How To Get Started

Step-by-Step Instruction in Getting Started with the Physician Quality Reporting System (PQRS)

STEP 1:

Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of medical care professionals considered eligible to participate in PQRS is available in the "Downloads" section of this page by clicking on the link titled List of Eligible Professionals. Read this list carefully, as not all entities are considered “eligible professionals” because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS).

STEP 2:

Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An eligible professional may chose from the following methods to submit data to CMS: claims-based, registry-based, qualified Electronic Health Record (EHR), or the Group Practice Reporting Option (GPRO).

In order to satisfactorily report, it is important to review each method’s specific reporting criteria. For additional guidance, refer to the "2013 Physician Quality Reporting System Participation Decision Tree" in Appendix C of the "2013 Physician Quality Reporting System (PQRS) Implementation Guide", which is available below as well as in the "Downloads" section on the link titled Measures Code.

Reporting via registry or qualified EHR requires eligible professionals to utilize vendors. Registry information, including reporting criteria and vendors, is available in the “Downloads” section of the link titled "Registry Reporting".

EHR reporting information, including reporting criteria and qualified vendors, is available in the “Downloads” section of the link titled Electronic Health Record Reporting.

GPRO information may be reviewed under the “Downloads” section of the link titled Group Practice Reporting Option.

STEP 3:

If the chosen method to report is claims-based or registry-based, determine which measure reporting option (individual measures or measures group) best fits your practice. Review the specific criteria for the chosen reporting option in order to satisfactorily report.  

Eligible professionals who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. Refer to MAV information available in the "Downloads" section of the link titled "Analysis and Payment".  

All PQRS measures and their available reporting methods can be reviewed in the "2013 Physician Quality Reporting System (PQRS) Measures List", available below as well as in the "Downloads" section of link titled "Measures Codes".  

STEP 4:

Individual Measures or Measures Group

Eligible professionals may choose at least three individual measures or one measures group as an option to report on measures to CMS. Review the following supporting documentation for specific criteria to satisfactorily report on these two options.

If already participating in PQRS, there is no requirement to select new/different measures for the 2013 PQRS. NOTE: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, eligible professionals will need to review them for any revisions or measure retirement for the current program year.

Notice that each measure or measure group has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period by each individual eligible professional (NPI). The reporting frequency (i.e., report each visit, once during the reporting period, each episode, etc.) is found in the instructions section of each measure specification or in the Measure Group Overview section. Ensure that all members of the team understand and capture this information in the patients’ medical record to facilitate reporting.

Individual Measures

1. 2013 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Individual Claims and Registry Reporting for instructions on how to report claims-based or registry-based individual measures. Just print the pages for the measure specifications you are reporting as the document is very lengthy. The document is available below and in the "Downloads"section of the link titled "Measures Codes".

2. 2013 Physician Quality Reporting System (PQRS) Implementation Guide which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Form CMS-1500 format. The guide is available below and in the "Downloads" section of the link titled "Measures Codes".

Measures Groups

1. 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual and Release Notes, available below and in the “Downloads” section of the link titled  “Measures Codes", for claims-based or registry-based reporting of measures groups. Just print the pages for the measure specifications, including the measure group denominator coding, you are reporting. Note that the specifications for a measures group are different from those for individual measures because they identify a common denominator across the measures group. Be sure you use the correct specifications.

2. Getting Started with 2013 Physician Quality Reporting System (PQRS) Measures Groups is the implementation guide for reporting measures groups. It is available below and in the "Downloads"section of the link titled "Measures Codes".

As you read the specifications and reporting instructions, you will notice that each of the measures has a Quality-Data Code (QDC) (a Current Procedural Terminology [CPT] II code or G-code) associated with it. Note that several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Only allowable CPT II modifiers may be used with a CPT II code. Eligible professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice's quality improvement goals.

To qualify for the incentive, the correct numerator QDC must be reported on at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. A claim is considered "eligible" in PQRS when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes on the claim match the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification.

Refer to the "2013 Physician Quality Reporting System (PQRS) Quality-Data Code Categories" for a complete list of how each code will be used to calculate performance rates. This document is available below and in the "Download" section of the link titled Measures Codes.

STEP 5:

Review information on the PQRS Payment Adjustment. To avoid being subject to a future PQRS payment adjustment, the numerator QDC must be reported at least once during the 12-month reporting period, or the eligible professional must satisfactorily report at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. Refer to the "Payment Adjustment Information" titled link for complete information on how to avoid future PQRS payment adjustments.

Need Assistance?

Contact the QualityNet Help Desk for help with:

• General CMS PQRS & eRx information
• PQRS Portal password issues
• PQRS/eRx feedback report availability and access
• PQRS-IACS registration questions
• PQRS-IACS login issues

Monday – Friday; 7:00 a.m.–7:00 p.m. CST

Phone: 1-866-288-8912

TTY: 1-877-715-6222

Email: qnetsupport@sdps.org

FAQs
Visit our Frequently Asked Questions by scrolling to the  "Related Links" section of this page and click on the "Physician Quality Reporting System FAQ" link. There you will be able to enter keywords in the search box to find answers on How do I get started or any other area of the program you may have questions about.

To view all of the 2013 PQRS Program Requirements, click on the link titled "2013 Medicare PFS Final Rule" in the "Related Links" section on the "Statute Regulations Program Instructions" page at left.