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PQRS Frequently asked Questions - from CMS


* If only one eligible professional in the group practice satisfactorily reports Physician Quality Reporting System quality measures, how will the financial incentive be calculated and paid?


The analysis of satisfactory reporting for Physician Quality Reporting will be performed at the individual eligible professional level for each NPI/TIN, using the individual-level NPI. Incentives earned by individual eligible professionals will be paid to the TIN under which his or her claims were submitted, aggregating individual incentives earned by members of groups that bill under one TIN.

Ref: https://questions.cms.hhs.gov/app/answers/detail/a_id/8263/kw/PQRI


* If my Medicare patient population during the reporting period(s) is such that there are only one or only two applicable measures available within the Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI), will I automatically be included in measure-applicability validation (MAV) process?

CMS encourages eligible professionals to review the Physician Quality Reporting measures list to find three or more applicable measures, including structural measures, to report. If you satisfactorily submit data for only one or only two Physician Quality Reporting measures, and you do not submit any quality-data code (QDC) for any other Physician Quality Reporting measure, you will be subject to the MAV process. For eligible professionals included in the validation process, if the CMS analysis determines there are no other measures you should have reported, and the eligible professional does not submit QDCs for any other measure, he or she will be eligible to receive a Physician Quality Reporting financial incentive. The MAV process for the program year, including the list of clusters and the measures included within each, can be found in "Physician Quality Reporting System Measure-Applicability Validation Process for Claims-Based Participation", available as a download from the Analysis and Payment page of the CMS Physician Quality Reporting website at: http://www.cms.gov/PQRS/25_AnalysisAndPayment.asp

* What if I submit quality-data codes (QDCs) at a rate of at least 50% for each of three 2011 Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) measures but the three measures are in different (measure-applicability validation or MAV) clinical clusters?

If you satisfactorily submit data for three or more Physician Quality Reporting measures, whether or not the measures are in a single cluster or not, you would not be subject to MAV. Please note that other Medicare program integrity statutes and regulations may apply to Physician Quality Reporting.

* Will CMS permit more than one eligible professional to submit quality data for the same Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) measures on the same patient(s)?

Yes. See the example provided at the end of the Physician Quality Reporting Measures List posted on the Measures Codes section of the CMS Physician Quality Reporting website.

* When is the cut-off for Physician Quality Reporting System (Physician Quality Reporting, formerly PQRI) data submission?

The Tax Relief and Health Care Act of 2006 (TRHCA) permits a two-month data submission period for claims following the end of the reporting period(s). All reporting periods for any given program year end December 31st. All claims-based data for services furnished during the reporting period(s) must be submitted by the last Friday in February of the following year.
Submission of registry and EHR data, as well as Group Practice Reporting Option (GPRO) data, must be completed in the first quarter following the reporting year.

* Why is measure-applicability validation (MAV) important for the Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) program's claims-based submission of individual measures option?

CMS is required by statute to validate, prior to making any incentive payment to participants reporting individual measures through claims, whether participating eligible professionals have satisfactorily submitted quality data for at least the statutory minimum number of measures, based on the number of available measures that are applicable to their practices. Thus, CMS will apply MAV on situations where eligible professionals have submitted quality data for fewer than three quality measures and achieved at least a 50% reporting rate for 2011 (previously 80% ) on each measure for which data were submitted. If CMS finds that there are additional measures applicable to such professionals' practices for that reporting period, these professionals will not be eligible for a Physician Quality Reporting incentive payment.
Detailed descriptions of the MAV processes for each program year are available from the Analysis and Payment page on the CMS Physician Quality Reporting website.

* I have questions about which Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) measures are most applicable to my specialty and practice, and about how to best implement Physician Quality Reporting in my practice. Where can I get more information and advice on these topics?

For specialty- or practice-specific questions, please contact your professional organization or specialty association for guidance. In many cases, these organizations are represented on measure development workgroups and will have information about which measures are applicable to a particular specialty/practice. Begin by reviewing the Physician Quality Reporting System Measures List for the current program year, available in the Measures Codes section of the CMS Physician Quality Reporting website. Reference: http://www.cms.gov/pqrs

* If I am participating in the Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) and/or the Electronic Prescribing (eRx) Incentive Program, should I use my individual National Provider Identifier (NPI) or my group NPI?

An eligible professional participating in Physician Quality Reporting and/or the eRx Incentive Program should use his or her individual NPI. If reporting via claims, the individual NPI must be on the claim as the only performing or "rendering" NPI, or if multiple NPIs are on the same claim, the individual rendering NPI must be on each of the payable service and quality-data line items. For registry-based reporting, eligible professionals need to submit the following to their registry: their individual NPI (not the group NPI) AND their Employer Identification Number/Taxpayer Identification Number/Social Security Number (EIN/TIN/SSN) under which they are reimbursed by Medicare. It is this TIN/NPI combination that is used to calculate an individual's allowed charges for the reporting period, and then calculate the incentive payment based on the percentage rate for that program year. Read more...

* Is the primary diagnosis the only diagnosis that is applicable to the quality measure being reported or will Physician Quality Reporting System (Physician Quality Reporting, previously known as PQRI) consider all diagnoses reported on a claim?

Regardless of the reference number in the diagnosis pointer field, all are considered for the analysis of reporting and apply to all rendering providers on the claim reporting the measures. Note that many Physician Quality Reporting measures only require encounter codes in the denominator. The Physician Quality Reporting quality measure specifications identify the combinations of diagnosis and encounter codes making a claim eligible for each measure. Eligible professionals should review ALL diagnosis and encounter codes listed on the claim to ensure they are capturing ALL reported measures applicable to that patient's encounter. Due to using all diagnoses on the base claim, it is highly recommended that participants avoid including multiple dates of service and/or multiple rendering providers on the same claim. This will help eliminate diagnosis codes associated with other services being attributed to another provider's services.

* Why do some of the Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) quality measures (e.g., asthma, depression, pregnancy) apply only to patients who can't be Medicare beneficiaries since they are under age 65?

Medicare is a health insurance benefit for the aged and disabled. Medicare covers persons under the age of 65 who are eligible on the basis of permanent disability or end-stage renal disease. For more information on Medicare eligibility, please visit the CMS beneficiary-focused website at: http://www.Medicare.gov. The CMS Physician Quality Reporting web site is located at: http://www.cms.gov/pqrs.

* I am an eligible professional choosing to report on 2011 Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) measures groups for the 30-patient sample method through registry-based submission. Which patients are included?

Only Medicare Part B Fee-For-Service patients (including Railroad Retirement Board and Medicare Secondary Payer) are included in this reporting option.

* Can a physician or other eligible professional who is enrolled in Medicare, but has not signed the Participation agreement (CMS form 460) to accept assignment on all claims, report Physician Quality Reporting System (Physician Quality Reporting, formerly called PQRI) and the Electronic Prescribing (eRx) Incentive Program information and be eligible for the incentive?

Yes. Medicare-enrolled physicians and other eligible professionals who have not completed a Participation agreement, but who do submit Part B Medicare Physician Fee Schedule (PFS) claims, can participate in Physician Quality Reporting and eRx. A physician or other eligible professional who is not enrolled in Medicare cannot participate in these programs.

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