In general, quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined Medicare patient population which receives a particular process of care that is subsequently reported to Medicare. Only Medicare Part B patients should be included in PQRS data reported to CMS.
The denominator population is defined by certain ICD-10 and/or CPT Category I codes specified in the measure that are submitted by eligible professionals as part of a claim for covered services under the Medicare Physician Fee Schedule. Some measure coding specifications are adapted as needed for implementation in PQRS in agreement with the measure developer. For example, CPT codes for non-covered services such as preventive visits are not included in the denominator. If the specified denominator codes for a measure are not included in the patient's claim as submitted, then the patient does not fall into the denominator population, and the PQRS measure does not apply to that particular patient.
If the patient does fall into the denominator population, the applicable CPT Category II code (or temporary G-code, where CPT Category II codes are not yet available) that defines the numerator should be submitted. When a patient falls into the denominator population but specifications define circumstances in which a patient may be excluded from the measure's denominator population, CPT Category II code modifiers such as 1P are available to describe medical, patient, system, or other reasons for such exclusion.
To successfully report quality data for a measure under the PQRS program, it is necessary in all circumstances to report numerator coding (CPT Category II code and/or G-code), with or without an applicable CPT Category II code modifier. Instructions specific to each measure (available in the measure specifications) provide additional reporting information and details on what the measure is intended to accomplish.
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically (e.g. once per year).
The measure specifications are organized to provide the following information:
- Measure title
- Reporting option available
- Measure description
- Instructions on reporting including frequency, timeframes, and applicability
- Denominator definition and coding
- Numerator definition and coding
- Rationale statement for measure
- Clinical recommendations or evidence forming the basis or supporting criteria for the measure
Domains of Care
Beginning in 2014, PQRS includes requirements for domains of care, which have been assigned through the National Quality Strategy (NQS). Each measure has been assigned a domain. If a provider or a practice is using individual measures, at least nine measures covering at least three domains of care must be reported in order to earn the incentive. The domains associated with PQRS measures are:
- Patient Safety
- Person and Caregiver-Centered Experience and Outcomes
- Communication and Care Coordination
- Effective Clinical Care
- Community/Population Health
- Efficiency and Cost Reduction
Additionally, at least one cross-cutting measure must be included in the 9 measures used. There are 23 such measures from which to choose, and many are already on the AUA's list of recommended measures.
Individual measures are exactly what they sound like—one specific condition which a provider must assess for each applicable patient. Most urologists opt to report via individual measures. CMS assigns each measure to a domain of care.
In 2016, PQRS participants must report on at least nine measures covering at least three domains of care to avoid the payment adjustment (penalty). At least one of the nine measures must be a cross-cutting measure.
Attached are two lists which will help you successfully participate in the 2016 Physician Quality Reporting System (PQRS).
- A list of 20 individual measures that the AUA believes would be easiest for urology practices to report.
- A list of measures which the Centers for Medicare & Medicaid Services (CMS) believes the "typical" urologist should be able to report for PQRS. You will note many similarities to the AUA's list.
If you are searching for another measure that is not contained on these lists, here is a list of all possible 2016 PQRS measures that are also available.
Measures groups reporting involves selecting a CMS-designated specified group of measures with a common denominator set that cover one patient condition and reporting on a representative set of 20 consecutive patients for all these measures. While you only need to report on 20 patients, you must report each measure in the measure group (typically five to six) for each one of your 20 patients. If you select to use a measures group, you must report via a registry.
None of the measures groups directly pertain to the services normally provided by urologists. However, some urologists have had success using the Preventive Care group and the Chronic Kidney Disease group. Access a list of all 2016 PQRS measures groups.
Group Reporting Option (GPRO)
Group Reporting Option (GPRO) is a reporting option available to group practices; however, the definition of a "group practice" changed in the 2013 PQRS regulations. The new definition of a physician group practice, as defined by a single Taxpayer Identification Number (TIN), that has 2 or more individual eligible professionals (as identified by individual National Provider Identifiers or NPIs) who have reassigned their billing rights to the TIN.
The group practice must have registered to participate in PQRS through GPRO by June 30, 2016, and be selected by CMS to participate in the GPRO reporting option.
Group practices with 25 or more eligible professionals (EPs) may participate in GPRO using the PQRS web interface, a qualified registry, a Qualified Clinical Data Registry (QCDR) or electronic health record (EHR) reporting. Those with less than 25 EPs may use either a qualified registry, a Qualified Clinical Data Registry (QCDR) or EHR reporting. Additionally, practices with less than 100 EPs may couple measure reporting with use of CAHPS for PQRS. Choosing this option allows practices to substitute CAHPS for three measures. In other words, these practices would report 6 measures (covering two domains of care) and CAHPS for PQRS. All practices with over 100 EPs must use CAHPS for PQRS in addition to their other reporting.
NOTE: A practice should ensure that is it able to report on the measures included in the GPRO web interface. If it cannot, the practice will fail and be subject to the payment adjustment (penalty).
Read more information on GPRO [pdf].