CMS PQRS: Claims-based Reporting vs. Registry Reporting


The measure group consists four or more related measures that's created by CMS' streamline reporting. The specialties are involved in creating the measures group. If there's not a physician quality reporting measures group for your specialty, you need to get your academy involved with CMS to get them to help create a measures group for your specialty.

Right now, there are only 14 PQRS measures groups. And as you know, the measures group don't necessarily cover every specialty. For example, if you are a urology group, what measures group are you going to use?

If you are an otolaryngology group, you would have thought, “Oh, yay! I got asthma. I can use that.” But asthma is not going to be really applicable because how many patients between five and 50 are going to have asthma and also be a Medicare patient? That became a problematic measures group because through 2010, you only needed two Medicare patients. The rest of them didn't have to be Medicare patients.

But as of now, they changed the requirement and all 30 patients have to be Medicare patients. And although there's preoperative care, the preoperative care within the denominator limits the CPT code in which you're able to use the preoperative care and it's not for every type of surgery that may be done. So it's limited to specific CPT codes that may be done for the surgeries. So it's not for every surgery that may be done.

Mar 26, 2019
Duane C. Abbey

Back pain is a great one for orthopedics or neurosurgery. So that's a great example if you are in orthopedics or neurosurgery. If you are in a primary care, preventative care is terrific. If you're in primary care taking care of diabetes mellitus, it's great. Taking care of coronary artery disease, it may actually be as applicable to you as it is to a cardiologist. If you're in infectious disease, obviously taking care of HIV Aids is going to be applicable to you.

So what's really important is, if there's not a measures group that's applicable to you and you want to be able to do it the easy way which is doing a registry-based PQRS measures group, when you only have to report on 30 patients after the fact, you don't have to do it while you're doing your claims. You just need to pull 30 charts.

You run your practice management and say, “I need 30 patients with these diagnoses,” and you need to pull 30 charts and do it after the fact and do it with your registry which is the easiest way to do PQRS reporting but you can't do it because there's not a measures group that applies to you, you need to get your specialty society, your American Academy or your College-of to work with CMS to create a measures group.

You need to get that created and proposed to CMS so that you in 2012 can be able to do registry-based reporting using a measures group.

If you see your denominator medical coding has been modified, your eligible professional must inform CMS their intention to report measures reporting using the QDC. So if you're intending to report G8485 using a measures group, this is if you're reporting individual measures reporting using a measures group, you actually use a G8485 which means you intend to report the diabetes mellitus measures group using claim-based reporting.

That's when you're doing the measures group the hard way. You're doing measures group via claim-based reporting. If you're using a measures group, why aren't you using a registry which is the easy way?

Because you are 50% of your patients is way more than 30 patients, you are sure that what's going to happen if by mistake you only successfully report on 45% of your patients and therefore you are not a successful CMS PQRS reporter? Whereas, it's way easier to do 30 patients.

Because you know what happens is if you're doing 30 patients through a registry and one of them is not accurate and there's a problem with one of them, the registry gets back to you before they have to report to CMS. And you make all your corrections that you need to do.

And so the registry makes sure you have 30 good clean patients before it goes to Medicare. And then you know you're going to be a successful measures group reporting via registry.

Claim-based thresholds

If you're doing claim-based, you have two methods. The three-sample is 12 months if you're doing registry. This is not claim-based. This is registry. This is registry-based, 30 patients for your 12 months or 80% if you're doing individual measures, not measures groups on your 12 months.

The advantage of doing the 80% versus the 50% is if you messed up and you didn't submit everything with your claims, you submit it with your registry, your registry enables you to do it after the fact. Your registry scrubs it for you and your registry makes sure you have 80% where your claim doesn't do any of that for you. Your healthcare coding claims have to be concurrently when you're doing your claims. Your claim doesn't make sure you have 50% successful.

Your registry lets you do it after the fact and your registry makes sure you meet your 80%. So that's the difference between the two.

So you have your 6-month or your 12-month. So if you're doing six months, you would have 15 patients instead of 30 patients. And then for PQRS measures groups, there's a flowchart again that comes from Medicare. You also have EHR reporting which. You have to use a qualified EHR vendor. You can only do 12-month reporting period and the qualified data submitted has to be at least three measures and it has to be 80% of applicable patients.

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