR vendors and their EHR products have been approved, CMS will
not guarantee that any other product or version of software from the listed vendors will
be compatible for EHR-based submission for Physician Quality Reporting. An example
of the 2011 qualified EHR vendors are published on the CMS Web site at:
https://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp
Note: Providers should review the CMS Physician Quality Reporting EHR site regularly
for updates. The 2011 qualified EHR vendor list will be added in the future.
Eligible professionals who wish to participate in Physician Quality Reporting by using
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the EHR-based reporting should contact the EHR vendors listed for additional details
about their software and about the Physician Quality Reporting participation processes.
Providers should contact their EHR vendor if unsure that the product/system is qualified
for use in the Physician Quality Reporting EHR-based reporting.
Providers must select and report at least three of the 51 EHR measures to qualify for
the incentive. The measures can be submitted through direct EHR-based reporting or
through EHR data submission vendor reporting.
 Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes
Mellitus.
 Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in
Diabetes Mellitus.
 Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus.
 Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic
Dysfunction.
 Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy.
 Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD
Patients With Prior Myocardial Infarction.
 Measure #8: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD).
 Measure #9: Antidepressant Medication Management: (a) Effective Acute Phase
Treatment; (b) Effective Continuation Phase Treatment.
 Measure #12: Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation.
 Measure #18: Diabetic Retinopathy: Documentation of Presence or Absence of
Macular Edema and Level of Severity of Retinopathy.
 Measure #19: Diabetic Retinopathy: Communication With the Physician
Managing Ongoing Diabetes Care.
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Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years
and Older.
Measure #47: Advance Care Plan.
Measure #48: Urinary Incontinence: Assessment of Presence or Absence of
Urinary Incontinence in Women Aged 65 Years and Older.
Measure #53: Asthma: Pharmacologic Therapy.
Measure #64: Asthma: Assessment of Asthma Control.
Measure #66: Appropriate Testing for Children With Pharyngitis.
Measure #71: Breast Cancer: Hormonal Therapy for Stage IC–IIIC Estrogen
Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer.
Measure #72: Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients.
Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging
Low-Risk Prostate Cancer Patients.
Measure #110: Preventive Care and Screening: Influenza Immunization.
Measure #111: Preventive Care and Screening: Pneumonia Vaccination for
Patients 65 Years and Older.
Measure #112: Preventive Care and Screening: Screening Mammography.
Measure #113: Preventive Care and Screening: Colorectal Cancer Screening.
Measure #117: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient.
Measure #119 (NQF 0062): Diabetes Mellitus: Urine Screening for Microalbumin
or Medical Attention for Nephropathy in Diabetic Patients.
Measure #128: Preventive Care and Screening: Body Mass Index (BMI)
Screening and Follow-Up.
Measure #163: Diabetes Mellitus: Foot Exam.
Measure #173: Preventive Care and Screening: Unhealthy Alcohol UseScreening.
Measure #197: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDLCholesterol.
Measure #200: Heart Failure: Warfarin Therapy for Patients With Atrial
Fibrillation.
Measure #201: Ischemic Vascular Disease (IVD): Blood Pressure Management
Control.
Measure #204: Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic.
Measure #226: Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention.
Measure #236: Hypertension (HTN): Controlling High Blood Pressure.
Measure #237: Hypertension (HTN): Blood Pressure Measurement.
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Measure #238: Drugs to Be Avoided in the Elderly.
Measure #239: Weight Assessment and Counseling for Children and
Adolescents.
Measure #240: Childhood Immunization Status.
Measure #241: Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low
Density Lipoprotein (LDL-C) Control.
Measure #305: Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment: (a) Initiation; (b) Engagement.
Measure #306: Prenatal Care: Screening for Human Immunodeficiency Virus
(HIV).
Measure #307: Prenatal Care: Anti-D Immune Globulin.
Measure #308: Smoking and Tobacco Use Cessation, Medical Assistance
(a) Advising Smokers and Tobacco Users to Quit,(b) Discussing Smoking and
Tobacco Use Cessation Medications, (c) Discussing Smoking and Tobacco Use
Cessation Strategies.
Measure #309: Cervical Cancer Screening.
Measure #310: Chlamydia Screening for Women.
Measure #311: Use of Appropriate Medications for Asthma.
Measure #312: Low Back Pain: Use of Imaging Studies.
Measure #313: Diabetes Mellitus: Hemoglobin A1c Control (< 8 percent.)
Measure #316: Preventive Care and Screening: Cholesterol – Fasting Low
Density Lipoprotein (LDL) Test Performed and Risk-Stratified Fasting LDL.
Measure #317: Preventive Care and Screening: Screening for High Blood
Pressure.
The example below was taken from Measure #1: Diabetes Mellitus, under the 2012
EHR measure specifications analytic narratives. This measure has been dissected to
point out key elements to assist in successful reporting. The complete listing can be
found in the 2012 EHR Measure Specifications Manual, which can be located in the
2012 EHR Documents for Eligible Professionals file on the CMS Web site at:
http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp
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applicable reporting options available. This measure is specifically designed for
EHR reporting.
Description: The measure describes age restrictions. Patients must have a
diagnosis of diabetes and must be between the ages of 18 and 75.
Denominator Inclusions (Measure requirements): The measure details:
○ The patient must have at least one face-to-face visit (acute inpatient or
emergency department) or at least two face-to-face encounters with the
eligible provider. One visit could be during the year prior to the measure
period but at least one visit must be during the reporting period.
Or,
o The patient was prescribed a medication indicative of diabetes during the
measurement period.
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Numerator Inclusions (Measure Requirements): Defines the lab test as well as the
A1c test results, or indicates that no lab test was submitted during the measurement
period.
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Denominator Exclusions (Measure Requirements): Specifies what to do in the event
the most recent A1c test was not recorded or if the test results were less than or equal
to 9.0 percent.
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Rationale: The rationale is the “logic” of maintaining the A1c level used when
determining the measure specifications. The diabetes rationale states intensive therapy
of glycosylated hemoglobin reduces the risk of microvascular complications.
Clinical recommendation statements: Clinical recommendation statements are
provided at the end of the measures and detail the “clinical logic” that was used during
the measure development. These clinical statements are outside expert clinical medical
recommendations/statements to provide additional medical clarification after measure
development.
Steps for Successful EHR Reporting
Step 1:
Determine if you are eligible. A list of eligible professionals who can
participate can be found on the CMS Physician Quality Reporting Web site at:
http://www.cms.gov/PQRS/03_How_To_Get_Started.asp.
Step 2:
Review the EHR Measure Specifications to determine which electronically
specified Physician Quality Reporting measures apply to the practice. The
measures can be viewed on the CMS Web site at:
Step 3:
Determine if the EHR product is a CMS Physician Quality Reporting EHR
system. Providers can verify the qualified vendor listing from the CMS Web
site or by calling the EHR vendor directly. The most recent qualified vendor
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listing can be viewed on the CMS Web site at:
Step 4:
Carefully review the Physician Quality Reporting EHR Measures
Specifications and Notes to determine the measures that apply to the practice
and implement those measures for the reporting period.
Step 5:
The patient care and all related information should be documented within the
EHR system. Capture all eligible instances for the measures that were
selected.
Step 6:
Register for an Individual Authorized Access to CMS Computer Services
(IACS).
Once the IACS account is obtained, request an EHR submitter role for a Two
Factor Authentication. This is an additional method that will allow identity
verification and allow for the submission of secure data through the Physician
Quality Reporting Portal. More information can be found under the Alternative
Reporting Mechanisms section of the Physician Quality Reporting CMS Web
site at: http://www.cms.gov/PQRS//20_AlternativeReportingMechanisms.asp.
Step 7:
Work with the vendor to create a reporting file from the EHR system. All CMS
“qualified” systems should be programmed to generate this file.
Step 8:
Submit the final EHR reporting files with the measure data by the submission
deadline to be analyzed and used for the measure calculations. File uploads
will be limited to 10 MB in size; complete data submission may require
several files to be uploaded into the Physician Quality Reporting portal.
Following a successful upload, notification will be sent to the IACS user’s e-mail
address indicating the files were submitted and received. Submission reports will then
be available to indicate file errors, if applicable.
Group Practice Reporting Option for 2012
Providers considering this reporting option had to send a self-nomination letter to CMS,
requesting acceptance in this option. Detailed technical and other requirements to be
selected is published by CMS and located on the CMS Web site at:
All measures outlined under GPRO must be completed on all the eligible Medicare
patient population. CMS will send the eligible group practice a GPRO database that has
been pre-populated with an assigned beneficiary sample and the quality measures will
serve as a data collection tool to use in collecting the data. The data collected will be
based on services furnished during January 1, 2012, through December 31, 2012.
For each disease module or preventive care measure, the selected GPRO practice
must complete the data collection tool and submit the data to CMS.
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There are 29 quality-endorsed measures for the GPRO reporting option:
 Seven disease:
○ Care Coordination/Patient Safety (Care) (two measures).
○ Chronic Obstructive Pulmonary Disease (COPD) (one measure).
○ Coronary Artery Disease (CAD) (three measures).
○ Diabetes Mellitus (DM) (eight measures).
○ Heart Failure (HF) (five measures).
○ Hypertension (HTN) (one measure).
○ Ischemic Vascular Disease (IVD) (two measures).
And,
 Four preventive care (seven measures).
Each narrative measure specification includes the following information:
 Symbol identifying measure developer and measure title.
 NQF number.
 Measure description.
 Denominator statement.
 Exclusions if applicable to measure.
 Numerator statement.
 Rationale statement(s).
 Clinical recommendations or evidence forming the basis for supporting criteria for
the measure.
Below is an example of the GPRO Care-1 (NQF 0097) module. This is an excerpt and
only shows the Medication Reconciliation measure. The complete GPRO measures
listing can be found on the CMS Web site at:
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Description: The measure describes age restrictions of 65 years and older and
those patients discharged from any inpatient facility and seen in the office by the
physician providing the patient’s on-going care, within 60 days following
discharge for a reconciliation of discharge medications.
Denominator: Describes the patient’s age again and the requirement of
discharge from inpatient facility within 60 days.
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Numerator: The measure details patients who had reconciliation of discharge
medications and a current medication list in the outpatient medical record
documented.
Rationale: The rationale is the “logic” of medication reconciliation after hospital
discharge. Often medications are changed between inpatient care and office
ongoing care; reconciliation of medications is essential in patient care.
Clinical recommendation statements: Clinical recommendation statements are
provided at the end of the measures and detail the “clinical logic” that was used
during the measure development. These clinical statements are outside expert
clinical medical recommendations/statements to provide additional medical
clarification after measure development. This rationale also provides additional
instruction that is required to meet this measure: (1) a medication list must be
collected; and (2) three questions must be asked of the patient. If “no” to all three
questions, the process is complete. A “yes” to any question indicates the patient
needs to receive clear instructions about what to do.
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Steps for Successful GPRO Reporting
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Groups must self-nominate to CMS and be selected by CMS to participate in this
reporting option.
Must complete the GPRO database that has been pre-populated with an
assigned beneficiary sample
Report the consecutive, confirmed and completed patients for each of the
disease module and preventive care measures for the 12-month period.
○ 25–99 eligible professionals:
 Self-nominate between January 3, 2012, and January 31, 2012.
 Report for 12 months: January 1, 2012 – December 31, 2012.
 Report on all measures included in the GPRO data base for the prepopulated beneficiary sample.
 Report consecutive, confirmed and completed beneficiaries for each:
 Disease module + preventive care measures.
○ 100 or more eligible professionals:
 Self-nominate between January 3, 2012, and January 31, 2012.
 Report for 12 months: January 1, 2012 – December 31, 2012.
 Report on all measures included in the GPRO data base for the prepopulated beneficiary sample.
 Report consecutive, confirmed and completed beneficiaries for each:
 Disease module + preventive care measures.
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MEASURE-APPLICABILITY VALIDATION PROCESS
The Physician Quality Reporting System includes a validation process. Under the
claims-based reporting method of individual measures, the determination of satisfactory
reporting will itself serve as a general validation because the analysis will access
whether the quality-data codes are appropriately submitted in a sufficient proportion of
the instances when quality reporting exists. In addition, those eligible professionals who
satisfactorily report fewer than three measures will fall under the applicability validation
to determine whether they should have submitted quality data for additional measures.
CMS will use a two-step process:
 A “clinical relation” test.
And,
 A “minimum threshold” test.
Those who fail the validation process will not earn the incentive payment.
Those who submit quality-data codes for only one or two measures for at least 50
percent of their patients or encounters eligible for each measure and who do not submit
any other quality-data codes for any other measures will be subject to the measureapplicability validation process. Selection of the eligible professionals for the measureapplicability validation may be done through a sampling mechanism by CMS.
Step 1:
The clinical relation test will be applied to those who are subject to the validation
process. The test will be based on:
 An extension of the statutory presumption that if an eligible professional submits
data for a measure, then that measure applies to his practice.
And,
 The concept that if one measure in a cluster of measures related to a particular
clinical topic or eligible professional service is applicable to an eligible
professional’s practice, then other closely related measures (measures in that
same cluster) may also be applicable.
As an example, an eligible professional submits one measure that is related to
pneumonia. CMS will determine whether another pneumonia measure within the current
list of quality measures could also have been submitted.
CMS publishes a listing of the “cluster” quality measures for claims-based reporting on
the CMS Web site. Some examples of a “cluster” might be preventive, chronic diabetic
care or COPD. This listing can be found under the Analysis and Payment Downloads
section within the 2012 Physician Quality Reporting System Measure Applicability
Validation Documents at:
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Measure-Applicability Validation Process
MEDICARE PART B
https://www.cms.gov/PQRS/25_AnalysisAndPayment.asp
Below is a snapshot of the Clusters of Clinically Related Measures as an example. In
the pneumonia cluster, there are four measures dealing specifically with pneumonia.
These additional measures would be compared during the validation process.
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Measure-Applicability Validation Process
MEDICARE PART B
FUTURE PAYMENT ADJUSTMENTS FOR NON-PARTICIPATION
Beginning January 1, 2015, eligible providers not participating in the Physician Quality
Reporting System will receive a 1.5 percent payment adjustment. To prevent this
adjustment, providers must begin participating in 2013. The Physician Quality Reporting
System is voluntary; however, to prevent the negative impact on the 2015 physician
reimbursement, eligible providers are encouraged to begin participating by selecting
one of the many reporting methods.
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65
Future Payment Adjustments for
Non-Participation
MEDICARE PART B
CMS PHYSICIAN QUALITY REPORTING RESOURCES
The CMS Physician Quality Reporting Web site address is:
http://www.cms.gov/pqrs/
Below is a screenshot of the CMS Physician Quality Reporting Measures Codes page
found at:
http://www.cms.gov/PQRS//15_MeasuresCodes.asp
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CMS Physician Quality Reporting Resources
MEDICARE PART B
The 2012 Physician Quality Reporting Measures List
Physician Quality Reporting System measures were developed by various organizations
for 2012. CMS provides a detailed listing of the measures along with the measure
developer, method of reporting and contact information. Questions regarding the
content of a measure or its intent should be referred to the measure developer.
Below is a screenshot of the 2012 Physician Quality Reporting Measures List found
under the Downloads section in the 2012 Physician Quality Reporting System Measure
List and Implementation Guide within the 2012 Phys_QualRptg_MeasuresList_111011
file at:
Rev. 02/2012
67
MEDICARE PART B
Scroll to the bottom of the document to access the developer contact list.
Rev. 02/2012
68
MEDICARE PART B
Below is a screen shot of the 2012 Physician Quality Reporting Measure Specifications
Manual for Claims and Registry Reporting of Individual Measures. This document is
found under the Downloads section in the 2012 Physician Quality Reporting System
Measure Specification Manual, Release Notes, Single Source Code Master and QualityData Code Categories within the
2012_PhysQualRptg_MeasureSpecificationsManual_111011 file at:
Below is a screen shot of the 2012 Physician Quality Reporting Measure Specifications
Manual for Claims and Registry Reporting of Individual Measures. This is an allinclusive document that also includes details of each 2012 measure.
Rev. 02/2012
69
MEDICARE PART B
2012 Physician Quality Reporting Measures Groups Specifications
Manual
Measures group specifications are different from those of the individual measures that
form the group. Therefore, the specifications and instructions for measures group
reporting are provided in a separate manual. This document is found under the
Downloads section in the 2012 Physician Quality Reporting System Measure Groups
Specifications and Release Notes, Getting Started With 2012 Measures Groups, 2012
Quality-Data Code Categories and 2012 Groups Single Source Code Master within the
2012_PhysQualRptg_MeasuresGroups_SpecificationsManual_111011 file at:
Below is a screen shot of the 2012 Physician Quality Reporting Measures Group
Specifications Manual for Claims and Registry Reporting of Individual Measures. This is
an all-inclusive document that also includes details of each 2012 measures groups and
the “I intend to report” codes.
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70
MEDICARE PART B
FEEDBACK REPORTS
Incentive payments for Physician Quality Reporting are paid the year following the
reporting period. CMS notifies Medicare of the eligible professionals and the amount of
incentive each Tax Identification Number (TIN) should receive.
Each year, CMS generates feedback reports through a separate process. A feedback
report is available for every TIN under which at least one eligible professional submitted
Medicare Part B claims with at least one valid Physician Quality Reporting System
measure. Once the incentive payment has been made, providers may request a
feedback report for either an individual provider or a group.
Individual Eligible Professionals Feedback Reports
Effective October 19, 2009, providers can contact the Provider Contact Center (PCC)
and request their individual feedback reports. This includes eligible professionals who
are part of a group practice. The following information is required from the eligible
professional requesting the feedback reports:
 Provider name.
 Provider individual NPI.
 Provider e-mail address.
 Provider phone number.
 Caller’s first and last name.
An e-mail will be sent to the eligible professional within 30 days of the request. If no
report is available, a notification e-mail will be sent.
Group Practice TIN Feedback Reports
TIN or group practice information reports require access via the Physician Quality
Reporting Portal after first registering with the Individuals Authorized Access to CMS
Computer Services (IACS). The data released in the feedback reports is sensitive and
could pose a risk to providers as well as beneficiaries. Policies have been established to
control the risk; therefore, providers must register in a secure site to be approved to
receive the requested reports.
Original/Group TIN Process
There is no registration deadline, but registration must be completed before reports can
be accessed:
 IACS registration.
 Request access to Physician Quality Reporting application via IACS.
 Enter the Physician Quality Reporting application.
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Feedback Reports
MEDICARE PART B
Individuals Authorized Access to CMS Computer Services (IACS)
IACS is a security system used by CMS that allows individuals to be identified
electronically and access certain Web-based applications. Through this system
providers can manage their staff as well as request feedback reports for the Physician
Quality Reporting System as well as Electronic Prescribing (eRx).
During registration through IACS, the provider’s IACS registration information is verified
with the Medicare enrollment data. Providers who have not updated their Medicare
enrollment application since November 2003 will need to update the CMS-855 form in
order for the IACS to complete the registration.
Providers will not be able to view their feedback report until the Medicare contractor
reviews and approves their Medicare enrollment application.
CMS has numerous job tools available to help with IACS registration. The IACS User
Guide will assist with the log-in and registration process. The user guide can be found
on the CMS Web site at:
https://www.cms.gov/MAPDHelpDesk/downloads/IACS_User_Guide_for_CMS_User_C
ommunities_2010_03.pdf
Reminders:
 Before beginning the registration process, the user will need to know the
organization’s legal name, TIN, street address, etc.
 Once registration has been completed, the provider will receive an IACS ID and
password. These will be received in two separate e-mails.
 Questions from new or existing users should be directed to the QualityNet Help
Desk at:
Phone: (866) 288-8912
TTY: (877) 715-6222
Email: Qnetsupport@sdps.org
Note: If the professional has successfully registered with IACS, it is not necessary to
register again; however, professionals must keep their password current. Users must
change their IACS password every 60 days.
 To view the feedback report, providers must have an approved enrollment record
in CMS’ national provider enrollment system known as the Provider Enrollment,
Chain and Ownership System (PECOS).
The TrailBlazer Provider Enrollment page contains additional information regarding the
Medicare enrollment process, including links to the current versions of the paper CMS855 applications and to Internet-based PECOS:
Rev. 02/2012
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Feedback Reports
MEDICARE PART B
http://www.trailblazerhealth.com/Provider Enrollment
Steps to Access Feedback Reports
IACS registration can be completed from the CMS Web site at:
https://applications.cms.hhs.gov/warning.html
Step-by-step instructions professionals need to access their feedback reports are found
in the following CMS MLN Matters® articles:
 SE 0747 – “Individuals Authorized Access to CMS Computer Services (IACS) –
Provider/Supplier Community (IACS-PC): The First in a Series of Articles.”
http://www.cms.gov/MLNMattersArticles/downloads/SE0747.pdf
Provider/Supplier Community (IACS-PC): The Second in a Series of Articles.”
http://www.cms.gov/MLNMattersArticles/downloads/SE0753.pdf
Provider/Supplier Community (IACS-PC): The Third in a Series of Articles.”
https://www.cms.gov/MLNMattersArticles/downloads/SE0754.pdf
For assistance, contact the QualityNet Help Desk at:
Telephone:
(866) 288-8912
(877) 715-6222 – TTY/TDD
Monday – Friday, 7 a.m. – 7 p.m. CT
Email:
Qnetsupport@sdps.org
Effective November 15, 2010, all IACS issues for Physician Quality Reporting should go
through the QualityNet Help desk. QualityNet can assist with how to register, accessing
the IACS account and help with changing the IACS account.
Reminder: The QualityNet Help Desk can assist callers in understanding the feedback
reports as well as assisting the provider in understanding a particular measure.
Obtaining Feedback Reports
To verify that a feedback report is available, providers can search the QualityNet Web
site at: https://www.qualitynet.org/portal/server.pt/community/pqri_home/212.
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Feedback Reports
MEDICARE PART B
An example of the QualityNet Web site search is listed below:
To verify if a feedback report is available, locate the “Verify Report Portlet” function in
the lower left corner of the Web site. The user should enter the tax ID of the eligible
professional under TIN and select Lookup. If a report is available, the search box will
return the message, “A report is available for the TIN XXXXX.”
Providers can log in to the QualityNet Web site to verify if a feedback report is available
before registration steps are taken through the IACS Web site. To verify if a feedback
report exists:
 Log in to the QualityNet Web site at:
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212.
 You are not required to have an existing account or be a member to verify if a
report is available.
 Enter the TIN or NPI of the eligible professional in the lower left corner and select
Lookup. Make sure to indicate the TIN or NPI in the selection field above the
Rev. 02/2012
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Feedback Reports
MEDICARE PART B


number entered to allow a proper search of the reports.
Return search of “no report is available for the TIN/NPI xxxxx1111” indicates
there is no Physician Quality Reporting quality feedback report available for the
requested provider. A report will be available for any provider that filed at least
one claim that included a Physician Quality Reporting measure. Providers can
call the Provider Contact Center or the QualityNet help desk for further
assistance.
Return search of “a report is available for the TIN/NPI xxxxx1111” indicates there
is a Physician Quality Reporting quality feedback report available. The provider
must then log in to the CMS IACS application/system at:
https://applications.cms.hhs.gov/warning.html. If the user does not have an
account, please register. Prior users will sign in using prior account settings.
Additional registration and log-in user guides can be found on the QualityNet
Web site in the left navigation bar at:
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212.
Rev. 02/2012
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Feedback Reports
MEDICARE PART B
INCENTIVE CALCULATIONS







The analysis contractor will generate confidential feedback reports made
available through a secure Web site at the conclusion of the program.
The analysis contractor will generate an incentive payment file for approval by
CMS.
Based on the incentive payment file provided to the MAC by CMS, the MAC will
process the incentive payment at the conclusion of the program.
Incentive amounts were calculated at the individual eligible provider (NPI) level.
Incentive payments were paid at the practice (TIN) level.
Payments to TINs billed through contractors’ carriers/MACs may have been split
among carriers/MACs.
The incentive payment method is the same method through which the provider
receives its Medicare payments (Electronic Funds Transfer (EFT) or paper).
Physician Quality Reporting Online Resources
Also available on the CMS Physician Quality Reporting Web site are the following online
resources:
 Physician Quality Reporting: http://www.cms.gov/pqrs/.
 How to Get Started: http://www.cms.gov/PQRS/03_How_To_Get_Started.asp.
 CMS-Sponsored Calls (Educational Calls):
http://www.cms.gov/PQRS/04_CMSSponsoredCalls.asp.
 Physician Quality Reporting Measures Codes:
 Physician Quality Reporting Alternative Reporting Mechanisms (EHR and
Registry): http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp.
 Physician Quality Reporting Group Practice Reporting:
http://www.cms.gov/PQRS/22_Group_Practice_Reporting_Option.asp.
 Maintenance of Certification Program Incentive:
http://www.cms.gov/PQRS/23_Maintenance_of_Certification_Program_Incentive.
asp.
 Analysis and Payment: http://www.cms.gov/PQRS/25_AnalysisAndPayment.asp.
 Educational Resources:
http://www.cms.gov/PQRS/30_EducationalResources.asp.
Help Desk Support
http://www.cms.gov/PQRS/36_HelpDeskSupport.asp
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Incentive Calculations
MEDICARE PART B
Physician Quality Reporting Portal User Guide
https://www.qualitynet.org/imageserver/pqri/documents/Portal_User_Manual_V4.1.pdf
.
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77
Incentive Calculations
MEDICARE PART B
REVISION HISTORY
Date
Section
October
2009
Feedback Reports
March
2010
PQRI Background
Revision
Added alternative feedback report options
based on CR 6441.


PQRI – Who Is
Eligible?
Expanded this section to detail all providers
eligible to participate in the PQRI incentive.
PQRI Quality
Measures
Added additional details to define the
denominator component of the measure.
CPT II Modifiers
Added minor language changes from 2009 to
2010 PQRI performance exclusion and
reporting modifier definitions.
Individual Measures
Included clarification for the yearly CMS
measure listing.
Measures Groups
Intent to Report ‘G’
Codes

Measures Groups
Composite ‘G’ Codes



Rev. 02/2012
Included PQRI publication references for
the PQRI initiative and the updates to the
existing program.
Included an overview of 2007, 2008 and
2009 PQRI measures and reporting
periods.
Three new “intent to report” codes added
for 2010: G8545, G8546 and G8547.
Included four new registry-only “intent to
report” codes: G8544, G8548, G8549
and G8491.
Three new composite codes added for
2010: G8549, G8550 and G8552.
Included four new registry-only
composite codes: G8497, G8498, G8500
and G8551.
Registry-Based
Reporting Criteria
Added clarification to registry-based data
submission.
Electronic Health
Record (EHR)
Criteria
Added new section for EHR reporting criteria.
Group Practice
Reporting Option
Added new section for GPRO.
78
Revision History
MEDICARE PART B
Date
Section
Revision
(GPRO) Criteria
2010 PQRI Reporting
Overview












CMS Resources
Rev. 02/2012
Added new section for the 2010 PQRI
incentive including measures and
reporting periods.
Added individual measure overview
along with CMS screen prints of an
individual measure as an example.
Added a claim example to reflect the
claims-based reporting option for an
individual measure.
Added measures group overview along
with screen prints of a measures group.
Added claim examples to reflect the
claims-based reporting option for a
measures group.
Added EHR-based measure overview.
Included a sample of the qualified
vendors.
Added the 10 measures for the EHR
reporting option.
Included a sample of a measure from the
EHR Measure Specifications analytic
narratives.
Added GPRO overview.
Added an example of the GPRO Disease
Modules and Preventive Care Measures.
Included an example of the GPRO
Measure.
Updated the following CMS screen shot
references:
 PQRI Initiative home page.
 2010 PQRI downloads.
 2010 Measures List.
 2010 PQRI QDC categories.
 2010 Measures Group Specifications
Manual.
 Included CMS-1500 claim form
79
Revision History
MEDICARE PART B
Date
Section
Revision
examples.
September
2010
PQRI – Reporting
Criteria/Reporting
Options
Included note to view Appendix C of the 2010
PQRI Implementation Guide for a participation
decision tree. CMS Web link included.
Claims-Based
Reporting Criteria
Included additional clarification on reporting and
diagnosis/CPT I coding/claims submission
requirements.
Common ClaimsBased Reporting
Errors
Included new data from CMS on most common
claim-based reporting errors.
EHR-based Overview



January
2011
Steps to Access
Feedback Reports
Included details related to quality feedback
reports on QualityNet Web site prior to
obtaining IACS user account.
PQRI Online
Resources
Added additional educational resource links to
the CMS Web site.
Physician Quality
Reporting Initiative
(PQRI)




Rev. 02/2012
Included information regarding EHR
Measure Specifications Manual along
with the CMS Web link.
Included information to contact EHR
vendor on system qualifications.
Included nine steps for successful EHR
reporting.
CMS changed the name of this incentive
to Physician Quality Reporting System
(Physician Quality Reporting).
Removed references to PQRI and
changed to Physician Quality Reporting.
Updated all 2010 information to 2011
Web site links and all references.
Incentive payment reduced from 2
percent to 1 percent for 2011 incentive.
Physician Quality
Reporting
Background
Added overview of 2011 Physician Quality
Reporting incentive.
Physician Quality
Reporting Quality
Measures
Added information that the numbering system
reflects measures that have been retired so the
numbering will be sequential but not allinclusive.
80
Revision History
MEDICARE PART B
Date
Section
Revision
CPT II Modifiers
Added information that not all measures allow
for performance exclusions.
Claims-Based
Reporting Criteria
Change from 80 percent to 50 percent of
eligible claims must be reported.
EHR Criteria
Final rule has 20 measures, up from 10 in 2010.
GPRO
GPRO has been expanded to reflect GPRO
Option 1 and Option II. Included information for
both options for 2011.
2011 Physician
Quality Reporting
Individual Measures
Reporting





2011 Physician
Quality Reporting
Measures Group






EHR-Based Overview



Rev. 02/2012
81
Updated total number of measures for
2011.
Updated each screen shot of Measure 1
example to reflect new language/format.
Updated CMS-1500 claim form example
for billing claim-based individual
measures.
Updated Claim Submission Reminders.
2011 claim-based reporting changed
from 80 percent to 50 percent of the
applicable Medicare patients.
Updated total number of measures
groups for 2011.
Additional measures group “I intend to”
report for asthma (G8645).
Additional measures group composite
code to report for asthma (G8646).
Updated CMS-1500 claim form example
for billing measures group.
Updated Claim Submission Reminders.
2011 measures group reporting changed
from 80 percent to 50 percent of the
applicable Medicare patients.
Updated total number of measures for
2011 from 10 to 20.
Included new measures in bulleted list.
Revision History
MEDICARE PART B
Date
Section
Group Practice
Reporting Option for
2011
Revision

Updated Web site references under
“Steps for Successful EHR Reporting.”

Updated section to include Option I and
Option II differences.
Updated screen shot examples for
GPRO.
Updated total number of GPRO
measures to eight.
Added “Steps for Successful GPRO
Reporting” for Option I and Option II.




CMS Physician
Quality Reporting
Resources
Steps to Access
Feedback Reports
Updated all CMS screen shots to reflect 2011
Web content.


February
2012
Physician Quality
Reporting Online
Resources
Updated all Web site links for 2011 educational
references.
Physician Quality
Reporting Portal User
Guide
Included Web site link to the Physician Quality
Reporting Portal.
Physician Quality
Reporting System
Background




Rev. 02/2012
IACS contact information has changed.
All contacts should be directed through
QualityNet. QualityNet information
updated in this section.
Updated QualityNet screen shot to reflect
2011 Web content.
Added 2012 program updates.
Added new Maintenance of Certification
Program incentive.
Added future incentive payments.
Added future payment adjustments for
non-participation.
CPT II Modifiers
Added additional information to the 8P modifier.
Where to Start
New section added.
Claims-Based
Reporting Criteria
Included 2012 claims-based reporting criteria
for individual and group measures.
82
Revision History
MEDICARE PART B
Date
Section
Registry-Based
Reporting Criteria
Revision



EHR-Based
Reporting Criteria



Group Practice
Reporting Criteria


Maintenance of
Certification Program
Criteria
Rev. 02/2012
Included 2012 registry-based reporting
guidelines.
Added registry requirements.
Added 2012 registry reporting criteria for
individual measures and measures
group.
Included 2012 EHR-based reporting
guidelines.
Added 2012 criteria for direct EHR
reporting and vendor EHR reporting.
Included Web link for vendor
requirements for 2012.
Included 2012 group practice reporting
guidelines.
Added 2012 group practice reporting
criteria.
Added a new section to include:
 Maintenance of Certification Program
background.
 Program guidelines.
 Self-nomination process.
 Included a sample letter for the selfnomination process.
 List of qualified Maintenance of
Certification Program Incentive entities.
 Minor language changes in individual
measure formatting overview.
Individual Measures:
 Added individual measures 2012
reporting criteria.
 Updated example snapshots for the
individual 2012 Measure #1.
 Updated the individual measure claim
example.
 Added additional information for
clarification under claim reminders.
 Updated claims-based reporting errors.
Measures Groups:
 Updated measures groups listing for
2012.
83
Revision History
MEDICARE PART B
Date
Section
Revision

Included 2012 claims-based reporting
and registry-based reporting criteria.
 Included a link to the CMS qualified
registry publication.
 Updated example snapshots for the 2012
Diabetes Measures Group.
 Updated the measures group claim
example. Two examples are now
included: 1) patient met all measures
within the measures group; 2) patient did
not meet all of the measures.
 Updated the 2012 intend to report
measures group codes for claims and
registry reporting.
 Updated the 2012 measures group
composite codes.
 Updated the claim reminders.
 Included the 2012 criteria for reporting
claims-based and registry-based
measures groups.
EHR-based:
 Added the EHR measures for 2012.
 Updated example snapshots for the EHR
measure #1, Diabetes.
 Included 2012 reporting criteria for
individual measures via EHR.
Group Practice:
 Added 2012 GPRO endorsed measures.
 Updated example snapshots for the
GPRO Care-1 module.
 Updated steps for successful GPRO
reporting.
Measure-Applicability
Validation Process
New section on validation process for providers
billing fewer than three individual measures
under the claims-based reporting method.
CMS Physician
Quality Reporting
Resources
Updated all CMS Web site screen snapshot
examples.
Feedback Reports
Rev. 02/2012


84
Included feedback overview.
Added additional information to group
practice feedback report information.
Revision History
MEDICARE PART B
Date
Section
Revision



Rev. 02/2012
Included new information on IACS.
Included links to the CMS MLN Matters®
articles listed as recourses.
Updated the QualityNet screen snapshot
example.
Future Payment
Adjustments for NonParticipation
Included new guidelines for payment
adjustment in 2015.
Physician Quality
Reporting Online
Resources
Updated resource links and added a new link
for Maintenance of Certification Program
Incentive.
85
Revision History

P h y s

Transcription

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