AdvantEdge Healthcare Solutions - PQRS 2015 Resource Guide · 4 WHAT IS PQRS? The Physician Quality Reporting System or PQRS is a voluntary individual reporting program to report

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AdvantEdge Healthcare Solutions - PQRS 2015 Resource Guide

February 2015

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2015 PQRS Resource Guide _____________________________________________________________________________________________

We have created this PQRS Resource Guide so that the most pertinent PQRS information for 2015 can be

found in one document. Most of the information has been taken directly from CMS documents. Links

have been provided to access more detailed information provided on the CMS website.

Table of Contents

WHAT IS PQRS? ............................................................................................................ 4

DEFINITIONS ................................................................................................................. 4

2015 PQRS BASICS ....................................................................................................... 4

ELIGIBLE PROFESSIONALS (EPs) (Providers) ............................................................. 5

2015 PQRS REPORTING OPTIONS .............................................................................. 5

Reporting as an Individual EP ......................................................................................... 6

A. Individual Measure Reporting ................................................................................. 7

B. “Measures Groups” Reporting ................................................................................. 8

C. Qualified Clinical Data Registry .............................................................................. 9

Reporting as a Group Practice (GPRO) ........................................................................ 10

A. Qualified Registry ................................................................................................. 11

B. Direct CEHRT EHR or EHR CEHRT Data Submission Vendor ............................ 11

C. GPRO Web Interface Reporting (25 or more EPs) ............................................... 11

D. Certified Survey Vendor ....................................................................................... 12

E. Registration to Participate as a GPRO ................................................................. 14

2015 REPORTING MECHANISMS ............................................................................... 15

A. Claims-Based Reporting ....................................................................................... 15

B. Registry Reporting ................................................................................................ 15

C. EHR Reporting (Electronic Health Records) ......................................................... 16

D. GPRO Web-based Interface .................................................................................. 18

E. CMS-Certified Vendor ............................................................................................ 18

Measure Applicability Validation (MAV) ......................................................................... 19

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ADDENDUMS ............................................................................................................... 22

Addendum A .............................................................................................................. 22

Addendum B .............................................................................................................. 23

Addendum C .............................................................................................................. 24

Addendum D .............................................................................................................. 26

Addendum E .............................................................................................................. 28

Addendum F .............................................................................................................. 29

Addendum G .............................................................................................................. 31

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WHAT IS PQRS?

The Physician Quality Reporting System or PQRS is a voluntary individual reporting program to report

data on quality measures for Medicare Part B Physician Fee Schedule services (including Railroad

Retirement Board and Medicare Secondary Payer). Medicare Part C (Medicare Advantage) beneficiaries

are not included in PQRS.

DEFINITIONS The following abbreviations will be used in this Resource Guide to be consistent with the CMS’

PQRS descriptions:

EP – Eligible professional QDC (Quality Data Code) – PQRS Code

GP – Group Practice FFS – Fee for Service

2015 PQRS BASICS There is no incentive payment for reporting PQRS measures in 2015. Incentive/bonus payments

may be earned via the Value Based Modifier Program.

EPs who do not successfully participate in 2015 will receive a -2% payment adjustment on their

2017 Medicare payments

All claims for service dates of January 1, 2015 – December 31, 2015 must be received at CMS by

February 28, 2016, to be included in the PQRS analysis.

There are a total of 255 individual measures and 22 Measures Groups

20 NEW INDIVIDUAL MEASURES FOR 2015 - See Addendum B - 3 Individual Measures – Claims and Registry Only

- 12 Individual measures – Registry Reporting Only

- 5 Individual measures - Registry and Measures Groups Reporting

2 NEW MEASURES GROUPS

- Sinusitis

- Acute Otitis Eterna

MEASURES RETIRED FOR 2015 – See Addendum C - 50 Individual measures

- 4 Measures Groups

DOMAIN CHANGES – See Addendum D - 22 Individual Measures have Domain Changes

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ELIGIBLE PROFESSIONALS (EPs) (Providers) A listing of all providers eligible to participate in the PQRS program in 2015 is located in

Addendum A at the end of this guide or you may find the list here on the CMS website. Physicians,

as well as physician assistants, nurse practitioners, psychologists, social workers, therapists and other

non-physician professionals are eligible to participate in PQRS.

PQRS measures are analyzed by the individual NPI number even if the member is part of a group. The

exception is if a group practice of 2 EPs or more reports their measures through the Group Practice

Reporting (GPRO) method, in which case the group’s NPI number is used in analyzing measure data.

2015 PQRS REPORTING OPTIONS Reporting Periods

The 2015 reporting period for all PQRS participants is the 12 month reporting period of January 1, 2015 –

December 31, 2015, no matter the chosen reporting mechanism. The 2014 6-month reporting period for

measure groups through a registry has been eliminated for 2015.

Measure Selection

PQRS quality measures may be reported by individual EPs or Group Practices (GPs). There are several

types of measure selections available for reporting through any of the following methods.

A. Individual Measure Reporting

B. Measures Groups Reporting

C. Group Practice Reporting (GPRO) Measures

D. Measures Selected by Qualified Clinical Data Registry

E. Certified Survey Vendor (a companion to some of the above measure selections)

The Maintenance of Certification (MOC) program is not available for reporting in 2015.

It is important to note that measures were deleted and/or changed in 2015. If a provider participated in

the 2014 PQRS program and wants to report the same measures for the 2015 program, it is essential to:

Determine if the measures are still available

Check the Release Notes to determine if the criteria for these measures changed in 2015.

Check to see if the measure(s) are available for the reporting method selected by the provider.

The “Release Notes” manuals are specifically written to show only the changes from 2014 to 2015.

Reporting Methods

The same six reporting methods available in 2014 are still available in 2015

A. Claims-based

B. Qualified Registry

C. EHR (including direct EHR products and indirect EHR Data Submission Vendor Products)

D. Group Practice Reporting Option (GPRO) Web Interface

E. Certified Survey Vendors for the CAHPS for PQRS Measures

F. Qualified Clinical Data Registry

Resources

CMS Link - 2015 Physician Quality Reporting System (PQRS) Implementation Guide.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf

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Reporting as an Individual EP Individual EPs may report the type of PQRS measures as follows:

1. Individual Measures

2. Measure Groups

3. Qualified Clinical Data Registry

Individual quality measures may be reported to CMS via:

1. Claim-based reporting - on Medicare Part B claims

2. A qualified PQRS Registry

3. A qualified (CEHRT) electronic health record (EHR) product, or

4. A qualified (CEHRT) Data Submission Vendor

5. Qualified Clinical Data Registry

Measures Groups may only be reported via a Qualified Registry

New Reporting Requirement – Cross-Cutting Measures

Individual and Group Practice EPs who submit individual PQRS measures through the claims-based or

registry reporting methods must now report a “cross-cutting” measure inclusive to the required PQRS

measures. If an EP or GP sees at least 1 Medicare patient in a face-to-face encounter, the EP or GP must

report on at least 1 measure in the cross-cutting measure set.

Services associated with face-to-face encounters would include general office and outpatient visit codes,

and surgical procedures. All CPT codes designated as face-to-face codes for reporting cross-cutting

measures can be found in then 2015 PQRS List of Face-To-Face Encounter Codes. Telehealth visits will not

be included as face-to-face encounters for the purposes of PQRS cross-cutting reporting.

In the instance where an EP does not have at least 9 measures applicable to his/her practice, the EP is still

required to report at least 1 cross-cutting measure, if applicable.

Resources

See Addendum E for the list of Cross-Cutting Measures.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015-PQRS-List-of-Face-To-Face-Encounter-Codes-.zip

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A. Individual Measure Reporting Claims-Based Reporting

Report on at least 9 individual measures covering 3 NQS domains for at least 50% of the EP’s

Medicare Part B FFS patients.

New - An EP who sees at least 1 Medicare patient (face-to-face encounter) must report on 1

cross-cutting measure which counts towards the 9 measures.

EPs who report fewer than 9 PQRS measures across 3 NQS domains for at least 50% of the EP’s

Medicare Part B FFS patients OR who submit data for 9 or more PQRS measures across fewer

than 3 domains for at least 50% of the EP’s Medicare Part B FFS patients eligible for each

measure will be subject to Measure-Applicability Validation (MAV)

Measures with a 0% performance rate will not be counted.

For more information on the measure-applicability validation process and how it is calculated, see the

Measure Applicability Validation (MAV) section in this Guide.

Registry Reporting

Report on at least 9 individual measures covering 3 NQS domains for at least 50% of the EP’s

Medicare Part B FFS patients.

New - An EP who sees at least 1 Medicare patient (face-to-face encounter) must report on 1

cross-cutting measure which counts towards the 9 measures.

EPs who report fewer than 9 PQRS measures across 3 NQS domains for at least 50% of the EP’s

Medicare Part B FFS patients OR who submit data for 9 or more PQRS measures across fewer

than 3 domains for at least 50% of the EP’s Medicare Part B FFS patients eligible for each

measure will be subject to Measure-Applicability Validation (MAV)

Measures with a 0% performance rate will not be counted.

EHR Reporting - EHR Direct Product and EHR Data Submission Vendor

EPs must report at least 9 measures covering at least 3 NQS domains.

If an EP’s certified EHR (CEHFT) does not contain patient data for at least 9 measures covering

at least 3 domains, then the EP must report the measures for which there is Medicare patient data.

An EP must report on at least 1 measure for which there is Medicare patient data.

**NQS (National Quality Strategy) DOMAINS

In 2015, measures are classified according to the following 6 NQS domains based on the NQS’s

priorities.

Patient Safety

Effective Clinical Care

Person and Caregiver-Centered Experience and Outcomes

Community/Population Health

Communication and Care Coordination

Efficiency and Cost Reduction

Resources Addendum B lists all new individual measures for 2015

CMS Link - 2015 PQRS Measures List

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

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B. “Measures Groups” Reporting

Measures Groups are a CMS-defined subset of four or more PQRS measures that have a particular

clinical condition or focus in common. Only those measures groups defined in the PQRS Measures Group

document can be utilized. All other individual measures included in PQRS but not defined as included in

a measures group cannot be grouped together to define a measures group.

There are 22 Measures Groups available for reporting in 2015.

With the “measure groups” option, providers may report on a group of clinically-related measures

through a Qualified Registry only. Claims-based reporting is not allowed for measures groups in

2015.

Providers need to report ONE measures group AND report each measures group for at least 20

patients, a majority (11) of which must be Medicare Part B FFS patients to qualify for PQRS

payment.

If the EP does not have at least 11 unique Medicare part B FFS patients who meet patient sample

criteria for the measures group, the EP will need to choose another measures group or choose

another reporting option.

Measure groups containing a measure with a 0% performance rate will not be counted.

Each measures group has an Intent G Code. This code is used once to inform Medicare that the provider

will be submitting via the Measures Group reporting method and will indicate which measures group will

be reported. It is not necessary to submit the measures group-specific intent G-code for registry-based

submissions. However, the measures group-specific intent G-code has been created for registry only

measures groups for use by registries that utilize claims data.

Each measures group has a Composite Code. This code is used if the EP is reporting on ALL measures

within the measures group. This code is used instead of reporting each measure separately.

The patient sample for the 20 Patient Sample Method is determined by diagnosis and/or specific

encounter parameters common to all measures within a selected measures group. All applicable measures

within a group must be reported for each patient within the sample that meets the criteria (e.g., age or

gender) as published in the Measures Groups Manual.

IMPORTANT: Individual measures within the Measures groups may have different criteria and

specifications than the same measure reported individually. Individual measures within the measures

groups may have also changed since 2014. Therefore, it is important that the requirements for each

measure are reviewed within the specifications and instructions for measures group reporting. These

requirements are provided in a separate manual from the individual measures.

Resources

Addendum G - Lists all Measures Groups, the measures within each group, the Intent Code,

Composite Code and how the measures may be submitted.

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C. Qualified Clinical Data Registry

The Qualified Clinical Data Registry (QCDR) option is distinct and separate from the qualified registry

option also used to submit PQRS data. CMS defines a QCDR as a “CMS approved entity (such as a

registry, certification board, collaborative, etc.) that collects medical and/or clinical data for the purposes

of patient and disease tracking to foster improvement in the quality of care furnished to patients.”

This program is only available to individual EPs that satisfactorily participate or report data on quality

measures for covered Physician Fee Schedule services. Data that may be submitted for the PQRS

program through the QCDR covers quality measures measure across multiple payers and is not limited to

Medicare beneficiaries. The QCDR is also not limited to PQRS measures.

A QCDR may submit measures from one or more of the following categories with a maximum of 30 non-

PQRS measures allowed:

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS)

National Quality Forum (NQF)-endorsed measures

Current 2015 PQRS

Measures used by boards or specialty societies, and

Measures used in regional quality collaborations.

Criteria for reporting to avoid a penalty:

Report on a minimum of 9 measures available for reporting under a QCDR covering at least 3of

the NQS domains for at least 50% of the EPs applicable patients seen during the 2015

participation period.

Of the measures reported, the EP must report on at least 2 outcome measures OR if 2 outcome

measures are not available, report on at least 1 outcome measure and at least 1 of the following

types of measures.

- Resource Use

- Patient Experience of Care

- Efficiency/Appropriate Use

- Patient Safety

Resources

CMS Link - 2015 PQRS QCDR Participation Made Simple

CMS Link - 2015 Physician Quality Reporting System: Qualified Clinical Data Registry Data

Submission Criteria

CMS Link - 2014 Qualified Clinical Data Registries – The list of CMS-designated 2015 Qualified Clinical

Data Registries should be on the CMS QCDR website in mid-2015.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015PQRS_QCDR_MadeSimple.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_QCDRVendorCriteria.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_QCDRVendorCriteria.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014QCDRPosting.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html

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Reporting as a Group Practice (GPRO) A GPRO (Group Practice Reporting Option) practice is defined as a single TIN with 2 or more EPs, as

identified by their NPI, who have reassigned billing rights to the TIN. Group practices must register to

participate in PQRS through the group practice reporting option (GPRO) to be analyzed at the group

(TIN) level.

An individual EP who is a member of a group practice participating in PQRS GPRO is not eligible to

separately report under PQRS as an individual EP under that same TIN (that is, for the same TIN/NPI

combination). This means that some EPs in the group cannot report PQRS individually and others report

under GPRO.

Once a group practice (TIN) registers to participate in the GPRO, this is the only PQRS reporting method

available to the group and all individual NPIs who bill Medicare under the group’s TIN for 2015. If an

organization or EP changes TINs, the participation under the old TIN does not carry over to the new TIN,

nor is it combined for final analysis.

The group practice will determine its size based on the number of EPs billing under the TIN at the time

of registration. During registration, group size will be categorized as 2-24 EPs, 25-99 EPs and 100 or

more EPs. The group practice will need to indicate their group size to CMS by selecting one of these size

categories. Reporting requirements and available reporting methods vary based on the group size.

IMPORTANT: PQRS group practices must register for their selected reporting mechanism by June 30,

2015.

Requirements to be considered as a 2015 PQRS GPRO

Have billed Medicare Part B PFS on or after January 1, 2015 and prior to December 31, 2015;

Agree to have the results on the performance of their PQRS measures publicly posted on the

Physician Compare website;

Have the following technical capabilities, at a minimum: standard PC image with

Microsoft®Office and Microsoft® Access software installed; and minimum software

configurations (only applies to group practices reporting via the Web Interface);

Be able to comply with a secure method for data submission;

Allow CMS access to review the Medicare beneficiary data on which PQRS GPRO submissions

are founded or provide to CMS a copy of the actual data;

Indicate desire to participate in PQRS through the GPRO via registration; and

Provide all requested data through the Physician Value-Physician Quality Reporting System (PV-

PQRS) Registration System during registration.

Methods for submitting:

Qualified PQRS Registry (2+ EPs)

EHR Direct Product or EHR data submission vendor that is CEHRT (2+ EPs)

GPRO web interface provided by CMS (25+ EPs)

CAHPS for PQRS using CMS-certified survey vendor (2+ providers)

Resources CMS Link - Group Practice Reporting (GPRO) Criteria for 2015

CMS Link - Group Practice Reporting – CMS Website

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_GPRO_Criteria.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/GPRO_Web_Interface.html

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A. Qualified Registry Must report on at least 9 measures covering at least 3 of the NQS domains and report each

measure for at least 50 percent of the GP’s Medicare Part B FFS patients seen during the

reporting period,

Group practices that submit quality data for only 1 to 8 PQRS measures for at least 50% of their

patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS

measures covering less than 3 domains for at least 50% of their patients or encounters eligible for

each measure will be subject to MAV.

Measures with a 0 percent performance rate are not counted.

B. Direct CEHRT EHR or EHR CEHRT Data Submission Vendor Must report on at least 9 measures covering at least 3 of the NQS domains

If an EP’s CEHRT does not contain patient data for at least 9 measures covering at least 3 NQS

domains, then the EP must report the measures for which there is Medicare patient data.

A group practice must report on at least one measure for which there is Medicare patient data.

C. GPRO Web Interface Reporting (25 or more EPs) The GPRO Web Interface is a web-based reporting tool partially pre-populated with an assigned sample

of Medicare Part A and B PFS beneficiaries; this sample is based on the claims history for the group

practice, and contains demographic and utilization information for those assigned beneficiaries.

GPs will be required to populate all of the remaining data fields necessary for capturing quality

measure information for each consecutively assigned Medicare beneficiary (248 beneficiaries for

all group sizes) with respect to services furnished during the 2015 reporting period.

If the group practice is assigned fewer than 248 Medicare beneficiaries, then the group practice

must report on 100 percent of its assigned beneficiaries.

A group practice must report on at least 1 measure for which there is Medicare patient data.

Group practices will be able to access the GPRO Web Interface for 2015 data submission, during

the first quarter of 2016.

Group practices participating in 2015 PQRS GPRO via GPRO Web Interface are required to use

2014 CEHRT to populate the GPRO Web Interface to participate in both 2015 PQRS and the

EHR Incentive Program.

Group practices participating in the 2014 PQRS GPRO via the Web Interface are required to report on all

17 quality measures in eight disease modules including:

Care Coordination/Patient Safety (CARE),

Preventive Care Measures (PREV),

Coronary Artery Disease Module (CAD),

Diabetes Composite

Heart Failure (HF),

Hypertension (HTN),

Ischemic Vascular Disease (IVD), and

Mental Health Disease Module (MH)

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Resources Addendum F for the 2015 GPRO Web-Based Measures.

2015 GPRO Web Interface Made Simple

2015 GPRO Web Interface Measure Documents

This website contains a Zip file that includes the following documents.

- 2015 GPRO Web Interface Narrative Specifications , Measures List and Release Notes

- 2015 GPRO Web Interface Supporting Documents and Release Notes

- 2015 GPRO Web Interface Performance Calculation Measure Flows

D. Certified Survey Vendor A CMS-certified survey vendor is a newer reportingmethod , beginning in 2014, available to group

practices only. This method reports the Clinician & Group Consumer Assessment of Healthcare Providers

and Systems (CG CAHPS) survey and is a survey taken by patients based on their experience and care

from the reporting group practice.

This reporting mechanism is available to group practices of 2+ EPs wishing to supplement their PQRS

reporting with CAHPS for PQRS survey. (In 2014, this option was only available to GPs of 25+ EPs)

CAHPS reporting is voluntary for GPs of 2-99 EPs but mandatory for GPs of 100+EPs. Group Practices

planning to report CAHPS must indicate this option when registering their GPRO reporting method.

(Deadline for registration is June 30, 2015)

CMS will select the survey vendors during an application process. CMS-certified survey vendors will be

responsible for distributing and collecting the CAHPS for PQRS survey, which will occur during the first

quarter of the 2016 calendar year.

Groups of 2-99 EPs

Reporting via certified vendor for groups of 2-99 EPs is an extra and companion reporting option for

group practices and can be reported via qualified registry, EHR and GPRO web interface. Instead of

reporting 9 individual measures, the CAHPS for PQRS survey is equal to 3 individual measures and 1

NQS domain. (Basically replacing 3 of the minimum 9 measures needed to report.)

Groups 2+ EPs – Qualified Registry with CAHPS for PQRS o Must participate via CMS-certified survey vendor to have 12 CAHPS for PQRS measures

for the 12- month reporting period

o Must report at least 6 additional measures, outside of CAHPS for PQRS, covering at least

2 NQS domains

o If fewer than 6 measures apply, up to 5 measures must be reported

o If an EP in the group sees at least 1 Medicare patient face to-face, the group must report 1

cross-cutting measure

o Groups reporting on fewer than 6 measures will be subject to Measure-Applicability

Validation (MAV)

Groups 2+ EPS - EHR with CAHPs for PQRS

o Must report all 12 CAHPS for PQRS measures for the 12-month reporting period

o Must report at least 6 additional measures, outside of CAHPS for PQRS, covering at least

2 NQS domains

o At least 1of these measures must contain Medicare patient data

o If less than 6 measures apply to the GP, the GP must report up to 5 measures

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_GPROWI_Made_Simple.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_GPRO_WI-Measure_Docs.zip

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Groups 25-99 EPs - GPRO Web Interface o Must report all 12 CAHPS for PQRS measures for the 12-month reporting period

o Must report all 21 measures within the GPRO Web Interface and populate date fields for

the first 248 consecutively ranked and assigned beneficiaries

o If fewer than 248 beneficiaries are available, groups must report on 100 percent of

assigned beneficiaries

o At least 1 measure containing Medicare patient data must be reported.

Groups of 100+ EPs

o CAHPS is a requirement for groups of 100+ EPs

o Group practices with 100 or more EPs reporting through the GPRO Web Interface will be

required to report the CAHPS for PQRS measures through a CMS-Certified Survey

Vendor in addition to satisfactorily reporting PQRS measures via the GPRO Web

Interface.

The 12 CG CAHPS summary survey modules will include the following:

o Getting timely care, appointments, and information

o How well providers communicate

o Patient’s rating of provider

o Access to specialists

o Health promotion & education

o Shared decision making

o Health status/functional status

o Courteous and helpful office staff

o Care coordination

o Between visit communication

o Helping you to take medication as directed

As of this publishing date, CMS has not issued the list of CME-certified survey vendors for 2015. It is

expected that CMS will issue this listing soon.

In 2014, CMS paid the cost of administering CAHPS for group practices of 100+ EPs. In 2015, CMS

will not bear the cost of administering CAHPS for PQRS, no matter the size of the group practice.

Resources CMS Link - 2015 CMS-certified Survey Vendor Made Simple

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015PQRS_CMS-CertifSurveyVendorMadeSimple.pdf

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E. Registration to Participate as a GPRO In order for EPs to participate in the PQRS program as a Group Practice through a Registry, EHR or

GPRO Web-based interface, registration must be completed through the Physician-Value/Physician

Quality Reporting (PV-PQRS ) online Registration System during the registration period, April 1, 2015 -

June 30, 2015. The PV-PQRS Registration System is a web-based application that serves the PV and

PQRS programs. The group practice will need to designate a Security Official (SO) PV-PQRS Role and

Representative PVPQRS Role to complete registration.

Here are the registration basics:

STEP 1: Go to the PV-PQRS Registration System website. On the right hand side, select Login

to CMS Secure Portal.

STEP 2: After accepting the Terms and Conditions, enter your IACS User ID and Password in

the Welcome to CMS Enterprise Portal screen. Select Log In to continue.

STEP 3: Select the PV-PQRS tab at the top of the screen, and then select Registration from the

dropdown menu.

STEP 4: You will see a screen where the group practice(s) and EP(s) (if applicable) that are

associated with your IACS account are listed. To register a group practice for the first time, select

the Register link to the right of the group practice you want to register.

Note: If your group practice is participating in an Accountable Care Organization (ACO), then you do

not need to register for PQRS GPRO via the PV-PQRS System.

Complete information and step-by-step instructions for registering a new group for participation in 2015

PQRS GPRO or for modifying a previous registration is available on the Self Nomination/Registration

page of the Medicare FFS Physician Feedback Program/Value-Based Payment Modifier website or see

the following resource material.

Resources

Self-Nomination Registration Information

https://portal.cms.gov/wps/portal/unauthportal/home/

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html

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2015 REPORTING MECHANISMS There are 5 reporting mechanisms to report PQRS Data:

A. Claims-based Reporting

B. Registry Reporting

C. EHR Direct and EHR Vendor Submission Reporting

D. GPRO Web-based Interface (for Group Practices of 25+ EPs)

E. CMS-Certified Survey Vendor (Optional for GPs of 2-99 EPs, Required for GPs of 100+EPs)

A. Claims-Based Reporting PQRS measures are reported on each claim submitted to Medicare when the CPT and diagnosis

combination qualifies for the PQRS measures the provider has chosen. Claims-based reporting may only

be utilized by Individual EPs. This method is not available for Group Practice GPRO reporting.

Only individual measures may be submitted via the claims-based reporting method. Criteria for claims-

based reporting can be found under the section of this guide.

CMS Link - 2015 PQRS Individual Claims Registry Measure Specification Supporting

Documents.

B. Registry Reporting Individual EPs and GPs may submit their measures through a CMS-qualified Registry. A registry is a

third-party database that many professionals already use to report data to researchers about common care

processes for diabetes, kidney disease and preventive medicine. An EP or group practice would be

required to enter into and maintain an appropriate legal arrangement with a qualified PQRS registry. The

Registry acts as a HIPAA Business Associate and agent of the EP.

Individual EPs may report individual measures or measures groups via registry reporting.

EPs reporting through a Group Practice (GPRO) may report only individual measures via registry

reporting.

Reporting Criteria for Individual EPs can be found in the

C. Qualified Clinical Data Registry section under “Reporting as an Individual EP.”

Reporting Criteria for Group Practices can be found in the A. Qualified Registry section under

“Reporting as a Group Practice.”

Once EPs and GPs have chosen the measures they will report in 2015, they should access the CMS-

qualified registry list to find registries that report their individual measures or “measures groups”

depending on what the reporting mechanism is chosen. Not all registries report measures groups and not

all registries report all individual measures.

Eligible professionals or group practices participating in GPRO should work directly with their chosen

registry for information on how to submit data on the selected measures or measures group. Each

registry operates differently and accepts different forms of data.

The 2015 PQRS registry list will be available late spring/early summer of 2015 on the Registry

Reporting page of the CMS PQRS website. The list includes the registry name, contact information, cost

and which measures/reporting options the registry can report.

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2015_PQRS_IndividualMeasureSpecs_SupportingDocs_111214.zip


http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html


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Resources

CMS Link - 2015 PQRS Individual Claims Registry Measure Specification Supporting

Documents.

CMS Link - Registry Reporting – CMS Website

CMS Link - 2015 PQRS: Registry Reporting Made Simple

CMS Link - 2015 Registry Vendor Criteria.

C. EHR Reporting (Electronic Health Records) The criteria for satisfactory reporting, as well as the Clinical Quality Measures (CQMs) available for

reporting under the PQRS EHR-based reporting mechanism, are aligned with the Medicare EHR

Incentive Program and the e-CQM specifications will be used for both programs.

As of 2014, CMS discontinued the PQRS qualification requirement for Data Submission vendors and

Direct EHR vendors. The EHR products or EHR data submission vendor will have to be Certified EHR

Technology (CEHRT) under the program established by ONC (Office of Nat’l Coordination for Health

Information Technology). For purposes of PQRS, the EPs’ or group practices’ direct EHR product or

EHR Data Submission Vendor must be certified to the CMS specified versions of the e-CQMs.

If an EP or GP satisfactorily reports for 2015 PQRS using the EHR-based reporting option, the EP or GP

will also satisfy the CQM component of the EHR Incentive Program; however, EPs (including individual

EPs inside the GP) will still be required to meet the other Meaningful Use objectives through the

Medicare EHR Incentive Program Registration and Attestation System.

EPs and GPs should reference the 2015 PQRS Measures List to find the appropriate versions of the

eCQMs.

Individual EP Reporting

EPs must report on at least 9 measures covering 3 National Quality Strategy (NQD) domains.

If the EP’s CEHRT(Certified EHR technology) does not contain patient data for at least 9

measures covering at least 3 domains, then the EP must report the measures for which there is

Medicare patient data.

An EP must report on at least 1 patient for which there is Medicare patient data.

Group Practice Reporting

A group practice (GP) must register with CMS to report via EHR under the GPRO for 2015

PQRS.

GPs must report on at least 9 measures covering 3 National Quality Strategy (NQD) domains.

If the GP’s CEHRT does not contain patient data for at least 9 measures covering at least 3

domains, then the GP must report the measures for which there is Medicare patient data.

A GP must report on at least 1 patient for which there is Medicare patient data.

Direct and Indirect EHR Reporting

Data submitted through a Direct EHR vendor EHR product OR DSV must be transmitted using the

QDM-based QRDA Category I or III formats. Although products must be able to transmit data using the

QDM-based QRDA Category I and III formats, for purposes of reporting PQRS quality measures data to

CMS, EPs and GPs need only submit data via their EHR using one of these formats




http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_Registry_Reporting_Made_Simple.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_RegistryVendorCriteria.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Certification.html


http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

17

For 2015, EPs may submit quality measure data to CMS:

1. Directly from the EP’s (eligible professional) CEHRT (Certified EHR Technology) qualified

EHR in the CMS-specified manner , or

2. Indirectly from a CEHRT qualified EHR data submission vendor (on the EP’s behalf), in the

CMS-specified manner.

Direct EHR Vendor Direct EHR vendors are those vendors who are certifying an EHR product and version for EPs or group

practices to utilize to directly submit their measure data to CMS in the CMS-specified format(s) on their

behalf.

If submitting directly, EPs and GPs must register for an IACS account. Information on registering for an

IACS account can be found on the “Physician and Other Health Care Professionals Quality Reporting

Portal” (Portal) at https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

Request the appropriate Submitter Role when registering for an IACS account – either Individual

PQRS Submitter and PQRS Representative, or PQRS Submitter.

If you already have an IACS account, you will need to request adding the role to your account.

Refer to the IACS Quick Reference Guides document on the Portal home page

If assistance is needed, contact the QualityNet Help Desk at 866-715-6922 or via email at

[email protected]

Indirect EHR Data Submission Vendor (DSV) – A DSV is an entity vendor that collects an EP’s or

group practices’ clinical data directly from the EP’s or GP’s EHR. DSVs will be responsible for

submitting PQRS measures data from an EP’s or GP’s certified EHR to CMS in a CMS-specified

format(s) on behalf of the EP or GP.

EPs or GPs using the DSV option do not need to register for an IACS account.

Submission of Clinical Quality Measures (eCQMs) EPs and group practices must submit final EHR reporting files with quality measure data, or ensure that

their EHR Data Submission Vendor submits files by the data submission deadline of February 28, 2016,

to be analyzed and used for 2015 PQRS EHR measure calculations.

If reporting QDM-based QRDA Category I files, a single file must be uploaded/submitted for

each patient. Files can be batched but there will be file upload size limits. It is likely that several

batched files will need to be uploaded to the Portal for each eligible provider.

Following each successful file 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.

Reporting via EHR using the QRDA Category III format is one of two reporting methods (EHR,

and QCDR) that provide calculated reporting and performance rates to CMS.

Note: Measures with a 0% performance rate will not be counted.

Resources CMS Link - 2015 PQRS EHR Reporting Made Simple

CMS Link - PQRS Submitter Role Guide

CMS Link - Certified EHR Technology Website

CMS Link – 2015 CQM Reporting Options

https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

mailto:[email protected]

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015PQRS_EHR_Made_Simple.pdf

https://www.qualitynet.org/imageserver/pqri/documents/EHR%20Submitter%20Role.pdf



18

D. GPRO Web-based Interface The GPRO Web-based Interface reporting option may only be used for submitting PQRS measures by

Group Practices of 25+ EPs.

All information on GPRO Web-based interface reporting can be found under the

C. GPRO Web Interface Reporting (25 or more EPs) section under “Reporting as a Group Practice” in

this guide.

E. CMS-Certified Vendor The CMS-Certified Vendor reporting option may only be used by Group Practices. For group practices

made up of 2-99 EPs, it is a voluntary, optional companion to reporting PQRS measures. This reporting

option is mandatory for those Group Practices of 100+ EPs.

The CMS-Certified Survey Vendor reporting method is used to report Consumer Assessment of

Healthcare Providers and Systems (CAHPS) for PQRS.

All information on CMS-Certified Vendor submission of CAHPS can be found in the

D. Certified Survey Vendor section of “Reporting as a Group Practice” in this guide.

19

Measure Applicability Validation (MAV) When an EP reports on fewer measures than the reporting method calls for, CMS will perform a review

(measure applicability validation or MAV) to determine whether there are other closely related measures

(such as those that share a common diagnosis or those that are representative of services typically

provided by a particular type of EP). If the EP does not report on those additional measures, then the EP

could be subject to a -2% payment adjustment in 2017 if the EP fails the MAV test

The MAV will be applied only to those EPs who submit PQRS measures through a claims-based or

registry reporting method.

Prerequisites for MAV in 2015

Eligible professionals who report fewer than nine measures or fewer than three NQS domains will

be subject to MAV in 2015.

EPs who report on at least 50 percent of their eligible patients or encounters for each measure

At least one cross-cutting measure must be satisfactorily reported for those individual providers

with face-to-face encounters.

For measures reported, there must be at least one patient or procedure in the numerator of the rate

for the measure to be counted as meeting performance.

MAV will Not Apply and the 2017 Payment Adjustment will Automatically be Applied if:

EPs report on fewer than 50% of Medicare Part B FFS patients, or

EPs with face-to-face encounters do not satisfactorily report at least one cross-cutting measures,

or

No patient or procedure qualifies for the numerator of the performance measure (i.e. rate =0% or

100% for inverse measures)

CMS will apply a two-step process to operationalize the MAV.

1. Clinical Relation/Domain Test

2. Minimum Threshold Test

Step 1: Clinical Relation Test

This test is based on:

1. A presumption that if a provider submits data for a measure, then that measure applies to her/his

practice and

2. The concept that if one measure in a cluster of measures related to a particular clinical topic or

professional service is applicable to a provider’s practice, then other closely-related measures

(measures in that same cluster) may also be applicable.

20

Step 2: Minimum Threshold Test

The minimum threshold test is based on the concept that only if, during the 2015 reporting period, a

provider treated more than a certain number of Medicare patients with a condition to which a certain

measure applied, then that EP should be accountable for submitting the QDC(s) for that measure.

For the 2015 reporting period, the common minimum threshold, based on statistical and clinical

frequency considerations, will not be less than 15 patients or encounters for the 12-month reporting period

for each 2015 measure

CMS example of how the clinical relation test will be applied:

A pathologist, identified as an eligible professional who is subject to MAV due to meeting the pre-

requisites for MAV, reported QDCs for Measure #395, one of the PQRS measures related to

pathology. CMS will determine if the reported measure is contained within a cluster or is excluded

from a cluster. If the measure is contained within a cluster, then CMS will analyze claims data to

evaluate if any of the other measures or domains within the clinical cluster may have also been

applicable.

If there are other measure(s)’ denominators criteria that are applicable, CMS will proceed to Step 2

(Minimum Threshold Test) to determine whether any of the other pathology measure(s) in the

pathology cluster could also have been submitted.

CMS determined that the reported measure was part of a measure cluster for pathologists. Upon

further analysis CMS determined that some of the other measures in the cluster (left unreported by the

physician) would be applicable to the physician’s practice and could have been reported.

CMS example of how the minimum threshold test will be applied:

The Pathologist, from the Clinical Relation Case Study above, reported measure #395 Lung Cancer

Reporting (Biopsy/Cytology Specimens). This measure is found in Cluster 14: Pathology Lung

Cancer, which contains two measures - #395 and #396.

Based on Cluster 14, CMS will evaluate if measure #396 Lung Cancer Reporting (Resection

Specimens) could have been reported. CMS then proceeds to the Minimum Threshold Test which will

evaluate if there were at least fifteen denominator eligible encounters for measure #396 for the eligible

professional. If there are at least fifteen encounters, then CMS will conclude that this measure was

applicable and should have been reported by the Pathologist. If less than fifteen encounters are

identified, then CMS would not hold this eligible professionals accountable for reporting measure

#396.

Note: If chosen measures are part of more than one cluster, then each cluster is reviewed under MAV.

Example – If an EP reports measure #130 (found in Cluster 3 - Lung Care) and #226 (found in Cluster

5- Cancer Care) and there were at least 15 denominator events for the measures within Cluster 3 and 5,

then all measures of both clusters must be reported to pass the MAV and avoid the penalty.

21

CMS may determine that it is necessary to modify the measure-applicability validation process after the

start of the reporting periods. However, any changes will result in the process being applied more

leniently, thereby (1) allowing a greater number of professionals to pass validation and (2) causing no

professional who would otherwise have passed to fail.

Resources

2015 PQRS Measure-Applicability Validation (MAV) Process for Claims-Based Reporting

of Individual Measures – provides guidance for those eligible professionals who satisfactorily

submit quality-data codes for fewer than nine PQRS measures or for fewer than three NQS

domains, and how the MAV process will determine whether they should have submitted QDCs

for additional measures. This also includes the process flow depicting the MAV process.

2015 PQRS Measure-Applicability Validation (MAV) Process for Registry-Based Reporting

of Individual Measures – provides guidance for those eligible professionals who satisfactorily

submit via a Qualified Registry for fewer than nine PQRS measures or for fewer than three NQS

domains, and how the MAV process will determine whether they should have submitted

additional measures. This also includes the process flow depicting the MAV process.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_MAV_Claims-BasedProcessDocument.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_MAV_Claims-BasedProcessDocument.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_MAV_Registry-BasedProcessDocument.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_MAV_Registry-BasedProcessDocument.zip

22

ADDENDUMS

Addendum A

Eligible Professionals to report the 2015 PQRS Measures

1. 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

2. Practitioners

Physician Assistant

Nurse Practitioner *

Clinical Nurse Specialist *

Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)

Certified Nurse Midwife*

Clinical Social Worker

Clinical Psychologist

Registered Dietician

Nutrition Professional

Audiologists

*Includes Advanced Practice Registered Nurse (APRN)

3. Therapists

Physical Therapist

Occupational Therapist

Qualified Speech-Language Therapist (as of 7/1/2009)

Please Note: Beginning in 2014, professionals who reassign benefits to a Critical Access Hospital (CAH) that bills

professional services at a facility level, such as CAH Method II billing, can now participate (in all reporting methods

except for claims-based) in PQRS. To do so, the CAH must include the individual provider NPI on their institutional

(FI) claims.

Eligible But Not Able to Participate Some professional may be eligible to participate per their specialty, but due to billing method may not be able to

participate.

Professionals, who do not bill Medicare at an individual National Provider Identifier (NPI) level, where the

rendering provider’s individual NPI is entered on CMS-1500 type paper or electronic claims billing,

associated with specific line-item services.

Services payable under fee schedules or methodologies other than the PFS are not included in PQRS such as

services provided in federal qualified health center, independent diagnostic testing facilities, independent

laboratories, hospitals (including method I critical access hospitals), rural health clinics, ambulance providers, and

ambulatory surgery center facilities.

23

Addendum B C-Claims R- Registry MG - Measures Group

New Individual Measures for PQRS in 2015

PQRS # NQS Domain Measure Reporting Method

383 Patient Safety Adherence to Antipsychotic Medications for Individuals with Schizophrenia

R

384 Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment Repair Success Rate

R

385 Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate

R

386 Person and Caregiver-Centered Experience and Outcomes

Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

R

387 Effective Clinical Care Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

R, MG

388 Patient Safety Cataract Surgery w/Intra-Operative Complications (Unplanned rupture of Posterior Capsule Requiring Unplanned Vsitrectomy)

R, MG

389 Effective Clinical Care Cataract Surgery: Difference Between Planned and Final Refraction

R, MG

390 Person and Caregiver-Centered Experience and Outcomes

Discussion and Shared Decision Making Surrounding Treatment Options

R, MG

391 Communication and Care Coordination

F/U after Hospitalization for Mental Illness (FUH) R

392 Patient Safety HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

R

393 Patient Safety HRS-9 Infection within 180 Days of Implantable Electronic Device (CIED) Implantation, Replacement or Revision

R

394 Community/Population Health Immunizations for Adolescents R


Lung Cancer Reporting (Biopsy/Cytology Specimens) C,R


Lung Cancer Reporting (Resection Specimens) C,R


Melanoma Reporting C

398 Effective Clinical Care Optimal Asthma Control R

399 Effective Clinical Care Post-Procedural Optimal Medical Therapy Composite (Percutaneous Coronary Intervention)

R

400 Effective Clinical Care Hepatitis C: One-time Screening for Hepatitis C Virus (HCV) for Patients at Risk

R

401 Effective Clinical Care Screening for Hepatocellular Carcinoma (HCC) in patients w/ Hepatitis C Cirrhosis

R, MG

402 Community/Population Health Tobacco Use and Help with Quitting Among Adolescents

R, MG

24

Addendum C

Deleted Measures for 2015 PQRS

# Measure Description Reporting Method

C-Claims R- Registry MG - Measures Group

20 Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician

C, R

28 Aspirin at Arrival for Acute Myocardial Infarction (AMI) C, R

30 Perioperative Care: Timing of Prophylactic Antibiotic – Administering Physician C, R

31 Stroke and Stroke Rehabilitation: Venous Thromboembolism (VTE) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage

C, R

35 Stroke and Stroke Rehabilitation: Screening for Dysphagia C, R

36 Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered C, R

45 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures)

C, R

49 Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older

C, R

55 Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope C, R

56 Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Vital Signs

C, R

59 Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic

C, R

64 Asthma: Assessment of Asthma Control – Ambulatory Care Setting R

83 Hepatitis C: Confirmation of Hepatitis C Viremia R

106 Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

C, R

123 Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL

C, R

142 Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications

C, R

148 Back Pain: Initial Visit MG

149 Back Pain: Physician Exam MG

150 Back Pain; Advice for Normal Activities MG

151 Back Pain: Advice Against Bed Rest MG

157 Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection

C, R

159 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed R

169 Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge R

170 Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge R

171 Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge R

197 Coronary Artery Disease (CAD): Lipid Control R

198 Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment R

228 Heart Failure (HF): Left Ventricular Function (LVF) Testing R

25

Deleted Measures (Cont’d)

PQRS # Measure Description Deleted Measures

Reporting Method

231 Asthma: Tobacco Use: Screening - Ambulatory Care Setting C, R

232 Asthma: Tobacco Use: Intervention - Ambulatory Care Setting C, R

233 Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal Cancer Resection

R

234 Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection (Pneumonectomy, Lobectomy, or Formal Segmentectomy)

R

245 Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure)

C, R

246 Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure)

C, R

247 Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence

C, R

248 Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence

C, R

267 Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome C, R

269 Inflammatory Bowel Disease (IBD): Type, Anatomic Location MG

272 Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization MG

273 Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization

MG

295 Hypertension: Use of Aspirin or Other Antithrombotic Therapy MG

296 Hypertension: Complete Lipid Profile: MG

297 Hypertension: Urine Protein Test MG

298 Hypertension: Annual Serum Creatinine Test MG

299 Hypertension: Diabetes Mellitus Screening Test MG

300 Hypertension: Blood Pressure Control: MG

301 Hypertension: Low Density Lipoprotein (LDL-C) Control MG

302 Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed:

MG

26

Addendum D

Domain Changes in 2015 PQRS

# Measure 2014 Domain 2015 Domain Reporting Method

46 Medication Reconciliation Patient Safety Communication & Care Coordination Claims, Registry

37 Melanoma: Continuity of Care -Recall System


Communication & Care Coordination Registry

88 Dementia: Caregiver Education and Support


Communication & Care Coordination

93 Parkinson's Disease: Rehabilitative Therapy Options


Communication & Care Coordination Measures Group

Parkinson's Disease: Medical & Surgical Treatment Options Reviewed


Communication & Care Coordination Measures Group

25

Adult Major Depressive Disorder (MDD): Coordination of Care of Patients w/Specific Comorbid Conditions


Communication & Care Coordination Registry

303

Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery


Person & Caregiver Centered Experience & Outcomes

Registry & Measures Group

331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis

Effective Clinical Care Efficiency & Cost Reduction


332

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients w/Acute Bacterial Sinusitis

Effective Clinical Care Efficiency & Cost Reduction


347

Rate of Endovascular aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital

Effective Clinical Care Patient Safety EHR

348

HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate

Effective Clinical Care Patient Safety EHR

354 Anastomotic Leak Intervention Effective Clinical Care Patient Safety Measures Group

355 Unplanned Reoperation within the 30 Days Postoperative Period

Effective Clinical Care Patient Safety Measures Group

111 Pneumonia Vaccination Status for Older Adults


Community/Population Health

Claims, Registry, EHR, GPRO Web Interface, Measures Group, ACO, MU2

82 Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute

Communication & Care Coordination Effective Clinical Care Registry

180 Rheumatoid Arthritis: Glucocorticoid

Communication & Care Coordination Effective Clinical Care Measures Group

280 Dementia: Staging of Dementia Communication & Care Coordination Effective Clinical Care Measures Group

93

Acute Otitis Externa(AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use

Communication & Care Coordination Efficiency & Cost Reduction

Claims, Registry, Measures Group

27

Domain Changes in 2015 (Cont’d)

PQRS # Measure 2014 Domain 2015 Domain

Reporting Method

58

Rate of Open Repair of Small or Moderate N0n-Ruptured Abdominal Aortic Aneurysms w/our Major Compications (Discharged to Home by Post-Operative Day #7)

Communication & Care Coordination Patient Safety Registry

59

Rate of Endovascular aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdomincal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)


60

Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)


326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Patient Safety


Claims, Registry

321 CAHPS for PQRS Clinician/Group Survey Communication & Care Coordination

Person & Caregiver Centered Experience & Outcomes CSV

28

Addendum E

Cross-Cutting Measures for PQRS in 2015 PQRS # NQS Domain Measure Reporting Method

402 Community/Population Health Tobacco Use and Help with Quitting Among Adolescents

R, MG

400 Effective Clinical Care Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

R

46 Communication and Care Co-ord. Medication Reconciliation C, R

47 Communication and Care Co-ord. Care Plan C, R, MG

110 Community/Population Health Preventive Care and Screening: Influenza Immunization

C, R, EHR, GPRO Web, MG, ACO, MU2

111 Community/Population Health Pneumonia Vaccination Status for Older Adults


128 Community/Population Health Preventive Care & Screening: Body Mass Index (BMI) Screening & F/U Plan


130 Patient Safety Documentation of Current Medications in the Medical Record


131 Communication and Care Co-ord. Pain Assessment and F/U C, R, MG

134 Community/Population Health Preventive Care and Screening: Screening for Clinical Depression and F/U Plan


182 Communication and Care Co-ord. Functional Outcome Assessment C, R

226 Community/Population Health Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

C, R, EHR, GPRO Web, MG, ACO, MU2, Million Hearts

236 Effective Clinical Care Controlling High Blood Pressure C, R, EHR, GPRO Web, MG, ACO, MU2, Million Hearts

240 Community/Population Health Childhood Immunization Status EHR, MU2

317 Community/Population Health Preventive Care and Screening: Screening for High Blood Pressure and F/U Documented

C, R, EHR, GPRO, MG, ACO, MU2, Million Hearts

318 Patient Safety Falls: Screening for Fall Risk EHR, GPRO Web, ACO, MU2

321 Person and Caregiver Experience and Outcomes

CAHPS for PQRS Clinician/Group Survey CSV, ACO

374 Communication and Care Co-ord. Closing the Referral Loop: Receipt of Specialist Report

EHR, MU2

1 Effective Clinical Care Diabetes: Hemoglobin A1c Poor Control C, R, EHR, GPRO, MG, ACO, MU2

C – Claims, R – Registry, EHR – Direct and Indirect,

MG – Measures Group, MU2 – Meaningful Use Stage 2, CSV – CMS Certified Survey

29

Addendum F

2015 - GPRO Web Interface Reporting Option Measures Alternative Measure Numbers

GPRO # Measure Title PQRS ACO NQF CMS

Care Coordination/Patient Safety and Preventive Care Measures

CARE-2 Falls: Screening for Future Fall Risk GO 318 13 0101 139v3

CARE-3 Documentation of Current Medications in the Medical Record GO 130 39 0419 68v4

Coronary Artery Disease (CAD) Disease Module

CAD-7

Coronary Artery Disease (CAD):Angiotensin-Converting Enzyme(ACE) Inhibitor or Angiotensin Receptor Blocker(ARB) Therapy - Diabetes of Left Ventricular Systolic Dysfunction (LVEF<40%) R 118 33 0066 N/A

Disease Composite

DM-2 Diabetes: Hemoglobin A 1c Poor Control CR 1 27 0059 122v3

DM-7 Diabetes: Eye Exam CR 117 41 0055 131v3

Heart Failure (HF) Disease Module (1 Measure)

HF-6 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction(LVSD) R 8 31 0083 144v3

Hypertension Disease Module

HTN-2 Controlling High Blood Pressure CR 236 28 0018 165v3

Ischemic Vascular Disease (IVD) Disease Module (2 Measures)

IVD-2 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic CR 204 30 0068 164v3

Mental Health Disease

MH-1 Depression Remission at Twelve Months CR ?? 40 0710 159v3

Preventive (PREV) Care Measures (8 Measures - Individually Sampled)

PREV-5 Breast Cancer Screening CR 112 20 NA 125v3

PREV-6 Colorectal Cancer Screening CR 113 19 0034 130v3

PREV-7 Preventive Care and Screening: Influenza Immunization CR 110 14 0041 147v4

PREV-8 Pneumonia Vaccination Status for Older Adults CR 111 15 0043 127v3

PREV-9 Preventive Care and Screening: Body Mass Index (BMI) Screening & Follow-up CR 128 16 0421 69v3

PREV-10 Preventive Care and Screening: TobacoUse; Screening and Cessation Intervention CR 226 17 0028 138v3

PREV-11 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented CR 317 21 NA 22v3

PREV-12 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan CR 134 18 0418 2v4

CR – Claims/Registry GO – GPRO R – Registry Only

30

Addendum G

2015 Measures Groups

Measures Groups may only be reported through the Quality Registry Option.

DIABETES MEASURES GROUP:

Intent Code: G8485 Composite Code: G8494 # 1. Diabetes: Hemoglobin A1c Poor Control

#110. Preventive Care and Screening: Influenza Immunization

#117. Diabetes: Eye Exam

#119. Diabetes: Medical Attention for Nephropathy

#163. Diabetes: Foot Exam

#226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

CHRONIC KIDNEY DISEASE (CKD) MEASURES GROUP

Intent Code: G8487 Composite Code: G8495 # 47. Care Plan


#121. Adult Kidney Disease: Laboratory Testing (Lipid Profile)

#122. Adult Kidney Disease: Blood Pressure Management

#130. Documentation of Current Medications in the Medical Record


THE PREVENTIVE CARE MEASURES GROUP:

Intent Code: G8486 Composite Code: G8496 # 39. Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

# 48. Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older


#111. Pneumonia Vaccination for Older Adults

#112. Breast Cancer Screening

#113. Colorectal Cancer Screening

#128. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

#134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan #173. Preventive Care and Screening: Unhealthy Alcohol Use – Screening


CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES GROUP:

Intent Code: G8544 Composite Code: G8497

# 43. Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

# 44. Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

#164. Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)

#165. Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

#166. Coronary Artery Bypass Graft (CABG): Stroke

#167. Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency

#168. Coronary Artery Bypass Graft (CABG): Surgical Re-exploration

RHEUMATOID ARTHRITIS MEASURES GROUP:

Intent Code: G8490 Composite Code: G8499 #108. Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy

#128. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

#131. Pain Assessment and Follow-Up

#176. Rheumatoid Arthritis (RA): Tuberculosis Screening

#177. Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

#178. Rheumatoid Arthritis (RA): Functional Status Assessment

#179. Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

#180. Rheumatoid Arthritis (RA): Glucocorticoid Management

31

HEPATITIS C MEASURES GROUP:

Intent Code: G8545 Composite Code: G8549 # 84. Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment

# 85. Hepatitis C: HCV Genotype Testing Prior to Treatment

# 87. Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment


#183. Hepatitis C: Hepatitis A Vaccination in Patients with HCV


#390. Discussion and Shared Decision Making Surrounding Treatment Options

#401. Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis

HEART FAILURE (HF) MEASURES GROUP:

Intent Code: G8548 Composite Code: G8551 # 5. Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left

Ventricular Systolic Dysfunction (LVSD)

# 8. Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

# 47. Care Plan




CORONARY ARTERY DISEASE (CAD) MEASURES GROUP:

Intent Code: G8489 Composite Code: G8498 # 6. Coronary Artery Disease (CAD): Antiplatelet Therapy

# 7. Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic

Dysfunction (LVEF<40%)

#128. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan



#242. Coronary Artery Disease (CAD): Symptom Management

HIV/AIDS MEASURES GROUP:

Intent Code: G8491 Composite Code: G8500 # 47. Care Plan

#134. Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

#160. HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

#205. HIV/AIDS: Sexually Transmitted Diseases Screening for Chlamydia, Gonorrhea and Syphilis


#338: HIV Viral Load Suppression

#339: Prescription of HIV Antiretroviral Therapy

#340: HIV Medical Visit Frequency

ASTHMA MEASURES GROUP


# 53. Asthma: Pharmacologic Therapy





#402. Tobacco Use and Help with Quitting Among Adolescents

COPD MEASURES GROUP


# 47. Care Plan

# 51. Chronic Obstructive Pulmonary Disease (COPD); Spirometry Evaluation

# 52. Chronic Obstructive Pulmonary Disease (COPD); Bronchodilator Therapy




32

INFLAMATORY BOWEL DISEASE (IBD) MEASURES GROUP





#270: IBD: Preventive Care: Corticosteroid Sparing Therapy

#271: IBD: Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment

#274. IBD: Testing for Latent TB Before Initiating Anti-TNF Therapy

#275. IBD: Assessment of Hepatitis B Virus Status Before Initiating Anti-TNF Therapy

SLEEP APNEA MEASURES GROUP





#276. Sleep Apnea: Assessment of Sleep Symptoms

#277: Sleep Apnea: Severity Assessment at Initial Diagnosis

#278: Sleep Apnea: Positive airway Pressure Therapy Prescribed

#279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

DEMENTIA MEASURES GROUP


# 47. Care Plan

#280. Dementia: Staging of Dementia

#281. Dementia: Cognitive Assessment

#282. Dementia: Functional Status Assessment

#283: Dementia: Neuropsychiatric Symptom Assessment

#284. Dementia: Management of Neuropsychiatric Symptoms

#285. Dementia: Screening for Depressive Symptoms

#286. Dementia: Counseling Regarding Safety Concerns

#287 Dementia: Counseling Regarding Risks of Driving

#288. Dementia: Caregiver Education and Support

PARKINSON’S MEASURES GROUP

Intent Code:G8903 Composite Code: G8761

# 47. Care Plan

#289. Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review

#290. Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment

#291. Parkinson’s Disease: Cognitive Impairment of Dysfunction Assessment

#292. Parkinson’s Disease: Querying about Sleep Disturbances

#293. Parkinson’s Disease: Rehabilitative Therapy Options

#294. Parkinson’s Disease: Medical and Surgical Treatment Options Reviewed

CATARACTS MEASURES GROUP



#191. Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

#192. Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures


#303. Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

#304. Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

#388. Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned

Vitrectomy)

#389. Cataract Surgery: Difference Between Planned and Final Refraction

33

ONCOLOGY MEASURES GROUP


#71. Breast Cancer: Hormonal Therapy for Stage IC – IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast

Cancer

#72. Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients



#143. Oncology: Medical and Radiation – Pain Intensity Quantified

#144. Oncology: Medical and Radiation – Plan of Care for Pain


TOTAL KNEE REPLACEMENT MEASURES GROUP




#350. Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

#351. Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

#352. Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

#353. Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

GENERAL SURGERY MEASURES GROUP




#354. Anastomotic Leak Intervention

#355. Unplanned Reoperation within the 30 Day Postoperative Period

#356. Unplanned Hospital Readmission within 30 Days of Principal Procedure

#357. Surgical Site Infection (SSI)

#358. Patient-Centered Surgical Risk Assessment and Communication

OPTIMIZING PATIENT EXPOSURE TO IONIZING RADIATION (OPEIR) MEASURES GROUP: (New in 2014)


#359. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed

Tomography (CT) Imaging Description

#360. Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed

Tomography (CT) and Cardiac Nuclear Medicine Studies

#361. Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

#362. Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up

and Comparison Purposes

#363. Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a

Secure, Authorized, Media-Free, Shared Archive

#364. Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected

Pulmonary Nodules According to Recommended Guidelines

SINUSITIS MEASURES GROUP: (New in 2015)





#331. Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use)

#332. Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis

(Appropriate Use)

#333. Adult Sinusitis: Compterized Tomography (CT) for Acute Sinusitis (Overuse)

34

ACUTE OTITIS EXTERNA (AOE) MEASURES GROUP: (New in 2015)


# 91. Acute Otitis Externa (AOE): Topical Therapy

# 93. Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use



#154. Falls. Risk Assessment

#155. Falls: Plan of Care


#317. Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented