2016 Physician Quality Reporting System(PQRS)Measure Specification and Measure Flow Guidefor Claims and Registry Reporting of IndividualMeasuresUtilized by Individual Eligible Professionals for Claims and Registry Reporting andClinical Practices Participating in Group Practice Reporting Option (GPRO) forRegistry Reporting11/17/151Version 1.0

IntroductionThis document contains general guidance for the 2016 Physician Quality Reporting System (PQRS) IndividualMeasure Specifications and Measure Flows for claims and registry reporting. The individual measure specificationsare detailed descriptions of the quality measures and are intended to be utilized by individual eligible professionalsreporting individual measures via claims or registry and by group practices reporting via registry for the 2016Physician Quality Reporting System (PQRS). In addition, each measure specification document includes ameasure flow and associated algorithm as a resource for the application of logic for reporting and performance.Please note that the measure flows were created by CMS and may or may not have been reviewed by theMeasure Steward. These diagrams should not be used in place of the measure specification but may be used asan additional resource.Reporting Mechanism for Individual Measures to Avoid the 2018 Negative Payment AdjustmentReport on at least 9 individual measures covering 3 National Quality Strategy (NQS) domains for at least 50% ofdenominator eligible Medicare Part B FFS patients. Individual eligible professionals (EPs) (and group practices for registry reporting) that submitquality data for only 1 to 8 PQRS measures covering 3 NQS domains for at least 50% of theindividual EP’s denominator eligible Medicare Part B FFS patients OR that submit data for 9 ormore PQRS measures covering less than 3 domains for at least 50% of the individual EP’sMedicare Part B FFS patients eligible for each measure will be subject to Measure-ApplicabilityValidation (MAV). (See 2016 PQRS Measure Applicability Validation (MAV) Process for Claimsand Registry-Based Reporting of Individual Measures within CMS Analysis and Payment Guide) Measures with a 0% performance rate will not be counted An EP that sees at least 1 Medicare patient in a face-to-face encounter must report a minimum of1 cross-cutting measure. (See 2016 PQRS List of Face-To-Face Encounter Codes within PQRSMeasures Codes)The PQRS Individual Measure Specifications for Claims and Registry Reporting may not be utilized for otherreporting mechanisms. Below outlines which measure specifications can be utilized for the other reportingmechanisms and where they can be found. Qualified Clinical Data Registries (QCDRs) can utilize the PQRSIndividual Measure Specifications for Claims and Registry Reporting as well as other measure specificationsoutlined below. Measure specifications for measures groups reporting are included in a separate manual, “2016 PhysicianQuality Reporting System Measures Groups Specifications Manual,” which can be accessed at: PQRSMeasures CodesGroup practices electing to participate in the PQRS group practice reporting option (GPRO) reportingPQRS via GPRO Web-Interface may access the GPRO Web Interface Narrative Specifications andsupporting documents at: GPRO Web InterfaceMeasure specifications for electronic health record (EHR) based reporting should access the electronicclinical quality measures (eCQMs) at: CMS Clinical Quality Measures BasicsInformation regarding CG-CAHPS may be found at: CAPHS Survey Information (Please note that this linkis directed to the Accredited Care Organization webpage.)2Version 1.0

PQRS Individual Measure SpecificationsEach measure is assigned a unique number. Measure numbers for 2016 PQRS represents a continuation innumbering from the 2015 measures. For 2016 PQRS measures that are continuing forward in the 2016 PQRS,measure specifications have been updated. In addition to the individual measure specifications documents and thisguide, please refer to the “2016 Physician Quality Reporting System Implementation Guide” for additionalinformation essential in assisting eligible professionals’ understanding and submission of measures. This documentcan be accessed at: PQRS Measures Codes.Eligible ProfessionalsEligible professionals submitting billable services on Part B claims for allowable Medicare Physician Fee Schedule(PFS) charges may report the quality action for selected PQRS quality measure(s). Providers not defined aseligible professionals are not eligible to participate in PQRS. A list of eligible professionals can be found on thePQRS website at: How to Get Started with PQRS.Frequency and Performance TimeframesThe measure instructions limit the frequency of reporting necessary in certain circumstances, such as for patientswith chronic illness for whom a particular process of care is provided only periodically. Each individual eligibleprofessional or group practices participating in 2016 PQRS should report according to the frequency and timeframelisted within each measure specification.Denominator Codes (Eligible Cases) and Numerator Quality-Data CodesQuality measures consist of a numerator and a denominator that permit the calculation of the percentage of adefined patient population that receive a particular process of care or achieve a particular outcome. Thedenominator population may be defined by demographic information, certain International Classification ofDiseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis, Current Procedural Terminology (CPT) andHealthcare Common Procedure Coding System (HCPCS) codes specified in the measure that are submitted byindividual eligible professionals as part of a claim for covered services under the PFS for claims-basedreporting. This same criterion is also applied for individual eligible professionals and group practices that chose toreport 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 ofservice) as submitted by the individual eligible professional, then the patient does not fall into the denominatorpopulation, and the PQRS measure does not apply to the patient. Likewise, if the specified denominator codes fora measure are not associated with a patient for an individual eligible professional or group practice submitting to aregistry, then the patient does not fall into the denominator population, and the PQRS measure does not apply tothe patient. Some measure specifications are adapted as needed for implementation in PQRS in agreement withthe measure steward. For example, CPT codes for non-covered services such as preventive visits are not includedin the denominator.PQRS measure specifications include specific instructions regarding CPT Category I modifiers, place of servicecodes, and other detailed information. Each eligible professional and group practice should carefully review themeasure’s denominator coding to determine whether codes submitted on a given claim or to a registry meetdenominator inclusion criteria.If the patient does fall into the denominator population, the applicable Quality Data Codes or QDCs (CPT CategoryII codes or G-codes) that define the numerator should be submitted to satisfactorily report quality data for ameasure for claims based reporting. When a patient falls into the denominator, but the measure specificationsdefine circumstances in which a patient may be appropriately excluded, CPT Category II code modifiers such as1P, 2P and 3P or quality-data codes are available to describe medical, patient, system, or other reasons forperformance exclusion. When the performance exclusion does not apply, a measure-specific CPT Category IIreporting modifier 8P or quality-data code may be used to indicate that the process of care was not provided for a3Version 1.0

reason not otherwise specified. Each measure specification provides detailed Numerator Options for reporting onthe quality action described by the measure. Although a registry may or may not utilize these same QDCs, thenumerator 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 thedenominator or numerator are described as QDC’s.For eligible professionals reporting individually, PQRS measures (including patient-level measure[s]) may bereported 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 individualNPI reporting if the patient encounter(s) meet denominator inclusion. The following is an example of two providerNPIs (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 andprescribes an aspirin and reports the appropriate quality-data code (QDC) for measure #6. Provider B sees thesame patient at an encounter on July 16, 2016 and verifies that the patient has been prescribed and is currentlytaking an aspirin. Provider B must also report the appropriate QDCs for the patient at the July encounter to receivecredit for reporting measure #6.Eligible professionals reporting under a group practice selecting to participate in the PQRS group practice reportingoption (GPRO) under the same Tax Identification Number (TIN), should be reporting on the same patient, wheninstructed within the chosen measure. For example, if reporting measure #130: Documentation of CurrentMedications in the Medical Record all eligible professionals under the same TIN would report each denominatoreligible instance as instructed by this measure.If the group practice choses a measure that is required to be reported once per reporting period, then this measureshould 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 bereported once per reporting period under the TIN.CMS recommends review of any measures that an individual eligible professional or group practice intend toreport. Below is an example measure specification that will assist with satisfactorily reporting. For additionalassistance please contact the QualityNet Help Desk at the following:QualityNet Help Desk – Available Monday – Friday; 7:00 AM–7:00 PM CSTPhone: 1-866-288-8912Email: [email protected] Specification Format (Refer to the Example Measure Specification Below)Measure title and domainReporting option available for each measure (claims-based and/or registry)Measure descriptionInstructions on reporting including frequency, timeframes, and applicabilityDenominator statement and codingNumerator statement and coding optionsDefinition(s) of terms where applicableRationale statement for measureClinical recommendations or evidence forming the basis for supporting criteria for the measureThe Rationale and Clinical Recommendation Statements sections provide limited supporting information regardingthe quality actions described in the measure. Please contact the measure owner for section references and furtherinformation regarding the clinical rational and recommendations for the described quality action. Measure owner4Version 1.0

contact information is located on the last page of the Measures List document, which can be accessed at: PQRSMeasures Codes.CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of theAmerican Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative valueunits, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and theAMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medicalservices. The AMA assumes no liability for data contained or not contained herein.5Version 1.0

Example Individual Measure Specification:6Version 1.0

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Interpretation of Individual Measure FlowsDenominatorThe Individual Measure Flows are designed to provide interpretation of the measure logic and calculationmethodology for reporting and performance rates. The flows start with the identification of the patient population(denominator) for the applicable measure’s quality action (numerator). When determining the denominator for allmeasures, please remember to include only Medicare Part B FFS patients and CPT I Categories without modifiers80, 81, 82, AS or TC.Below is an illustration of additional prerequisite denominator criteria to obtain the patient sample for all2016 PQRS Individual Measures:10Version 1.0

The Individual Measure Flows continue with the appropriate age group and denominator population for the measure.The Eligible Population box equates to the letter “d” by the patient population that meets the measures inclusionrequirements. Below is an example of the denominator criteria used to determine the eligible population for PQRS #6NQF # 0067: Coronary Artery Disease (CAD): Antiplatelet Therapy:11Version 1.0

Some measures, such as Measure #5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor orAngiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD), have multiple options todetermine the measure denominator. Patients meeting the criteria for either denominator option are included as part ofthe eligible population.12Version 1.0

NumeratorOnce the denominator is identified, the flow illustrates and stratifies the quality action (numerator) for reportingsatisfactorily. Depending on the measure being reported, there are several outcomes that may be applicable forreporting the measures outcome: Performance Met “a”/green, Performance Exclusion “b”/yellow, Performance NotMet “c”/gray, and Not Reported red box. On the flow, these outcomes are color-coded and labeled to identify theparticular outcome of the measure represented. This is illustrated below for PQRS #6 NQF # 0067: Coronary ArteryDisease (CAD): Antiplatelet Therapy:13Version 1.0

Denominator/Numerator Variation of Claims-Based vs. Registry-Based ReportingFor some measures reportable via claims and registry, two Individual Measure Flows may be included. Thedenominator for the registry-based Individual Measure Flow may differ slightly from the denominator as outlined inthe 2016 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures. Somemeasures, such as Measure #19, have a clarifying code and/or language (e.g. G-code G8397 for Measure #19) inthe numerator to identify eligible patients when no CPT I or ICD-10 diagnosis code exists. In the case of Measure#19, an applicable CPT I code does not exist for Dilated macular or fundus exam performed, including documentationof the presence or absence of macular edema AND level of severity of retinopathy. In claims-based reporting, aneligible professional would report the numerator code G8397 to identify patients who had a dilated macular or fundusexam with documentation of the results. To comply with the measure developer’s intent of the measures and sinceregistries may not necessarily be reliant on claims data; the flow shows these numerator codes in the denominator.Therefore the numerator quality-data code options for registry-based flows may vary from the 2016 PQRS MeasureSpecifications Manual for Claims and Registry Reporting of Individual Measures.Reporting and Performance AlgorithmsReporting AlgorithmThe Reporting Algorithm is based on the eligible population and sample outcomes of the possible quality actions asdescribed in the flow of the measure. Avoiding the 2018 PQRS Payment Adjustment is based on reportingsatisfactorily for PQRS by reporting on at least 50% of the eligible patients for the measure. The Reporting Algorithmprovides the calculation logic for patients who have been reported in the eligible professionals’ appropriatedenominator. Reporting satisfactorily may include the following categories provided in the numerator: PerformanceMet, Performance Exclusion, and Performance Not Met. Below is a sample reporting rate algorithm for Measure #6.In the example, 8 patients met the denominator criteria for eligibility, where 4 patients had the quality actionperformed (Performance Met), 1 patient did not receive the quality action for a documented reason (PerformanceExclusion), and 2 patients were reported as not receiving the quality action (Performance Not Met). Note: In theexample, 1 patient was eligible for the measure but was not reported (Reporting Not Met).Reporting Rate Performance Met (a 4 patients) Performance Exclusion (b1 b2 b3 1 patients) Performance Not Met (c 2 patients) 7 patients 87.50%Eligible Population / Denominator (d 8 patients) 8 patientsPerformance AlgorithmThe Performance Algorithm calculation is based on only those patients that were reported for the measure. For thosepatients reported, the numerator is determined by completing the quality action as indicated by Performance Met.Meeting the quality action for a patient, as indicated in the Individual Measure Specifications Manual, would add onepatient to the denominator and one to the numerator. Patients reporting with Performance Exclusions are subtractedfrom the performance denominator when calculating the performance rate percentage. Below is a sampleperformance rate algorithm that represents this calculation for Measure #6. In this scenario, the patient sampleequals 7 patients where 4 of these patients had the quality action performed (Performance Met) and one patient wasreported as having a Performance Exclusion.Performance Rate Performance Met (a 4 patients) Reporting Numerator (7 patients) – Performance Exclusion (b1 b2 b3 1 patient) 4 patients 66.67%6 patientsFor measures with inverse performance rates, such as Measure #1 Diabetes: Hemoglobin A1c Poor Control, a lowerrate indicates better performance. Reporting the Performance Not Met is actually the clinically recommendedoutcome or quality action.There are some measures that require the calculation of multiple performance rates. The Individual Measure Flow forthese measures includes algorithm examples to understand the different reporting and performance rates requiredfor the measure. Please note, only the performance rates outlined in the measure specification are to be submitted14Version 1.0

for registry submissions. The PQRS system will calculate an overall performance rate for the measure if none isspecified within the measure.Measure Analytical Reporting Frequency DefinitionsAnalytical reporting frequency labels are provided for each measure. The analytical reporting frequency defines thetime period or event in which the measure should be reported. Below are definitions of the analytical reportingfrequencies that are utilized for calculations of the individual measures: Patient-intermediate measures are reported a minimum of once per patient during the reporting period. The mostrecent quality-data code will be used, if the measure is reported more than once.Patient-process measures are reported a minimum of once per patient during the reporting period. The mostadvantageous quality-data code will be used if the measure is reported more than once.Patient-periodic measures are reported a minimum of once per patient per timeframe specified by the measureduring the reporting period. The most advantageous quality-data code will be used if the measure is reportedmore than once. If more than one quality-data code is reported during the episode time period, performancerates shall be calculated by the most advantageous quality-data code.Episode measures are reported once for each occurrence of a particular illness or condition during the reportingperiod.Procedure measures are reported each time a procedure is performed during the reporting period.Visit measures are reported each time a patient is seen by the individual eligible professional during thereporting period.15Version 1.0

3 Version 1.0 PQRS Individual Measure Specifications Each measure is assigned a unique number. Measure numbers for 2016 PQRS represents a continuation inFile Size: 2MBPage Count: 15Explore further2021 Quality Rating System Measure Technical Specificationswww.cms.govQuality Measures Fact Sheet - Centers for Medicare .innovation.cms.govPQRS Cheat Sheet - Practice Perfectpracticeperfectemr.comQuick reference guide for 2015 PQRS measures, procedure .www.apaservices.org2021 CMS Stars AND True Performance Measures CPT II .content.highmarkprc.comRecommended to you b