The 2016 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual contains detailed descriptions for each quality measure within each measures group. Denominator coding has been modified from the original individual measure as specified by the measure developer to allow for implementation as a measures group.
Quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receives a particular process of care or achieve a particular outcome. The denominator population may be defined by demographic information, certain International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis, Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes specified in the measure that are submitted by individual eligible professionals as part of a claim for covered services under the PFS for claims-based reporting.
This same criterion is also applied to individual eligible professionals and group practices that chose to report via a registry although this data is not necessarily submitted via a claim. If the specified denominator codes for a measure are not included on the patient’s claim (for the same date of service) as submitted by the individual eligible professional, then the patient does not fall into the denominator population, and the PQRS measure does not apply to the patient. Likewise, if the specified denominator codes for a measure are not associated with a patient for an individual eligible professional or group practice submitting to a registry, then the patient does not fall into the denominator population, and the PQRS measure does not apply to the patient.
The PQRS is one of several long-term quality initiatives developed by the Centers for Medicare and Medicaid Services (CMS). It is intended to, among other things; obtain information on the quality of care across the healthcare system. Specifically, the program collects data submitted by Eligible Professionals (EP), on quality measures for covered services provided to Medicare part B fee for service (FFS) beneficiaries.
Some measure specifications are adapted as needed for implementation in PQRS in agreement with the measure steward. For example, CPT codes for non-covered services such as preventive visits are not included in the denominator. PQRS measure specifications include specific instructions regarding CPT Category I modifiers, place of service codes, and other detailed information. Each eligible professional and group practice should carefully review the measure’s denominator coding to determine whether codes submitted on a given claim or to a registry meet denominator inclusion criteria. If the patient does fall into the denominator population, the applicable Quality Data Codes or QDCs (CPT Category II codes or G-codes) that define the numerator should be submitted to satisfactorily report quality data for a measure for claims based reporting.
When a patient falls into the denominator, but the measure specifications define circumstances in which a patient may be appropriately excluded, CPT Category II code modifiers such as 1P, 2P and 3P or quality-data codes are available to describe medical, patient, system, or other reasons for performance exclusion. When the performance exclusion does not apply, a measure-specific CPT Category II reporting modifier 8P or quality-data code may be used to indicate that the process of care was not provided for a 4 Version 1.0 reason not otherwise specified.
Each measure specification provides detailed Numerator Options for reporting on the quality action described by the measure. Although a registry may or may not utilize these same QDCs, the numerator clinical concepts described for each measure are to be followed when submitting to a registry. G-codes that are associated with billable charges and found within the denominator, within this reporting program, are referred to as HCPCS coding. G-codes that describe clinical outcomes or results and are found within the denominator or numerator are described as QDC’s. For eligible professionals reporting individually, PQRS measures (including patient-level measure[s]) may be reported for the same patient by multiple eligible professionals practicing under the same Tax Identification Number (TIN). If a patient sees multiple providers during the reporting period, that patient can be counted for each individual NPI reporting if the patient encounter(s) meet denominator inclusion.
The following is an example of two provider NPIs (National Provider Identifiers), billing under the same TIN who are intending to report PQRS Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy. Provider A sees a patient on February 2, 2016 and prescribes an aspirin and reports the appropriate quality-data code (QDC) for measure #6. Provider B sees the same patient at an encounter on July 16, 2016 and verifies that the patient has been prescribed and is currently taking an aspirin. Provider B must also report the appropriate QDCs for the patient at the July encounter to receive credit for reporting measure #6.
Eligible professionals reporting under a group practice selecting to participate in the PQRS group practice reporting option (GPRO) under the same Tax Identification Number (TIN), should be reporting on the same patient, when instructed within the chosen measure. For example, if reporting measure #130: Documentation of Current Medications in the Medical Record all eligible professionals under the same TIN would report each denominator eligible instance as instructed by this measure. If the group practice chooses a measure that is required to be reported once per reporting period, then this measure should be reported at least once during the measure period by at least one eligible professional under the TIN. Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy is an example of a measure that would be reported once per reporting period under the TIN.