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What are the Numerator and Denominator in PQRS

Physician Quality Reporting measures consist of two major components. Each component is defined by specific codes described in the respective measure’s specification along with the reporting instructions and use of modifiers.

The first measure component is the denominator, which describes the eligible cases for a measure or the eligible patient population. Physician Quality Reporting measure denominators are identified by ICD-9-CM (future ICD-10-CM), CPT Category I, and HCPCS codes, as well as patient demographics (age, gender, etc), and place of service (if applicable). For registry and EHR reporting, other clinical coding sets may be included such as SNOMED, LOINC, or RxNorm.

List of Denominator Codes

Psychiatry -90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862

Ophthalmology -92002, 92004, 92012, 92014

Behavioral Health – 96150, 96151, 96152

Office visits – 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215

Nursing facility care – 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316

Assisted Living/Domiciliary – 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

Home visits – 99341, 99342, 99343, 99345, 99347, 99348, 99349, 99350

Pelvic/clinical breast exam – G0101

Diabetes Self-management training – G0108, G0109

The second component is the numerator describing the specific clinical action required by the measure for performance. Eligible professionals may use the codes present in the numerator to report the outcome of the action as indicated by the measure. Physician Quality Reporting measure numerators are quality-data codes (QDCs) consisting of specified non-payable CPT Category II codes and/or temporary G-codes. For registry and EHR reporting, other clinical coding sets may be included such as SNOMED, LOINC, or RxNorm in order to capture a specific quality action, test, or value.

Calculating the Physician Quality Reporting System reporting rate (dividing the numerator by the denominator) identifies the percentage of a defined patient population that was reported for the measure. For performance rate calculations, some patients may be excluded from the denominator based on medical, patient or system exclusions allowed by the measure.

The final performance rate calculation represents the eligible population that received a particular process of care or achieved a particular outcome. It is important to review and understand each measure’s specification, as it contains definitions and specific instructions for reporting the measure.

Please see http://www.cms.gov/PQRS/15_MeasuresCodes.asp for more information.

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