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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 for EPs to satisfactorily report PQRS measures, EPs or 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 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 eligible professional. If it is determined that at least 1 cross-cutting measure was not reported, the individual eligible professional with face-to-face encounters will be automatically subject to the 2018 PQRS payment adjustment. For those individual eligible professionals with no face-to-face encounters as found within the 2016 PQRS List of Face-to-Face Encounters, CMS would not require the reporting of a cross-cutting measure.

Please reference the 2016 PQRS Measures List  or the2016 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 2015 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 documents pertaining to the 2016 PQRS quality measures are included in the zip file titled 2016 PQRS Measures List:

  • 2016 PQRS Implementation Guide – Provides guidance about how to select measures for reporting, how to read and understand a measure specification, and outlines the various reporting mechanisms available for 2016 PQRS. The Implementation Guide also details how to implement claims-based reporting of measures to facilitate satisfactory reporting of quality-data codes by EPs. (Coming Soon)
  • 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 web-based tool. This is a measures list tool that eligible professionals (EPs) can use to search for measures to report for the 2016 PQRS Program. 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 Individual Measure Specification.  It 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 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 eligible professionals who wish to pursue this alternative reporting method.
  • 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 eligible professionals 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 eligible professionals 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 method 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.

2015 PQRS

The PQRS measures documents for the current program year may be different from the PQRS measures documents for a prior year. EPs are responsible for ensuring that they are using the documents for the correct program year. The 2015 PQRS CMS-1500 claim is an example of how an individual National Provider Identifier (NPI) reporting on a single CMS-1500 claim for 2015 PQRS should look. The 2015 Physician Quality Reporting System (PQRS) Implementation Guide contains the 2015 PQRS CMS-1500 claim information.   

Selecting Measures for 2015 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 2015
  • Other quality reporting programs in use or being considered

2015 Cross-Cutting Measures Requirement

In order for EPs to satisfactorily report PQRS measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. EPs or 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. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services that are associated with face-to-face encounters under the Medicare Physician Fee Schedule (MPFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter.

Please reference the 2015 PQRS Measures List or the 2015 Cross-Cutting Measures List for broadly applicable measures that are defined as cross-cutting and reference the 2015 PQRS List of Face-To-Face Encounter Codes for the billable codes that identify face-to-face encounters for the purposes of 2015 PQRS reporting.  All stakeholders should be cognizant of the most up-to-date list and reference it for reporting purposes.

Resources for 2015 PQRS Measures

The following documents pertaining to the 2015 PQRS quality measures are included in the zip file titled 2015 PQRS Measures List:

  • 2015 PQRS Implementation Guide – Provides guidance about how to select measures for reporting, how to read and understand a measure specification, and outlines the various reporting mechanisms available for 2015 PQRS. The Implementation Guide also details how to implement claims-based reporting of measures to facilitate satisfactory reporting of quality-data codes by EPs.
  • 2015 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.

The following documents pertaining to the 2015 PQRS individual measures are included in the zip file titled 2015 PQRS Individual Claims Registry Measure Specification Supporting Documents.

  • 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures – Includes codes and reporting instructions for the 2015 PQRS measures for claims and/or registry-based reporting.
  • 2015 Physician Quality Reporting System (PQRS) Measure Specification Release Notes – Outlines 2015 updates made to the 2014 PQRS Measures Specifications Manual in the form of release notes.
  • 2015 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines, for each claims and registry measure, each QDC that should be reported for a corresponding quality action performed by the individual eligible professional as noted in the measures specification. This document identifies how each code will be used when CMS calculates performance rates. The QDC categories table also clarifies those measures that require 2 or more QDCs to report satisfactorily. Insufficiently reporting the QDCs (as specified in the 2015 PQRS measure specifications) will result as invalid reporting.
  • 2015 Physician Quality Reporting System (PQRS) Single Source Code Master – Includes a numerical listing of all codes (denominator and numerator) included in 2015 PQRS Individual Claims and Registry Measures for incorporation into billing software.

The following documents pertaining to the 2015 PQRS measures groups are included in the zip file titled 2015 PQRS Measures Groups Specifications Supporting Documents:

  • 2015 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 2015 measures groups specifications include codes and reporting instructions for the PQRS measures groups for registry-based reporting.
  • 2015 Physician Quality Reporting System (PQRS) Measures Groups Release Notes – Outlines 2015 updates made to the 2014 PQRS Measures Groups Specifications Manual in the form of release notes.
  • 2015 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups – Provides guidance about how to select measures groups for reporting, and how to read and understand a measure group specification in order to satisfactorily report.
  • 2015 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines every QDC that should be reported for a corresponding quality action performed by the individual EP as noted in the measures specification. This identifies how each code will be used when calculating performance rates. This also clarifies those measures that require two or more QDCs to report satisfactorily. Insufficiently reporting the QDCs (as specified in the 2015 PQRS) will result as invalid reporting.

Note: Measures groups specifications may differ from their individual measures counterpart. This document will define the differences between the QDCs for individual and measure group specifications.

  • 2015 Physician Quality Reporting System (PQRS) Measures Groups Single Source Code Master – Includes a numerical listing of all codes included in 2015 PQRS Measures Groups for incorporation into billing software.

2015 PQRS Individual Measures for Claims/Registry and Measures Groups Flow Documents

2015 PQRS Individual Measure Flow and Measure Group Flow documents are available as additional resources to assist in better understanding the reporting and performance algorithms for measures and measures groups. These measure flows should be utilized with the corresponding measure specification or measure group specification as they are supplemental documents. The Individual Measure Flows are included in the zip file titled 2015 PQRS Individual Measure Flows and Flow Manual. This zip file also includes an individual claims/registry measure flow manual to assist in interpreting the measure flows. The Measures Group Flows are included in the zip file titled 2015 PQRS Measures Groups Flows and Flow Manual. This zip file also includes a measures group flow manual to assist in interpreting the measures group flows.