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Measures Codes

The Measures Codes webpage contains information about Physician Quality Reporting System (PQRS) quality measures, including detailed specifications and related release notes for the individual PQRS quality measures and measures groups. This page also contains other measures-related documentation needed by individual eligible professionals (EPs) for reporting the PQRS measures through claims or qualified registry-based reporting.

Selecting Measures for 2016 PQRS

At a minimum, the following factors should be considered when selecting measures for reporting:

  • Clinical conditions usually treated
  • Types of care typically provided – e.g., preventive, chronic, acute
  • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
  • Quality improvement goals for 2016
  • Other quality reporting programs in use or being considered

2016 Cross-Cutting Measures Requirement

In order to satisfactorily report PQRS measures, individual EPs and PQRS group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter. A cross-cutting measure is defined as a measure that is broadly applicable across multiple providers and specialties. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule (MPFS). CMS does not consider telehealth visits as a face-to-face encounter.

At least 1 cross-cutting measure must be satisfactorily reported for those individual providers and PQRS group practices with face-to-face encounters. CMS will analyze claims data to determine if at least 15 cross-cutting measure denominator eligible encounters can be associated with the individual EP or PQRS group practice. If it is determined that at least 1 cross-cutting measure was not reported, the individual EP or PQRS group practice with face-to-face encounters will be automatically subject to the 2018 PQRS negative payment adjustment. For those individual EPs or PQRS group practices with no face-to-face encounters as found within the "2016 PQRS List of Face-to-Face Encounters", CMS will not require the reporting of a cross-cutting measure.

Please reference the "2016 PQRS Measures List" found below under Resources for 2016 PQRS Measures or the 2016 Cross-Cutting Measures List  for broadly applicable measures that are defined as cross-cutting, and reference the 2016 PQRS List of Face-To-Face Encounter Codes  for the billable codes that identify face-to-face encounters for the purposes of 2016 PQRS reporting.  All stakeholders should use the most up-to-date measures and supporting documentation for reporting purposes.
 

Resources for 2016 PQRS Measures

The following resources are available when trying to determine which 2016 PQRS quality measures to report and understand the basics on how to report:

  • 2016 PQRS Claims Reporting Made Simple – This beginner-level resource describes claims-based reporting and outlines steps EPs should take prior to participating in 2016 PQRS. 
  • 2016 PQRS Claims Based-Coding and Reporting Principles - This beginner-level resource provides detailed instructions for EPs participating in 2016 PQRS via claims, including coding tips and reporting guidance.
  • 2016 PQRS Measures List – Identifies and describes the measures used in PQRS, including all available reporting mechanisms, corresponding PQRS number and National Quality Forum (NQF) number, National Quality Strategy (NQS) domains, plus measure developers and their contact information.
  • New for 2016 PQRS: The "2016 PQRS Individual Measure Specifications for Claims and Registry Reporting" can be viewed on the PQRS Web-Based Measure Search Tool. This is a measures list tool that EPs can use to search for measures to report for 2016 PQRS. The web-based measures list tool allows users to search for measures using a number of criteria and then access detailed information about each measure, including measure specifications materials.

The following documents pertaining to the 2016 PQRS individual measures are included in the zip file titled 2016 PQRS Individual Claims Registry Measure Specifications.

  • 2016 Physician Quality Reporting System (PQRS) Individual Measure Specifications for Claims and Registry Reporting – Documents that include reporting instructions, coding to identify the measure’s intended patient population, and numerator options for the 2016 PQRS claims and/or registry-based reporting measures.
  • New for 2016 PQRS - The "2016 PQRS Measure Flows" have been incorporated within the "2016 PQRS Individual Measure Specifications". Each measure flow is currently displayed after the individual measure specification as a visualization of the reporting and performance algorithm for each individual specification.

The following supporting documents pertaining to the 2016 PQRS individual measures are also helpful resources to supplement the "2016 PQRS Individual Measure Specifications":

The following documents pertaining to the 2016 PQRS measures groups are included in the zip file titled 2016 PQRS Measures Groups Specifications Supporting Documents:

  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual –Measures group specifications are different from those of the individual measures that form the group. Therefore, the specifications and instructions for measures group reporting are provided in a separate manual. The "2016 PQRS Measures Groups Specifications" include common denominator coding to identify the measures group intended patient population, reporting instructions for the PQRS measures groups for registry-based reporting, and numerator options for each of the individual measures included in the measures group.
  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Release Notes – This document outlines 2016 measures groups specifications updates to the "2015 PQRS Measures Groups Specifications". The updates outlined may include items such as common denominator coding updates, revisions to numerator options, or general language updates that correlate to the most current clinical guidelines.
  • 2016 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups – This document contains general implementation guidance, measures groups strategies, and information to facilitate satisfactory reporting by EPs who wish to pursue this alternative reporting mechanism.
  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Single Source Code Master – This document includes a numerical listing of all codes included in 2016 PQRS measures groups that may be used to find measures for coding billed by individual EPs or group practices, billing software, or vendors that may report on 2016 PQRS measures groups.
  • 2016 Measures Group Flow Documents - "2016 PQRS Measure Group Flow" documents are available as additional resources to assist in better understanding the reporting and performance algorithms for measures groups. These measures group flows should be utilized with the corresponding measures group specifications as they are supplemental documents. The "Measures Group Flows" are included in the zip file titled 2016 PQRS Measures Group Flows and Flow Manual. This zip file also includes a measures group flow manual to assist in interpreting the measures group flows.

2016 Specialty Measure Sets

CMS has been collaborating with specialty societies to ensure that the measures represented within the "Specialty Measure Sets" accurately outline quality actions that may occur within a particular clinical area. The "Specialty Measure Sets" should be used as a guide for EPs to choose measures applicable to their specialty. The "Specialty Measure Sets" are NOT required measures but are suggested measures for specific specialties.  

The "2016 Specialty Measure Sets" are indicated below.

  1. 2016 Cardiology Preferred Specialty Measure Set
  2. 2016 Dermatology Preferred Specialty Measure Set
  3. 2016 Emergency Medicine Preferred Specialty Measure Set
  4. 2016 Gastroenterology Preferred Specialty Measure Set
  5. 2016 General Practice/Family Practice Preferred Specialty Measure Set
  6. 2016 General Surgery Preferred Specialty Measure Set
  7. 2016 Hospitalist Preferred Specialty Measure Set
  8. 2016 Internal Medicine Preferred Specialty Measure Set
  9. 2016 Mental Health Preferred Specialty Measure Set
  10. 2016 Multiple Chronic Conditions Preferred Specialty Measure Set
  11. 2016 Obstetrics/Gynecology Preferred Specialty Measure Set
  12. 2016 Oncology/Hematology Preferred Specialty Measure Set
  13. 2016 Ophthalmology Preferred Specialty Measure Set
  14. 2016 Pathology Preferred Specialty Measure Set
  15. 2016 Physical Therapy/Occupational Therapy Preferred Specialty Measure Set
  16. 2016 Radiology Preferred Specialty Measure Set
  17. 2016 Urology Preferred Specialty Measure Set

It is important to utilize the measure specifications and program requirements within each reporting mechanism chosen to satisfactorily report within PQRS. Links to the "PQRS Measure Specifications for Claims, Registry, and Measures Groups" are listed above on this web page.
 
The "2015 Specialty Measure Sets" are located here for reference.