CMS Pub. 100-22, ch. 1, § 50.2

Beginning in 2008, Individual eligible professionals may choose to participate in the Physician

Quality Reporting System via the registry-based reporting mechanism. Eligible professionals who

choose to participate in the Physician Quality Reporting System via the registry-based reporting

mechanism do not have to enroll or register to begin registry-based reporting of Physician Quality

Reporting System quality measures data to CMS. However, to report Physician Quality Reporting

System quality measures data via the registry-based reporting mechanism, an eligible

professional must select a registry qualified under the Physician Quality Reporting System for

the program year and enter into and maintain an appropriate legal arrangement with the selected

registry. Such arrangements should provide for the registry’s receipt of patient-specific data

from the eligible professional and the registry’s disclosure of quality measures results and

numerator and denominator data on Physician Quality Reporting System quality measures or

measures groups on behalf of the eligible professional to CMS. An eligible professional

choosing the registry-based reporting mechanism must submit information on Physician Quality

Reporting System individual quality measures or measures groups to his or her selected registry

in the form and manner and by the deadline specified by the registry. Thus the registry would

act as a Health Insurance Portability and Accountability Act of 1996 (Pub. L.104-191) (HIPAA)

Business Associate and agent of the eligible professional. Such agents are referred to as “data

submission vendors.” The “data submission vendors” would have the requisite legal authority to

provide clinical quality measures results and numerator and denominator data on individual

quality measures or measures groups on behalf of the eligible professional for the Physician

Quality Reporting System.

CMS qualifies registries to participate in each program year through a self-nomination process.

Registries that were qualified to submit data on behalf of eligible professionals in a prior

program year are not required to go through the qualification process again unless they were

unsuccessful at submitting Physician Quality Reporting System data for the prior program year

by the registry’s data submission deadline or CMS makes changes to the registry qualification

requirements. The final list of qualified registries for a particular program year is made available

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

The list is usually made available in the summer of the program year in question. For example,

the list of qualified registries for the 2008 Physician Quality Reporting System was made

available in the summer of 2008.