Healthcare Training: Different PQRS Reporting Mechanisms


Some of the things you're going to have to consider in Physician Quality Reporting System are what type of reporting mechanism that you're going to utilize. The most predominantly used is the claims-based reporting method. And this is where you are when you submit your charges to Medicare. You're also submitting the quality data codes.

The problem with the whole claims-based reporting is that Medicare wants to do away with it. Their intention is to possibly eliminate it. The Obama administration with the passage of the American Recovery and Reinvestment Act had a section called the HITECH Act. And through that, they are looking to computerize all medical records within the next five years.

They want to adapt electronic health records. One of the things the office HHS, they're new office that was created by the HITECH Act is entitled the Office of the National Coordinator for Health Information Technology.

They issued a Federal Regulation in the code or in the CFR and they define the meaningful use here recently. For those electronic medical record vendors, they're basically going to have to be able to submit these Physician Quality Reporting System data quality measures. They're also going to have to be able to submit claims from the electronic health record in order for them to be considered a qualified EHR. So, a lot is changing there.

Mar 31, 2019
Kelly Dennis

There's also a new group practice reporting option in which basically you have to nominate yourself as a group to CMS to participate, to practice with this. There is a pre-populated data collection tool that they send to you and it's based on whatever your patient population is. But you have to have more than 200 physicians in your group practice in order to participate with this and the details are located on the website.

For the individual PQRS, earlier PQRI, measures which most practices will be actually reporting, still doing it from the claims-based reporting. When you open up the 2010 Measure Specification Manual for Claims and Registry Reporting of Individual Measures and Release Notes, you'll notice for each of the measures, it will tell you whether it is reportable by claim, that's the “C”, or if it has to be reported by a registry or if you can do it with either/or.

You may also choose to report for a measure's group. This is a grouping of measures that you report together. So there are maybe, for example, the back pain measures. There are four individual quality measures that are grouped together in these PQRS measures group. Once again, you can look at the measure group specifications manual and see whether or not you can report those via your claims or via a registry as well.

And here we see the alternative electronic health record reporting option. There is a list of vendors located on the website under this alternative reporting mechanism link. And you'd have to use one of those vendors that are approved by CMS or qualified by CMS. And then, there are only ten measures that are available for reporting through the electronic health records. So, that's something you want to do this year, you're able to do it.

Once again, the reporting methods are different. You may choose to report these individual measures. To be successful with the individual measures in the claims-based method, you are looking at reaching 80% threshold on at least three measures.

So, you have to successfully report at least 80% of the time on the three measures. If you fall below that and you feel that there are not at least three measures that are applicable to your practice, then you report on what you can but you're going to be subject to a validation process and we'll discuss that a little bit later.

Similar to the registry base 80% on three options. With the registry-based reporting, there is no option if you fail to document at least or report on three applicable measures for your practice.

The measure groups as we discussed earlier, there are 13 groups of measures totaling 82 individual measures. And they basically all focus on the same condition. You've got diabetes. You've got chronic kidney disease, coronary artery bypass graft, rheumatoid arthritis, back pain, hepatitis C. You have the CAP measures, heart failure, CAD and IVD and HIV/AIDS. So if these are applicable to your practice, to your specialty, you may consider you choosing one of these groups to report on.

And the focus of having these groups is obviously one of two things -- perioperative care and preventive care and looking for a good patient outcome and improving the quality goals within your practice.

There is, once again, a separate measure group specification manual different from the individual measure groups manual. Make sure you are aware of that. It tells you how, of course, to successfully report for those measures groups.

You have three options there. You can have one measures group for 30 unique patients. It used to be consecutive patients, but this year they drop that because it was a burdensome to the providers. But you can choose 30 unique patients to report on.

Or you have an 80% on one measures group with a minimum of 15 patients, if you choose to do a 12-month reporting. If you choose to go with a six-month starting in July through December 31st, you can choose 80% on eight or more unique patients.

So, if you're new to all of these, how do you go about getting involved? Well, you need to review the list. There is a 2010 PQRI measures list and it has all 179 quality measures. It also contains the changes that are involved with the current measures. But you would first start with going through and perusing through that list to see which one is maybe applicable to your practice.

The release notes are important if you've already been participating to make sure that you're looking at any changes that have taken place. For example, for 2010, they retired four measures. You can also see the ultimate list of all the measures that have been ultimately retired since the program started in 2007.

We see also the new measures that were added. You had about 30 measures and these are some of the areas that they basically cover -- number of measures for functional communication, there's a number of measures for CAD, heart failure, et cetera.

In order to select measures, you want to go through that measure specification manual and pay close attention to the denominator, also to the instruction section. And you want to consider for your own particular practice, how applicable is it to your practice. What are the common conditions that you treat at your facility or at your location?

For example, we do billing for a lot of urging care groups. And the actual denominator code that they submit is just your outpatient E/M code. When you go and then look at all the measures that would be applicable for the outpatient E/M code, it's massive. And not all of those are really applicable in an urging care setting.

So, you want to look at those that are applicable. For example, pneumonia might be a common thing that is treated in the urging care setting. So common conditions, what's the usual treatment that you're providing? What's the typical place of service? And what are your improvement goals within your own group?

For more Physician Quality Reporting System updates and information, visit our CMS PQRS Page.

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