CMS Pub. 100-22, ch. 1, § 70.1.1

Measures for Claims-based Reporting

(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

As discussed in §60 above, eligible professionals have the option of reporting on individual

quality measures or on measures groups. The criteria for determining whether an eligible

professional satisfactorily reports data on Physician Quality Reporting System quality measures

for reporting individual quality measures are different from the criteria for satisfactory reporting

of measures groups.

To qualify for a Physician Quality Reporting System incentive payment through claims-based

reporting of individual measures prior to the 2011 program year, each eligible professional must

meet the following criteria for satisfactory reporting during the applicable reporting period:

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• Report at least 3 Physician Quality Reporting System measures for the relevant program

year, or 1-2 measures, if less than 3 measures apply to an eligible professional; and

• Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the

measure applies.

For years prior to the 2011 Physician Quality Reporting System, if an eligible professional

reports less than 3 measures, the eligible professional must:

• Report on all measures that apply to the services furnished by the professional, and

• Report each measure for at least 80% of the eligible professional’s Medicare Part B FFS

patients for whom services were furnished during the reporting period to which the

measure(s) applies.

The eligible professional may also be subject to a Measure Applicability Validation (MAV)

process, which would allow CMS to determine whether an eligible professional should have

reported QDCs for additional measures.

For the 2007 Physician Quality Reporting System, these criteria applied to the 6-month reporting

period beginning July 1st only.

For the 2008 and 2009 Physician Quality Reporting System, these criteria applied to the 12-month reporting period beginning January 1st only.

For the 2010 Physician Quality Reporting System, these criteria apply to both the 12-month

reporting period beginning January 1st and the 6-month reporting period beginning July 1st for

claims-based reporting of individual measures. This results in a total of 2 reporting options for

claims-based reporting of individual measures for the 2010 Physician Quality Reporting System.

The 2011 Physician Quality Reporting System retained the 2 reporting options established in the

2010 Physician Quality Reporting System. However, the 2011 Physician Quality Reporting

System reduced the percentage of instances eligible professionals must report per measure.

Eligible professionals need only report on 50% instead of 80% of the Medicare Part B FFS

patients to whom each measure applies.

The 2012 Physician Quality Reporting System retains 1 of the 2 reporting options established in

the 2011 Physician Quality Reporting System. The reporting option established for a 6-month

reporting period was eliminated. In addition, under all 2012 claims-based reporting options for

the 2012 Physician Quality Reporting System, measures reported with a zero percent

performance rate will not be counted.

The 2012 Physician Quality Reporting System criteria for satisfactorily reporting individual

quality measures through claims-based reporting that each eligible professional must meet under

these 2 reporting options are summarized in Table 1 below along with the relevant reporting

period for each reporting option.

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Table 1: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through

Claims

Reporting Criteria Reporting Period

• Report at least 3 Physician Quality Reporting System

measures, or

• 1-2 measures if less than 3 measures apply to an EP; and

• Report each measure for at least 50% of Medicare Part B

FFS patients to whom the measure applies.

If reporting less than 3 measures, the eligible professional must:

• Report on all measures that apply to the services

furnished by the professional, and

• Report each measure for at least 50% of the eligible

professional’s Medicare Part B PFS patients for whom

services were furnished during the reporting period to

which the measure(s) applies.

• May also be subject to a MAV process

January 1, 2012–

December 31, 2012

Eligible professionals who report on fewer than three individual Physician Quality Reporting

System individual quality measures may be subject to a two-step measure-applicability

validation (MAV) process. The purpose of the MAV is to determine whether the eligible

professional should have submitted quality-data codes for additional measures. If CMS finds

that eligible professionals who have reported fewer than three quality measures have not reported

additional measures that are also applicable to the services they furnished during the reporting

period, then those eligible professionals cannot earn the incentive payment. More information

on the MAV process for a specific program year is available in the Analysis and Payment section

of the CMS PQRS website at http://www.cms.hhs.gov/PQRS.

When claims-based reporting of measures groups was introduced in the 2008 Physician Quality

Reporting System program, the only reporting period available for claims-based reporting of

measures groups was the 6-month reporting period beginning July 1, 2008. However, there were

2 reporting options for claims-based reporting of measures groups for 2008. The first reporting

option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting

System consisted of the following criteria for satisfactory reporting:

• Report at least 1 measures group; and

• Report each measure in the measures group on at least 15 consecutively seen Medicare

Part B FFS patients to whom the measures in the measures group apply for each

participating eligible professional.

The term “consecutive” refers to the manner in which the patients are seen by the eligible

professional and are selected for inclusion in the eligible professional’s patient sample. The

patient sample must consist of at least 15 unique Medicare Part B FFS patients seen

consecutively, or in order, by date of service, by the eligible professional.

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The second reporting option for claims-based reporting of measures groups for the 2008

Physician Quality Reporting System consisted of the following criteria for satisfactory reporting:

• Report at least 1 measures group; and

• Report each measure in the measures group on at least 80% of Medicare Part B FFS

patients for whom the measures in the measures group apply for each participating

eligible professional.

Beginning with the 2009 Physician Quality Reporting System, CMS implemented two reporting

periods for claims-based reporting of measures groups: a 12-month reporting period beginning

January 1st and a 6-month reporting period beginning July 1st.

For the 2009 Physician Quality Reporting System, there were 3 reporting options for claims-based submission of measures groups. Whereas for the 2008 Physician Quality Reporting

System only the 6-month reporting period was available for claims-based submission of

measures groups, both the 12-month and the 6-month reporting periods are available for claims-based submission of measures groups for the 2009 Physician Quality Reporting System. In

addition, CMS eliminated the option of reporting on at least one measures group on 15

consecutive patients for the 6-month reporting period but added the option of reporting on at

least 30 consecutive Medicare Part B FFS patients during the 12-month reporting period instead.

We also added a minimum sample size requirement for eligible professionals reporting on at

least 80% of applicable Medicare Part B FFS patients. Eligible professionals reporting on 80%

of applicable Medicare Part B FFS patients for the 12-month reporting period must have at least

30 applicable patients. Eligible professionals reporting on 80% of applicable Medicare Part B

FFS patients for the 6-month reporting period must have at least 15 applicable patients.

CMS implemented the following changes to the 2009 Physician Quality Reporting System for

the 2010 Physician Quality Reporting System: (1) eliminated the requirement that the 30

patients be seen consecutively to allow an eligible professional to report on any 30 patients seen

at any time during the reporting period; and (2) reduced the minimum patient sample size

threshold for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS

patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively.

With respect to the reporting options for claims-based submission of measures groups, the 2011

Physician Quality Reporting System is largely identical to the 2010 Physician Quality Reporting

System. However, CMS implemented the following change in 2011: eligible professionals need

only report at least 50% (instead of the 80% that was required in the 2010 Physician Quality

Reporting System) of their Medicare Part B FFS patients seen during the reporting period to

which the measures group applies.

For the 2012 Physician Quality Reporting System, CMS retained the two 2011 reporting options

for the 12-month reporting period. However, CMS implemented the following change for 2012:

measures within a measures group with a zero percent performance rate will not be counted.

Therefore, the 2012 Physician Quality Reporting System criteria for satisfactorily reporting

measures groups through claims-based reporting that each eligible professional must meet under

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these 2 reporting options are summarized in Table 2 below along with the relevant reporting

period for each reporting option.

Table 2: 2012 Criteria for Satisfactory Reporting of Measures Groups through Claims

Reporting Criteria Reporting Period

• Report at least one measures group; and

• Report each measure within the measures group for at

least 30 Medicare Part B FFS patients to whom the

measures group apply

• Measures within a measures group with a zero percent

performance rate will not be counted.

January 1, 2012 –

December 31, 2012

• Report at least one measures group; and

• Report each measure within the measures group for at

least 50% of Medicare Part B FFS patients to whom the

measures in the measures group apply; but

• Report each measures group on at least 15 patients during

the reporting period for which the measures group

applies.

• Measures within a measures group with a zero percent

performance rate will not be counted.

January 1, 2012–

December 31, 2012

Eligible professionals choosing to participate in the Physician Quality Reporting System through

the claims-based reporting mechanism, regardless of whether they choose to report on individual

measures or measures groups, must have their own individual-level NPI and must consistently

use their individual NPI to correctly identify their services, procedures, and QDCs for an

accurate determination of satisfactory reporting. As stated in §30 above, the analysis of whether

an eligible professional has satisfactorily reported is performed at the individual eligible

professional level using the individual-level NPI. The eligible professional’s individual NPI must

be listed correctly along with the HCPCS codes for services, procedures, and QDCs on the claim.

More information on reporting options for a specific program year is available on the CMS

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