Revenue Cycle Management Blog | GroupOne Health Source

Selecting the Right PQRS Measures: Individual vs. Measures Groups

Written by Jeff Jones, CPHP | May 2, 2016

Taking time to select the right PQRS measures can make a huge difference in an Eligible Providers (EP) performance in PQRS. How? Because choosing PQRS measures that align with your specialty usually makes it easier to report for the PQRS. Therefore the measure selection process should begin with a review of the entire measure list to determine which measures are important to the EP and the practice.

How to Select PQRS Measures

The list of Individual Measures and Group Measures are available for download from the PQRS measures code section of the PQRS website. When selecting PQRS measures, EPs at a minimum, should consider the following factors:

  • Look at the clinical conditions that the EP usually treats
  • Types of care provided by the EP (chronic, preventative, acute)
  • Settings where EPs deliver care (e.g., office, emergency department, surgical suite)
  • The EP’s quality improvement goals for the current year

After carefully selecting potential measures based on this list the EP should review the specifications of each measure that are under consideration and then select the measures that apply to the services the EP provides most frequently to Medicare patients.

Individual EPs should review the measure denominator, including all diagnoses or services submitted on a claim to determine which measures apply to each patient. Additionally, EPs should check with their EHR vendor to confirm that the measure data can be captured accurately within the system.

[Also: Everything You Need to Know About PQRS Reporting Methods]

Individual Measures and Measures Groups

Measures for PQRS are divided into two groups: Individual Measures (281) and Measures Groups (25). 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.

What is a Cross-Cutting Measure?

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.

Reporting of Individual PQRS Measures

The requirement for reporting of Individual Measures is 9 or more measures across at least 3 National Quality Strategy domains and at least one cross-cutting measure for EPs with billable face-to-face encounters.

It is important to note that when reporting individual PQRS measures with a registry, usually a provider or a group practice participating in the Group Practice Reporting Option (GPRO) will need to report 9 measures across 3 different domains for at least 50% of applicable patients. CMS recognizes that a limited number of eligible professionals may not be able to identify nine measures across three domains that are applicable to their practice.

Eligible professionals or group practices that submit less than nine measures or less than three NQS domains will be subject to MAV (Measure-Applicability Validation).

What is Measure-Applicability Validation (MAV) Process?

The Measure Applicability Validation (MAV) process (essentially an audit), will be used to determine if the EP could report on more measures than he/she actually submitted.

If the EP is found to be in violation during the MAV process then the EP will fail the PQRS submission and be subject to the associated penalties. Thus, it is in an EPs best interest to submit at least 9 measures across 3 domains if possible.

Click here for more information about the Measure-Applicability Validation (MAV) Process 

Reporting Measures Groups

The requirement for reporting a Measures Groups is to select only one group and report on every measure within that group. An EP must report on every measure within the selected group and may not choose measures outside of that group.

An EP also may not select individual measures in order to create their own measures group; they must stay within the bounds of the predetermined measures groups.

For the 2016 reporting year there are 281 Individual Measures. All measures are not available for every reporting method; however they cover a wide range of topics in an attempt to give all EPs a significant amount of options to choose from.

The Measures Groups are only available through the registry reporting method. The Measures Groups all have at least 6 measures to ensure that the cross-cutting measure is included in each Measures Group, so that by choosing to report via a Measures Group the EP will automatically include the cross-cutting measure.

Why Measures Groups?

A measures group is composed of 6 to 11 individual measures that are created and approved by CMS. Measures groups are not editable to include or omit specific individual measures.

It is usually easier to report measures groups because a health provider only needs to report 20 patients (11 of which are Medicare Part B FFS*) that you have seen during 2016. For example, family practice or internal medicine providers usually report the Diabetes Measure Group or the Preventive Care Measures Group while Cardiologists would usually report the CAD Measures GroupIf there is no measures group that applies directly to your specialty, you could choose the Preventive Care Measures Group.