Need to Know: Claims-based reporting for PQRS in 2016

It is that time of year again—time to start thinking about reporting for the Physician Quality Reporting System (PQRS). With MIPS penalties set to start in CY 2019, the final year of payment adjustments under the Physician Quality Reporting System will come in CY 2018 and will be based on data reported during this year. As such, it is critical that physicians who are eligible for PQRS actually participate this year, even if the only mechanism available is via claims. In 2016, only individual eligible professionals may report PQRS via claims, as the reporting mechanism is not available to groups participating in PQRS via the Group Practice Reporting Option (GPRO).

New resources available in 2016

CMS made a big push to provide additional resources for PQRS this year, although it seems a bit late given that the program may end. Regardless, these new resources should make PQRS participation a bit easier this year, especially for folks who are just jumping on the bandwagon:

  • Quickly located individual measure specifications for measures available under claims and registry reporting using a new PQRS web tool. 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.
  • Measure flow sheets for each 2016 individual quality measure can now be found after the narrative measure specifications in the 2016 PQRS Individual Claims Registry Measure Specification manual.
  • A complete list of the numerator and denominator codes for 2016 PQRS Individual Claims and Registry measures can now be found in one easy-to-download Excel spreadsheet. This supportive document is a resource that may be used to find codes that will be billed by individual eligible professionals or group practices, billing software, or vendors that may report on 2016 PQRS Individual Claims and Registry Measures.

Quality Data Codes

Claims-based reporting for PQRS involves submitting Quality Data Codes (QDCs), or G-Codes, on Medicare Part B claims for applicable patients and select quality measures. QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes composed of specified CPT Category II codes and/or G-codes that describe the clinical action required by a measure’s numerator. Some measures require more than one clinical action and may have more than one CPT Category II code, G-code, or a combination associated with them.

To make sure that you are reporting the correct codes for the quality measures you choose for PQRS, you should review numerator reporting instructions for each measure carefully. A complete list of the specifications and measure flow sheets for the 2016 PQRS Claims and Registry Individual Measures can be found on the CMS website.

Claims-based reporting requirements

Eligible professionals reporting PQRS via claims in 2016 may satisfactorily report by meeting the following criteria:

  • Report on at least 9 measures covering three National Quality Strategy domains for at least 50% of applicable Medicare Part B patients. If you see at least one Medicare patient in a face-to-face encounter in 2015, then you must also report on at least one cross­-cutting measure.
  • Eligible professionals who submit quality data for fewer than 9 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR who submit data for 9 or more PQRS measures covering less than three domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure-Applicability Validation (MAV).
  • Measures with a 0% performance rate, meaning you do not report any patients who meet denominator and numerator requirements, will not be counted.

Best practices for claims-based reporting

The following best practices should be followed if you choose to report PQRS in 2016 using the claims-based reporting mechanism:

  • To reduce reporting burden, only submit QDC codes for Medicare Part B beneficiaries.
  • Always submit QDCs with a line-item charge of one penny ($0.01) at the time the associated covered service is performed, since the submitted charge field cannot be blank. Prior to 2015, this was an optional way to submit PQRS codes, but it is now required. The beneficiary will not be liable for this nominal amount.
  • Make sure to submit QDCs on the initial claim that applies to the patient visit, because claims may not be re-submitted for the sole purpose of adding or correcting QDCs.
  • Review your Remittance Advice (RA)/Explanation of Benefits (EOB) for denial code N620. This code indicates the PQRS codes are valid for the 2016 PQRS reporting year.

Reporting quality measures via Medicare Part B claims is one of the most popular methods for participating in the CMS quality improvement program. However, since CMS has made it clear that it plans to phase out quality measures that can be reported via claims, it may be worth exploring other reporting options this year in case CMS decides to do away with claims reporting under any new programs that come out of the MACRA legislation. For physicians who have previously relied on claims reporting, the registry reporting option may be the easiest transition.


Further reading:
MIPS Advancing Care Information: Frequently Asked Questions
Comprehensive Primary Care Plus (CPC+) quality measures for 2017

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