Need to Know: Claims-based reporting for PQRS in 2015

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Reporting quality measures for PQRS 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 they plan to phase out quality measures that can be reported via claims, it is a method that may not be available in future years. In 2015, only individual eligible professionals—not groups—may report PQRS via claims.

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 selected 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.

Claims-Based Reporting Requirements

Eligible professionals reporting PQRS via claims in 2015 may satisfactorily report by meeting the following criteria:

  • Report on at least 9 measures covering 3 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 onecross­-cutting measure.
  • Eligible professionals that submit quality data for fewer than 9 PQRS measures for at least 50% of their patients or encounters eligible for each measure OR that submit data for measures covering fewer than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to the CMS Measure Applicability Validation (MAV) process. 

  • 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

Consider the following best practices if you choose to report via claims:

  • 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, instead of leaving the submitted charge field blank. The beneficiary will not be liable for this charge.
  • 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.


Further reading:
Help! I can’t find six relevant MIPS measures for my specialty
Need to Know: New Physician Star Ratings

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