PQRS Claim-based Reporting

As discussed in previous post, PQRS reporting can be done using various methods:

  1. Claims-based
  2. Registry-based
  3. Qualified Electronic Health Record (EHR)
  4. Qualified Clinical Data Registry (QCDR)
  5. Group Practice Reporting Option (GPRO)

PQRS Claim-based reporting

The eligible professional must satisfactorily report on 50% of eligible instance for individual measure or 20 patients when reporting a measure group via claim to qualify for the incentive.

Claims Reporting Criteria

By meeting one of the following criteria for satisfactory reporting EPs (Eligible Professionals) may earn a PQRS incentive:

  1. Report on at least 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50% of the EP’s Medicare Part B FFS patients. EPs that submit quality data for only 1 to 8 PQRS for at least 50% of their patients or encounters eligible for each measure
  2. EPs that submit data for 9 or more PQRS measures across less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure-Applicability Validation (MAV)

MAV is a validation process to that helps EP or Group practice to now if they have to report additional measure or additional domain. In case of claim-based reporting MAV is applicable to individual provider. MAV only helps in avoiding PQRS penalty but does not help earning incentive.

Quality data reported to CMS through Medicare Part B claims (containing valid QDC line items for each individual professional’s NPI) are processed to final action by the Carrier or A/B MAC and subsequently transferred to the NCH where it is available for PQRS analysis. Quality measures data reported on claims denied for payment are not included in PQRS analysis. QDC line items from claims are analyzed according to the measure specifications, including coding instructions, reporting frequency, and performance timeframes.

CPT I codes, CPT 1 modifiers, CPT II (performance management), QDC codes (non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT Category II codes and/or G-codes (exclusive PQRS G-Codes)   used to indicated clinical action in numerator). CPT II modifiers (1P, 2P, 4P, 8P) are used for indicating denominator, numerator as required in each measure.

PQRS Claims-Based Measures for 2015

  • 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
  • 130 Documentation and Verification of Current Medications in the Medical Record
  • 131 Pain Assessment Prior to Initiation of Patient Treatment
  • 154 Falls: Risk Assessment
  • 155 Falls: Plan of Care
  • 182 Functional Outcome Assessment

Check if your PQRS reporting is successfully done with CMS

CMS Quality Net Help Desk can help you know if your reporting is successful or not. And we strongly urge you to verify with them at the following contact options.

Phone: 866-288-8912

Email: qnetsupport@sdps.org

For more extensive details regarding claims-based reporting click here.

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Meetu Sharma

Our in-house healthcare go-to person, who wishes to travel the world and beyond in the coming years!

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