CMS Pub. 100-22, ch. 1, § 20.3

Prior to 2010, the Physician Quality Reporting System was limited to eligible professionals and

the determination of whether an eligible professional satisfactorily reported quality data was

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made at the individual professional level, based on the National Provider Identifier (NPI). No

incentive payments were made to a group practice based on a determination that the group

practice, as a whole, satisfactorily reported the Physician Quality Reporting System quality

measure data. To the extent that individual eligible professionals (based on individuals’ NPIs)

are associated with more than one practice, or Tax Identification Number (TIN), the

determination of whether an eligible professional satisfactorily reported the Physician Quality

Reporting System quality measures data was made for each unique TIN/NPI combination.

Therefore, the incentive payment amount was calculated for each unique TIN/NPI combination

and payment was made to the holder of the applicable TIN (see §30 below).

As required by the MIPPA, group practices can qualify to earn a Physician Quality Reporting

System incentive payment beginning with the 2010 Physician Quality Reporting System based

on the determination that the group practice, as a whole, satisfactorily reports Physician Quality

Reporting System quality measures data. The criteria for satisfactory reporting for group

practices and the process for reporting by group practices under the Physician Quality Reporting

System group practice reporting option (GPRO) are discussed in §70.3 below. In 2010,” group

practice” was defined as a TIN with at least 200 individual eligible professionals (as identified

by NPIs) who have reassigned their billing rights to the TIN.

In 2011, the GPRO was expanded to include a second, smaller GPRO classification, GPRO II.

Thus, whereas GPRO I consists of group practices comprised of a TIN with at least 200

individual eligible professionals, under GPRO II, a “group practice” is defined as a TIN with 2-

199 eligible professionals. Therefore, in 2011, due to the addition of the GPRO II to the

Physician Quality Reporting System, for purposes of this reporting option, “group practice” was

defined as a TIN with at least 2 individual eligible professionals (as identified by NPIs) who

have reassigned their billing rights to the TIN.

In 2012, the definition of GPRO was further revised. First, the GPRO II option, along with its

reporting requirements, was eliminated. In lieu of GPRO II, the GPRO (classified as GPRO I in

2011) was extended to group practices comprised of a TIN with at least 25 or more eligible

professionals. Therefore, effective beginning January 1, 2012, “group practice” is defined as a

TIN with at least 25 eligible professionals (as identified by NPIs) who have reassigned their

billing rights to the TIN.

In order to participate in the Physician Quality Reporting System GPRO, group practices are

required to complete a self-nomination process and to meet certain specified requirements, which

include but are not limited to:

• Indicating group size to determine eligibility to participate in the GPRO

• Agreeing to attend and participate in all mandatory training sessions;

• Have billed Medicare Part B during a specified timeframe;

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• Providing CMS with an electronic file (such as, a Microsoft® Excel file) with the self-nomination statement that includes the group practice’s TIN and all rendering individual

NPI numbers, and name of the group practice;

• Providing a single point of contact for handling administrative issues as well as a single

point of contact for technical support purposes; and

• If desired, indicating the group practice’s participation in the eRx Incentive Program for

the applicable program year with either the intended reporting method or, if applicable, a

request for a hardship exemption from the applicable eRx payment adjustment.

The specific self-nomination requirements for the Physician Quality Reporting System GPRO

for a particular program year can be found in the Group Practice Reporting Option section of the

CMS Physician Quality Reporting System website at http://www.cms.gov/PQRS.

CMS assesses whether the participation requirements are met by each self-nominated group

practice and notifies group practices of a decision. Under section 1848(m)(3)(C)(iii) of the Act,

an individual eligible professional who is a member of a group practice selected to participate in

the Physician Quality Reporting System GPRO for a particular program year is not eligible to

separately earn a Physician Quality Reporting System incentive payment as an individual eligible

professional under that same TIN (that is, for the same TIN/NPI combination) for that year.

Once a group practice (TIN) is selected to participate in the GPRO for a particular program year,

this is the only Physician Quality Reporting System reporting option available to the group and

all individual NPIs who bill Medicare under that group’s TIN for that program year.