Revenue Cycle Management Blog | GroupOne Health Source

A Simple Guide to Understanding PQRS Measures and Specifications

Written by Jeff Jones, CPHP | May 19, 2016

In 2016, providers are able to select from a large number of measures to submit PQRS data. However, understanding PQRS measures and specifications can be overwhelming. And since the measures you choose have a large impact on your quality and cost scores, deciding on the right measures to report should not be taken lightly. Here we will guide you through how to better understand PQRS measures and the specifications for measures.

 

Before we dive into PQRS measures and specifications, it is important to note that PQRS measures change every year so you should check and make sure the measures you reported on last year are still available to you if you wish to report those same measures. 

Individual Measures and Measures Groups

Measures for PQRS are divided into two groups: Individual Measures and Measures Groups.

An EP may choose to report any combination of Individual Measures or choose a specific Measures Group. Measures Groups include a minimum of 6 individual measures and normally a maximum of 11 measures. The individual measures in the Measures Groups all relate to a specific diagnosis or problem such as diabetes, coronary heart disease, or others. Also, in 2016, EPs must include 1 cross-cutting measure.

[Also: Selecting the Right PQRS Measures-Individual vs. Measures Groups]

All together there are 281 Individual Measures and 25 Measures Groups available in 2016. Why are there so many you ask?

The PQRS program has included such a large number of measures so they can enable providers from various specialties to capture data that is specific to those specialties.

Each measure addresses a particular aspect of care such as prevention, chronic or acute care, procedure related care, resource utilization, or care coordination. Each measure must also pass rigorous tests in order to be included in the measures list.

Measure Instructions

Each measure includes instructions that define the frequency and reporting specifications that are required to report satisfactorily. In some circumstances where care is only provided periodically the reporting frequency may be limited to one time per year.

It is critical to pay attention to these instructions as each EP should report according to the frequency and timeframe listed within each measure specifications.

PQRS Measure Specifications

The first section of the Measure Specification displays

  • Official measure title
  • Measure number
  • National Quality Forum (NQF) number
  • National Quality Strategy (NQS) domain in which that measure is included.

Click here to view a PQRS measure specification PDF

The next section displays PQRS options for Individual Measures. Each individual measure specification identifies the available reporting option(s).

Description

The next section is the description, which includes a high-level description of the measure.

Instructions Section

Next you will see the instructions section. This section details when the measure should be reported and who should report. This will include the frequency, timeframe, and applicability in which the measure must be reported.

Denominator Statement and Coding Options Section

In this section you will also see denominator statements and coding options, a numerator statement and coding options, a rationale statement, and then clinical recommendations or evidence forming the basis for supporting the criteria for the measure.

The denominator for each specification describes the eligible cases. Eligible cases are patient specific diagnosis and specific encounter codes. The numerator for each measure will describe the clinical action required for reporting and the performance of patients within a particular diagnosis, which actions were taken or why an action was not taken.

It is important that every member of the EP’s team understands this information and captures it in the patient’s medical record.

Types of Codes for Each PQRS Measure Specification

In order to capture the information required for PQRS in the patient’s medical record, each member of the EP’s team must understand the types of codes that are included for each measure specification.

CPT I Codes

CPT I codes serve as the most widely accepted medical nomenclature to report medical procedures and services. All PQRS measures specifications define the eligible procedures or services and include instructions regarding the inclusion of particular CPT codes.

Unless specified CPT codes can be reported with or without CPT Modifiers, which are two-character codes that add clarification and additional details to the procedure codes original description.  So each EP’s team will need to refer to the measures specifications regarding CPT Modifiers that qualify or do not qualify a claim for denominator inclusion.

CPT II Codes

CPT II codes are optional supplemental tracking codes that can be used for measuring performance. These codes are intended to facilitate data collection about quality of care, by coding certain services in test results that support performance measures and that have been agreed upon to contributing to quality care.

By using CPT II codes, EPs and team members can decrease the need for chart reviews or record abstractions that increase administrative burdens and costs. The CPT II codes are not a requirement for correct coding and may not be used to substitute for any CPT I codes.

CPT II Modifiers

CPT II modifiers can be used to report measures by appending the appropriate modifier to a CPT II code as specified in a given measure. The modifiers are unique to the CPT II codes and only one modifier code can be used per CPT II code.

In order to utilize these modifiers correctly see the instructions in the numerator coding section of the measures specification. These modifiers serve as denominator exclusions for the purpose of measuring performance.

The different CPT II modifiers are:

  • 1P
    • Not indicated
    • Contraindicated
    • Other

  • 2P
    • Patient declined
    • Economic, social, or religious reasons
    • Other
  • 3P
    • Resources not available
    • Insurance coverage or payer-related
    • Other
  • 8P
    • Reason not documented

Quality Data Codes

These codes (QDC codes) are critical in the successful reporting of PQRS, especially for those EPs that decide to report via the claims-based reporting method.

The QDC codes correlate to a quality action performed by the EP and are used for the sole purpose of calculating performance rates. QDCs are non-payable HCPCS (Healthcare Common Procedure Coding System) codes that are comprised of specific CPT II codes and/or G-codes that describe the clinical action that was required by the measures numerator.

G-codes define certain individual clinical actions and only used when measures require more than one clinical action. Be sure to check the Measures and Specifications sheet to see if more than one G-code is required.

Note here that in most cases this applies to claims based reporting and in some cases registry based reporting. Note also that some measures will require more than one clinical action and as a result will require more than one QDC, CPT II code, G-code, or a combination associated with them.