There are several different reporting options from which a PQRS participant may choose in order to participate and avoid the noncompliance payment adjustment (penalty). For those reporting as individual eligible professionals, the options are:

  • Claims reporting (individual measures only)
  • Registry reporting (either individual measures or measures groups reporting)
  • Electronic Health Record (EHR) Direct Product that is Certified Electronic Health Record Technology (CEHRT)
  • Electronic Health Record (EHR) data submission vendor that is CEHRT
  • Qualified Clinical Data Registry (QCDR)
  • Claims reporting is the most frequently used process. It involves reporting extra CPT Category II codes along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the PQRS processor. An EP must report at least 9 measures covering at least 3 domains of care, and at least 1 of the nine measures must be a cross-cutting measure. Regardless of how many measures are reported, at least 50% of the applicable patients for each measure must be reported in order to successfully report that measure. Registry reporting may be used by both individuals or groups (GPRO). It is accomplished by contracting with a CMS approved data processing service that can compile patient claims data and generate reports on a provider or practice’s behalf directly to the PQRS processor. A registry can report either individual measures or a measures group. When using individual measures, at least 9 measures covering at least 3 domains of care must be reported, and at least 1 of the nine measures must be a cross-cutting measure. An EP or group practice must report on at least 50% of the applicable patients for each measure. If a measures group is used, the EP is only required to report on 20 patients (11 of whom must be Medicare patients). However, each measure in the measures group must be reported for each of the 20 patients. CMS annually posts a list of authorized registries. Direct EHR vendors are those vendors that are certifying an EHR product which will directly submit a provider or practice’s PQRS measures data to CMS in the CMS-specified format(s) on the provider’s or practice’s behalf. If providers or practices are submitting quality measure data directly from an EHR system, they must register for an IACS account. Check with the EHR vendor to see if they are a direct EHR vendor. EHR Data Submission Vendor (DSV) is an entity that collects an EP or group practice’s clinical quality data directly from the EP or group practice’s EHR. In other words, participants submit their data to the DSV, and the DSV submits everything to CMS. Check with the EHR vendor to see if they provide this service. A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. The data submitted to CMS via QCDR covers quality measures across multiple payers and is not limited to Medicare. Only individuals may report via a QCDR. When reporting via a QCDR, one must report on at least 9 measures covering at least 3 domains of care, and at least 2 of the nine measures must be outcome measures OR the nine measures must include at least one outcome measure and one of the following types of measures: resource use, patient experience of care, efficiency/appropriate use, or patient safety. A list of CMS-designated QCDRs is listed on the CMS’s website.  The GPRO Web Interface requires that users register their intent with CMS. Group practices with 25 or more individual eligible professionals must report on all measures included in the Web Interface AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, then the practice must report on 100% of assigned beneficiaries. NOTE: A practice must ensure that it can report on the GPRO Web Interface measures; if it cannot, it will fail and incur a payment adjustment (penalty). GPRO general reporting is available to practices of 2-24 providers or those with over 25 EPs that do not wish to utilize the GPRO Web Interface. These practices may utilize either a qualified registry or electronic health record (EHR) reporting. The practice may choose to report 9 measures covering at least 3 domains of care, and 1 of the 9 measures must be a cross-cutting measure. Or, the practice can opt to use CAHPS for PQRS (considered the equivalent of three measures and one domain of care) and have the data reported on its behalf by a CMS-certified survey vendor. In addition to the CAHPS data, the practice must report six measures covering at least two domains of care. A CMS-certified survey vendor is the reporting mechanism used when opting to report CAHPS for PQRS data. Beginning in 2015, CMS will no longer incur the cost of this mechanism; a list of authorized survey vendors will be available to interested practices later in 2015. All practices with over 100 EPs must report CAHPS for PQRS and thus use a CMS-certified survey vendor. It is an optional reporting mechanism to be used in conjunction with another GPRO reporting mechanism for all practices with less than 100 EPs. PQRS-CMS1500 Claim Example PQRS-Glossary of Terms

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