PQRS Coding and Documentation Quick Reference Guide

2011 PHYSICIAN QUALITY REPORTING SYSTEM

Information for ACG Membership

The Patient Protection and Affordable Care Act (known as the Affordable Care Act or ACA) authorizes a 1% incentive payment for physicians, group practices, and other eligible professionals (EP) who successfully participate in the Physician Quality Reporting System (PQRS).  This was formerly known as the Physician Quality Reporting Initiative (PQRI).  The ACA made the program permanent.

It is important to note that in 2015 and beyond, a payment adjustment will apply if an EP does not satisfactorily submit data on PQRS quality measures. Future incentive payments and penalties are as follows:

Year Payment Adjustment
2011 1% Bonus Payment
2012 .5% Bonus Payment
2013 .5% Bonus Payment
2014 .5% Bonus Payment
2015 1.5% Cut (EPs unsuccessfully reporting PQRS measures)

No bonus payment for EPs who successfully report PQRS data.

2016 and beyond 2% Reimbursement Cut (EPs unsuccessfully reporting PQRS measures)

No bonus payment for those EPs who successfully report PQRS data.

The incentive payment amount is calculated using estimated Medicare Part B physician fee schedule allowed charges for all covered professional services, not just those charges associated with the reported quality measures. Allowed charges include the beneficiary deductible and coinsurance.

 

PQRS Measures and the GI Clinician

While ACG members may submit data on any 2011 PQRS quality measure, the chart below provides some quality measures potentially applicable to the GI clinician.

Please click here for a complete list of 2011 PQRS measures and the specifications of each measure:
2011 Quality Reporting Measures List

2011 PQRS Specification Manual for Claims and Reg Reporting

GI Quality Measure Claims-Based Reporting
(6 Month or 1 Year Reporting Option)
Registry-Based Reporting
(6 Month or 1 Year Reporting Option)
EHR-Based Reporting Method
(1 Year Reporting Option)
** See additional requirements below
Part of a Measures Group?
Hepatitis
C: Testing for
Chronic Hepatitis
C – Conformation
of Hepatitis C
Viremia
(PQRS Measure No. 83)
NO Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO NO
Hepatitis
C: Ribonucleic
Acid Testing
Before Initiating
Treatment
(PQRS Measure No. 84)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Hepatitis
C: HCV
Genotype
Testing Prior to
Treatment
(PQRS Measure No. 85)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Hepatitis C: Antiviral Treatment Prescribed
(PQRS Measure No. 86)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

 

GI Quality Measure Claims-Based Reporting
(6 Month or 1 Year Reporting Option)
Registry-Based Reporting
(6 Month or 1 Year Reporting Option)
EHR-Based Reporting Method
(1 Year Reporting Option)
** See additional requirements below
Part of a Measures Group?
Hepatitis
C: HCV
Ribonucleic Acid
Testing at Week
12 of Treatment
(PQRS Measure No. 87)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Hepatitis
C: Counseling
Regarding Risk
of Alcohol
(PQRS Measure No. 89)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Hepatitis
C: Counseling
Regarding Use of
Contraception
Prior to Antiviral
Therapy
(PQRS Measure No. 90)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Preventive
Care and
Screening:
Colorectal
Cancer and
Screening
(PQRS Measure No. 113)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
Yes
Report at least 3 measures
(measures with a 0%
performance rate will not be counted) and report on each measure for
at least 80% of the EP’s
Medicare Part B FFS
patients seen during the
reporting period to whom
this measure applies.
Yes. Preventive Care Measures Group.

Note: Different reporting requirements for measure groups (see below)

Health IT: Adoption/Use of Electronic Medical Records
(PQRS Measure No. 124)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
Yes
Report at least 3 measures
(measures with a 0%
performance rate will not be counted) and report on each measure for
at least 80% of the EP’s
Medicare Part B FFS
patients seen during the
reporting period to whom
this measure applies.
Preventive Care
and Screening:
Body Mass Index
Screening and
Follow-Up
(PQRS Measure No. 128)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
Yes
Report at least 3 measures
(measures with a 0%
performance rate will not be counted) and report on each measure for
at least 80% of the EP’s
Medicare Part B FFS
patients seen during the
reporting period to whom
this measure applies.
Yes. Preventive Care Measures Group.

Note: Different reporting requirements for measure groups (see below)

Documentation
and Verification
of Current
Medications in
the Medical
Record
(PQRS Measure No. 130)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO
Preventive Care
and Screening:
Unhealthy
Alcohol Use –
Screening
(PQRS Measure No. 173)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
Yes
Report at least 3 measures
(measures with a 0%
performance rate will not be counted) and report on each measure for
at least 80% of the EP’s
Medicare Part B FFS
patients seen during the
reporting period to whom
this measure applies.
Yes. Preventive Care Measures Group.

Note: Different reporting requirements for measure groups (see below)

Hepatitis
C: Hepatitis A
Vaccination in
Patients with
HCV
(PQRS Measure No. 183)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group
Hepatitis C: Hepatitis B Vaccinations in Patients with HCV
(PQRS Measure No. 184)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO Yes.  Hepatitis C Measures Group

Note: Different reporting requirements for measure groups (see below)

Endoscopy &
Polyp
Surveillance:
Colonoscopy
Interval for
Patients with a
History of
Adenomatous
Polyps –
Avoidance of
Inappropriate
Use
(PQRS Measure No. 185)
Yes
Report at least 3 measures,
or 1-2 measures if less than
3 measures apply to the
EP and report on each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to whom this measure applies.
Yes
Report at least 3 measures (measures with a 0% performance rate will not be counted) and report on each measure for at least 80% of the EPs Medicare FFS patients seen during the period to whom this measure applies
NO

PQRS and EHR Reporting

EPs wanting to report using an EHR, must also meet the following requirements:

  • have a PQRS qualified EHR product (a list will be released in early 2011);
  • have access to the identity management system specified by CMS to submit clinical quality data extracted from the EHR to a CMS clinical data warehouse;
  • submit a test file containing real or dummy clinical quality data extracted from the EHR to CMS clinical data via an identity management system specified by CMS;
  • submit a file containing the EPs 2011 PQRS clinical quality data extracted from the EHR for the entire reporting period via the CMS-specified identity management system during the timeframe specified by CMS in early 2012.

PQRS Measure Groups
In addition to reporting individual measures, the GI clinician has the option of reporting PQRS Measure Groups.  The reporting options for PQRS Measures Groups are quite limited for the GI clinician, with potentially the “Hepatitis C” or “Preventive Services” Measures Groups as two options.

For successful PQRS Measure Group submission, CMS sets a minimum patient number and percentage for Medicare fee for service patients,

For those GI clinicians choosing to submit PQRS Measure Group data via a qualified registry, beginning in 2011, CMS will require that the minimum number of patient numbers and percentages exclusively be Medicare Part B FFS patients.

For a complete list of 2011 PQRS Measure Groups and specifications please click on the following link.
2011 PQRS Measure Groups Manual

Reporting Mechanism

Reporting Criteria

  12 Months (Jan – Dec) Reporting Option 6 Months (July – Dec.) Reporting Option
Claims-Based Reporting Report at least 1 measures group and report each measure group for at least 30 Medicare FFS patients.

OR

Report at least 1 measures group and report each measures group for at least 50% of EPs Medicare FFS patients to whom this measure group applies during the reporting period and report at least 15 Medicare FFS patients.

Report at least 1 measures group and report each measures group for at least 50% of EPs Medicare FFS patients to whom this measure group applies during the reporting period and report at least 8 Medicare FFS patients.
Registry-Based Reporting
(through a qualified registry)
Report at least 1 measures group and report each measures group for at least 30 Medicare FFS patients

OR

Report at least 1 measures group and report each measures group for at least 80% of EP’s Medicare FFS patients to whom this measure group applies during the reporting period and report at least 15 Medicare FFS patients.

Report at least 1 measures group and report each measures group for at least 80% of EP’s Medicare FFS patients to whom this measure group applies during the reporting period and report at least 8 Medicare FFS patients.


PQRS and Group Practices
GI clinicians in group practices may also submit PQRS data collectively under two of the group practice reporting options (GPRO).  A group practice is defined by a taxpayer identification number (TIN) with 2 or more individuals assigning their national provider identifier (NPI) billing rights to a TIN.

GPRO 1 requires practices 200 or more members.  Practices must report on 26 PQRS measures and must inform CMS that it wishes to participate in the GPRO 1 reporting option.  Due to its reporting requirements, it is likely the GI clinician may participate in this option only if he/she is part of the multi-specialty practice.

For more information on the GPRO 1 option for 2011 please click on the following links:
2011 PQRS GPRO 1 Measures List

2011PQRSGPRO1Narrative Specifications

2011 PQRS GPRO 1 Self-Nomination Requirements

GPRO 2 requires practices 2-199 members.  This option is only a pilot program for 2011, initially for 500 group practices.  It is worth noting that the Hepatitis C Measures Group is not one of the four registry-only measures groups selected by CMS.  Practices participating in GPRO 2 may, however, report the Hepatitis C Measures Group via claims-based reporting.

GI practices wishing to participate in the GPRO 2 pilot program must self-nominate by January 31, 2011.  When self-nominating, the group must provide the following:

  • Name of the group
  • Group TIN
  • Email address of the contact person
  • Names of the NPIs of all EPs practicing under the group TIN
  • Electronic file with the group practice’s TIN and NPIs
  • PQRS reporting mechanism (claims or registry)
  • Indication of whether the group intends to report as a group for the E-prescribing (eRx) Incentive Program and the reporting mechanism for the eRx Incentive Program

Self-nomination letters should be sent to:
GPRO II
c/o CMS
7500 Security Blvd.
Mail Stop S3-02-01
Baltimore, MD 21244

GPRO 2 Reporting Requirements

Group Size No. of PQRS Measures Groups to report % of Medicare Part B patients in denominator for claims reporting % of Medicare Part B patients in denominator for registry reporting Minimum number of patients in each measure group Number of Required Individual PQRS Measures to Report Required No. of Unique Visits Where an e-Rx was Generated
2-10 1 50% 80% 35 3 75
11-25 1 50% 80% 50 3 225
26-50 2 50% 80% 50 4 475
51-100 3 50% 80% 60 5 925
101-199 4 50% 80% 100 6 1875

For more information on the GPRO 2 reporting option, please click on the following link:
2011 PQRS GPRO 2 Self-Nomination Requirements

Physician Compare Website
CMS is required by the ACA to establish a “Physician Compare” website by January 1, 2011.  CMS will use the current Physician and Other Health Care Professional Directory as a foundation for this “Physician Compare” website.

For 2011, CMS will post on the “Physician Compare” website the names of EPs (or group practices) who have successfully submitted PQRS data and are eligible for a PQRS bonus payment.

Beginning January 1, 2013, CMS is required to publish all publicly reported physician performance information, including information on those EPs who did not participate in PQRS or did not qualify for a PQRS bonus payment.

As noted above, PQRS participation becomes mandatory in 2015.

Maintenance of Certification Programs
CMS is also required by the ACA to establish a process by which an EP may submit quality measures through maintenance of certification (MOC) program operated by the American Board of Medical Specialties (ABMS). EPs participating in these programs are eligible for an additional 0.5% incentive payment for 2011-2014.

EPs must meet the following requirements:

  • EPs seeking the additional incentive payment must meet the PQRS reporting requirements based on a 12-month reporting period. EPs can use the full range of PQRS reporting available options and reporting mechanisms. Alternatively, EPs may satisfactorily submit PQRS data from an MOC program provided that it has qualified as a PQRS registry
  • The EP must have data submitted on his/her behalf through an MOC program. Although the MOC program need not become a qualified registry for data submission for PQRS purposes, it must meet the criteria for a qualified registry
  • The EP must, more frequently than is required to qualify for or maintain board certification, participate in a MOC program for a year and successfully complete a qualified MOC practice assessment.  The “more frequently” threshold applies to both the elements of the MOC program as well as the requirement to successfully complete a qualified MOC practice assessment.
  • EPs must participate in at least one practice assessment.
  • EPs who do not have an MOC program practice assessment through their boards are not eligible for the 0.5% bonus payment. MOC programs that wish to enable their members to be eligible for the additional incentive payment for 2011 will need to go through a self-nomination process by January 31, 2011.

For more information please contact:
Brad Conway
Vice President, Public Policy
American College of Gastroenterology
bconway@acg.gi.org