Implementation Guide

2013_PQRS_ImplementationGuide_110912 -- REDUCED.pdf

Physician Quality Reporting System (PQRS)

Implementation Guide

OMB: 0938-1059

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2013 Physician Quality
Reporting System (PQRS):
Implementation Guide –
Claims-Based Reporting
for Incentive

11/09/2012
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Page

Table of Contents
Introduction
PQRS Measure Selection Considerations
PQRS Denominators and Numerators
Claims-Based Reporting Principles
Satisfactorily Reporting Measures
Timeliness of Quality Data Submission
Analysis of Data Reporting Frequency and Performance Timeframes

Appendix A: Glossary of Terms

Appendix B: Sample 2013 PQRS Measure

Appendix C: 2013 PQRS Participation for Incentive Payment Decision Tree

Appendix D: CMS-1500 Claim PQRS Example

Appendix E: Satisfactory Reporting Scenarios

Appendix F: PQRS Claims-Based Process for Incentive

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Introduction
Note: This document applies to PQRS for incentive payment eligibility only. Those who report satisfactorily
for the 2013 program year may avoid the 2015 PQRS payment adjustment. Additional information on how to
avoid future PQRS payment adjustments can be found through supporting documentation available on the
CMS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS.
This guide is provided to promote understanding about how to implement 2013 Physician Quality Reporting System
(PQRS) claims-based reporting of measures in clinical practice and to facilitate satisfactory reporting of quality data
by eligible professionals who wish to participate in PQRS. PQRS is a voluntary individual reporting program that
provides an incentive payment to identified eligible professionals who satisfactorily report data on quality measures
for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B beneficiaries (including Railroad
Retirement Board and Medicare Secondary Payer). Medicare Part C–Medicare Advantage beneficiaries are not
included in claims-based reporting of individual measures or measures groups.
Eligible professionals, using their individual rendering National Provider Identifier (NPI) to submit billable services on
Part B claims for allowable PFS charges, may report the quality action for selected PQRS measure(s). Providers not
defined as eligible professionals in the Tax Relief and Health Care Act of 2006 or the Medicare Improvements for
Patients and Providers Act of 2008 are not eligible to participate in PQRS. Services payable under fee schedules or
methodologies other than the PFS are not included in PQRS (for example, services provided in federally qualified
health centers, portable x-ray suppliers, independent laboratories including place-of-service code “81”, independent
diagnostic testing facilities, hospitals [including critical access], rural health clinics, ambulance providers, and
ambulatory surgery center facilities). Suppliers of durable medical equipment (DME) are not eligible to participate in
PQRS since DME is not paid under the PFS. A list of eligible professionals can be found on the PQRS website at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS.
In general, the quality measures consist of a unique denominator (eligible case) and numerator (clinical action) that
permit calculating the percentage of a defined patient population receiving a particular process of care or achieving a
particular outcome. It is important to review and understand each measure specification, which provides definitions
and specific instructions for reporting a measure. The 2013 Physician Quality Reporting System (PQRS) Measure
Specifications Manual for Claims and Registry Reporting of Individual Measures can be found at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html. Refer
also to Appendix A, “Glossary of Terms,” which further defines the terms denominator and numerator as well as
other terms commonly used in PQRS.
CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related
components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

PQRS Measure Selection Considerations
The measures in 2013 PQRS address various aspects of care, such as prevention, chronic- and acute-care
management, procedure-related care, resource utilization, and care coordination. Measure selection begins with a
review of the 2013 Physician Quality Reporting System (PQRS) Measures List to determine which measures may be
of interest to the practice and applicable to the eligible professional. The list is available as a downloadable document
from the Measures Codes section of the CMS PQRS website. At a minimum, the following factors should be
considered when selecting measures for reporting:
• Clinical conditions usually treated
• Types of care typically provided – e.g., preventive, chronic, acute
• Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
• Quality improvement goals for 2013
After making a selection of potential measures, review the specifications for each measure under consideration and
select those measures that apply to services most frequently provided to Medicare patients by the eligible
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professional/practice. Individual eligible professionals should review each measure’s denominator coding (including
all diagnoses and services submitted on a claim) to determine which PQRS measures are applicable to each patient.
See Appendix B (Sample 2013 PQRS Measure) to view the content included in a measure’s specification, using
PQRS Measure #19 as an example.
2013 PQRS submission of quality data may be performed via claims or via registry, each of which include multiple
reporting options for each method of submission. 2013 PQRS submission of quality data may also be performed via
a qualified electronic health record (EHR) or via the group practice reporting option (GPRO). Appendix C (2013
PQRS Participation for Incentive Payment Decision Tree) is a tool designed to help eligible professionals/practices
select among the multiple reporting options available. Select the reporting option (i.e., reporting individual measures
or measures groups) best suited for the practice. Eligible professionals should not choose individual measures that
do not or infrequently apply to services provided to Medicare patients by the eligible professional/practice. Eligible
professionals may choose to report on measures groups if all of the measures within the group are applicable to
services provided to Medicare patients by the eligible professional. Instructions for reporting measures groups are
included in a separate document, 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications
Manual, which can be found at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html.
Ensure that the practice identifies and reports on all eligible cases for the measures selected by the practice.
Consider implementing an edit on the billing software that will flag each claim every time a combination of codes
listed in a measure’s denominator is billed so the entry of quality-data codes (QDCs) is required prior to final
submission. Additional PQRS educational resources are available as downloads at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS.

PQRS Denominators and Numerators
Measures consist of two major components:
1) A denominator that describes the eligible cases for a measure (the eligible patient population associated with a
measure’s numerator)
2) A numerator that describes the clinical action required by the measure for reporting and performance
Each component is defined by specific codes described in each measure specification along with reporting
instructions and use of modifiers.

Use of Current Procedural Terminology (CPT) Category I Modifiers
PQRS measure specifications include specific instructions regarding inclusion of the CPT Category I modifiers.
Unless otherwise specified, CPT Category I codes may be reported with or without CPT modifiers. Refer to each
individual measure specification for detailed instructions regarding CPT Category I modifiers that qualify or do not
qualify a claim for denominator inclusion.
Note that surgical procedures billed by an assistant surgeon(s) will be excluded from the denominator population so
his/her performance rates will not be negatively impacted for PQRS. Analysis will exclude otherwise PQRS-eligible
CPT Category I codes, when submitted with assistant surgeon modifiers 80, 81, or 82. The primary surgeon, not the
assistant surgeon, is responsible for performing and reporting the quality action(s) in applicable PQRS measures.
Eligible CPT Category I procedure codes, billed by surgeons performing surgery on the same patient, submitted with
modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population for
applicable PQRS measure(s). Both surgeons participating in PQRS will be fully accountable for the clinical action(s)
described in the PQRS measure(s).

Quality-Data Codes
QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT
Category II codes and/or G-codes that describe the clinical action required by a measure’s numerator. Clinical
actions can apply to more than one condition and, therefore, can also apply to more than one measure. Where
necessary, to avoid shared CPT Category II codes, G-codes are used to distinguish clinical actions across measures.
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Some measures require more than one clinical action and, therefore, have more than one CPT Category II code, Gcode, or a combination associated with them. Eligible professionals should review numerator reporting instructions
for each measure carefully.

CPT Category II Codes
CPT Category II or CPT II codes, developed through the CPT Editorial Panel for use in performance measurement,
serve to encode the clinical action(s) described in a measure’s numerator. CPT II codes consist of five alphanumeric
characters in a string ending with the letter “F.” CPT II codes are not modified or updated during the reporting period
and remain valid for the entire program year as published in the measure specifications manuals and related
documents for PQRS.
Use of CPT II Modifiers
CPT II modifiers are unique to CPT II codes and may be used to report measures by appending the appropriate
modifier to a CPT II code as specified for a given measure. The modifiers for a code cannot be combined and their
use is guided by the measure’s coding instructions, which are included in the numerator coding section of the
measure specifications. Use of the modifiers is unique to CPT II codes and may not be used with other types of CPT
codes. Only CPT II modifiers may be appended to CPT II codes. Descriptions of each modifier are provided below to
help identify circumstances when the use of a modifier may be appropriate. Note that reporting an exclusion or
reporting modifier will alter an eligible professional's performance rate. Accurate reporting on all selected measures
will count toward incentive, whether the clinical action is reported as complete or not complete (or performance met
or not met).
Note: Measures with a 0% performance rate and measures groups containing a measure with a 0% performance
rate will not be counted.
CPT II code modifiers fall into two categories; exclusion modifiers and the 8P reporting modifier.
1) Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the measure was
not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers
serve as denominator exclusions for the purpose of measuring performance. Some measures do not allow
performance exclusions. Reasons for appending a performance measure exclusion modifier fall into one of three
categories:
• 1P Performance measure exclusion modifier due to medical reasons includes:
o Not indicated (absence of organ/limb, already received/performed, other)
o Contraindicated (patient allergy history, potential adverse drug interaction, other)
o Other medical reasons
•

2P Performance measure exclusion modifier due to patient reasons includes:
o Patient declined
o Economic, social, or religious reasons
o Other patient reasons

•

3P Performance measure exclusion modifier due to system reasons includes:
o Resources to perform the services not available (e.g., equipment, supplies)
o Insurance coverage or payer-related limitations
o Other reasons attributable to health care delivery system

2) The 8P reporting modifier is available for use only with CPT II codes to facilitate reporting an eligible case when
an action described in a measure is not performed and the reason is not specified. Instructions for appending
this reporting modifier to CPT Category II codes are included in applicable measures. Use of the 8P reporting
modifier indicates that the patient is eligible for the measure; however, there is no indication in the record that the
action described in the measure was performed, nor was there any documented reason attributable to the
exclusion modifiers.
• 8P Performance measure reporting modifier - action not performed, reason not otherwise specified
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The 8P reporting modifier facilitates reporting an eligible case on a given measure when the clinical action does
not apply to a specific encounter. Eligible professionals can use the 8P modifier to receive credit for satisfactory
reporting but will not receive credit for performance. Eligible professionals should use the 8P reporting modifier
sensibly for applicable measures they have selected to report. The 8P modifier may not be used freely in an
attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement
goals.
For example, an eligible professional has selected and submitted QDCs during the reporting period for 2013
PQRS Measure #6, Coronary Artery Disease (CAD): Antiplatelet Therapy. The eligible professional sees a
patient for whom he does not choose to prescribe oral antiplatelet therapy and the reason is not specified.
However, the claim(s) for services for that encounter contains International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), and CPT codes that will draw the patient into the measures’
denominator during analysis. The 8P modifier serves to include the patient in the numerator when reporting rates
are calculated for PQRS.
Note: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis
codes have been incorporated into the 2013 PQRS Measures Specifications. These codes are for REFERENCE
ONLY and will not count toward satisfactorily reporting the measures within PQRS in the 2013 program year.

Claims-Based Reporting Principles
Up to four diagnoses can be reported in the header on the CMS-1500 paper claim and up to eight diagnoses can
be reported in the header on the electronic claim.
o Only one diagnosis can be linked to each line item
o PQRS analyzes claims data using ALL diagnoses from the base claim (Item 21 of the CMS-1500
or electronic equivalent) and service codes for each individual eligible professional (identified by
individual NPI)
o Eligible professionals should review ALL diagnosis and encounter codes listed on the claim
to make sure they are capturing ALL chosen measures applicable to that patient’s care.
All diagnoses reported on the base claim will be included in PQRS analysis, as some measures require reporting
more than one diagnosis on a claim.
o For line items containing a QDC, only one diagnosis from the base claim should be referenced in
the diagnosis pointer field.
o To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference
number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on
the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on
the claim(s) are considered in PQRS analysis.
If your billing software limits the number of line items available on a claim, you may add a nominal amount such
as a penny to one of the line items on that second claim for a total charge of one penny.
o PQRS analysis will subsequently join claims based on the same beneficiary for the same date-ofservice, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and
analyze as one claim.
Providers should work with their billing software vendor/clearinghouse regarding line limitations for
claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.
A sample CMS-1500 form can be found in Appendix D of this document.
Principles for Reporting QDCs
The following principles apply for claims-based reporting of PQRS measures:
1. QDCs must be reported:
• On the claim(s) with the denominator billing code(s) that represents the eligible Medicare Part B
PFS encounter
• For the same beneficiary
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•
•

For the same date of service (DOS)
By the same eligible professional (individual rendering NPI) who performed the covered service,
applying the appropriate encounter codes (ICD-9-CM, CPT Category I or HCPCS codes). These
codes are used to identify the measure's denominator.

2. QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated
covered service is performed.
• The submitted charge field cannot be blank
• The line item charge should be $0.00
• If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted – the
beneficiary is not liable for this nominal amount
• Entire claims with a zero ($0.00) charge will be rejected
• Whether a $0.00 charge or a nominal amount is submitted to the Carrier or A/B Medicare
Administrative Contractor (MAC), the PQRS code line will be denied but will be tracked in the
National Claims History (NCH) for analysis
3. When a group bills, the group NPI is submitted at the claim level; therefore, the individual
rendering/performing physician’s NPI must be placed on each line item, including all allowed charges
and quality-data line items. Solo practitioners should follow their normal billing practice of placing their
individual NPI in the billing provider field (#33a on the CMS-1500 form or the electronic equivalent)
Note: Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. If a denied claim is
subsequently corrected through the appeals process to the Carrier or A/B MAC, with accurate codes that also
correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be included on
the resubmitted claim as instructed in the measure specifications.
Remittance Advice (R/A) / Explanation of Benefits (EOB)
The RA/EOB denial code N365 is your indication that the PQRS codes were received into the National Claims
History.
• N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.”
• The N365 denial code is just an indicator that the QDC codes were received. It does not guarantee the QDC
was correct or that incentive quotas were met. However, when a QDC is reported satisfactorily (by the
individual eligible professional), the N365 can indicate that the claim will be used for calculating incentive
eligibility.
• Keep track of all cases reported so that you can verify QDCs reported against the remittance advice notice
sent by the Carrier or A/B MAC. Each QDC line-item will be listed with the N365 denial remark code.

Submission through Carriers or A/B MACs
QDCs shall be submitted to Carriers or A/B MACs either through:
• Electronic-based Submission:
PQRS QDCs are submitted on the claim just like any other code; however, QDCs will have a $0.00 (or
nominal) charge. Electronic submission, which is accomplished using the ASC X 12N Health Care Claim
Transaction (Version 5010), should follow the current HIPAA standard version of the ASC x12 technical
report 3.
OR
• Paper-based Submission
Paper-based submissions are accomplished using the CMS-1500 claim form (version 08-05) as described
in the sample claim provided in Appendix D.
Group NPI Submission
When a group bills, the group’s NPI is submitted at the claim level, therefore, the individual rendering eligible
professional’s NPI must be placed on each line item, including all allowed charges and quality-data line items.

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Solo NPI Submission
The individual NPI of the solo practitioner must be included on the claim as is the normal billing process for
submitting Medicare claims. For PQRS, the QDC must be included on the claim(s) representing the eligible
encounter that is submitted for payment at the time the claim is initially submitted in order to be included in PQRS
analysis.
CMS-1500 Claim Example
An example of a claim in CMS-1500 format that illustrates how to report several PQRS measures is provided. See
Appendix D.
Satisfactorily Reporting Measures
PQRS participants should also refer to Satisfactorily Reporting 2013 Physician Quality Reporting System (PQRS)
Measures – Claims Reporting Made Simple and Satisfactorily Reporting 2013 Physician Quality Reporting System
(PQRS) Measures – Registry Reporting Made Simple. These documents serve as educational resources to assist
professionals and their staff with accurately reporting measures. These Fact Sheets provide helpful information on
how to get started with PQRS and are available as a downloadable documents in the Educational Resources section
of the CMS PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS.

Timeliness of Quality Data Submission
Claims processed by the Carrier or A/B MAC must reach the national Medicare claims system data warehouse
(National Claims History file) by February 28, 2014 to be included in the analysis. Claims for services furnished
toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not
be included in the analysis.

Analysis of PQRS Data
Reporting Frequency (Measure Tag) and Performance Timeframes
Reporting frequency and performance timeframes are considered whether reporting through claims, registry, CMS
qualified electronic health record, or the CMS group practice reporting option (GPRO).
Claims-based reporting: Quality data reported to CMS through Medicare Part B claims (containing QDC line items for
each individual professional’s NPI) are processed to final action by the Carrier or A/B MAC and subsequently
transferred to the NCH where it is available for PQRS analysis. See Appendix E. Quality measures data reported on
claims denied for payment are not included in PQRS analysis. QDC line items from claims are analyzed according to
the measure specifications, including coding instructions, reporting frequency, and performance timeframes. See
Appendix F for a flow diagram of the PQRS claims-based process.
Note: Registries are not required to submit QDCs.
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for
patients with chronic illness for whom a particular process of care is provided only periodically. Some measures, due
to their complexity, are reportable as registry only or reportable only as a measures group.
Each measure specification includes a reporting frequency (measure tag) for each denominator-eligible patient seen
during the reporting period. The reporting frequency described in the instructions applies to each individual eligible
professional participating in PQRS. PQRS uses the reporting frequency to analyze each measure for determination
of satisfactory reporting, according to the following measure tags:
• Patient-Process: Report a minimum of once per reporting period per individual eligible professional (NPI).
• Patient-Intermediate: Report a minimum of once per reporting period per individual eligible professional
(NPI).
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•
•
•
•

Patient-Periodic: Report once per timeframe specified in the measure for each individual eligible
professional (NPI) during the reporting period.
Episode: Report once for each occurrence of a particular illness/condition by each individual eligible
professional (NPI) during the reporting period.
Procedure: Report each time a procedure is performed by the individual eligible professional (NPI) during
the reporting period.
Visit: Report each time the patient is seen by the individual eligible professional (NPI) during the reporting
period.

A measure’s performance timeframe is defined in the measure’s description and is distinct from the reporting
frequency requirement. The performance timeframe, unique to each measure, outlines the timeframe in which the
clinical action described in the numerator may be completed. See Appendix A.

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Appendix A: Glossary of Terms
Terms

Base Claim
Diagnosis
Claim
CPT Category II
Codes

Denominator
(Eligible Cases)

Definitions

PQRS refers to all diagnoses listed (Item 21 of the CMS-1500 claim form) associated with
physician office, outpatient, and inpatient visits for reporting.
For PQRS purposes, one or more claims will be reconnected based on TIN, NPI, beneficiary
and date of service.
A set of supplemental CPT codes intended to be used for performance measurement. These
codes may be used to facilitate data collection about the quality of care rendered by coding
certain services, test results or clinical actions that support nationally established performance
measures and that the evidence has demonstrated to contribute to quality patient care.2
For PQRS, CPT Category II codes are used to report quality measures on a claim for
measurement calculation.
The lower part of a fraction used to calculate a rate, proportion, or ratio.
The denominator is associated with a given patient population that may be counted as eligible
to meet a measure’s inclusion requirements.
PQRS measure denominators are identified by ICD-9-CM, CPT Category I, and HCPCS codes,
as well as patient demographics (age, gender, etc.), and place of service (if applicable).

Denominator
Statement
Diagnosis Pointer

Eligible
Professional

Encounter

Note: ICD-10-CM diagnosis codes have been incorporated into the 2013 PQRS Measures
Specifications. These codes are for REFERENCE ONLY and will not count toward
satisfactorily reporting the measures within PQRS in the 2013 program year.
A statement that describes the population eligible for the performance measure. For example,
“Patients aged 18 through 75 years with a diagnosis of diabetes.”
Item 24E of the CMS-1500 claim form or electronic equivalent. For PQRS, the line item
containing the quality-data code (QDC) for the measure should point to one diagnosis (from
Item 21) per measure-specific denominator coding.
To report a QDC for a measure that requires reporting of multiple diagnoses, enter the
reference number in the diagnosis pointer field that corresponds to one of the measure’s
diagnoses listed on the base claim. Regardless of the reference number in the diagnosis
pointer field, both primary and all secondary diagnoses are considered in PQRS analysis.
Refer to http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS for a list of professionals eligible to participate in 2013 PQRS.
Providers not defined as eligible professionals in the Tax Relief and Health Care Act of 2006 or
the Medicare Improvements for Patients and Providers Act of 2008 are not eligible to
participate in PQRS and do not qualify for an incentive. Services payable under fee schedules
or methodologies other than the Medicare Physician Fee Schedule (PFS) are not included in
PQRS (for example, services provided in federally qualified health centers, portable x-ray
suppliers, independent laboratories, independent diagnostic testing facilities, hospitals, rural
health clinics, ambulance providers, and ambulatory surgery center facilities). In addition,
suppliers of durable medical equipment (DME) are not eligible for PQRS since DME is not paid
under the PFS.
Encounters with patients during the reporting period which include: CPT Category I E/M service
codes, CPT Category I procedure codes, or HCPCS codes found in a PQRS measure’s
denominator. These codes count as eligible to meet a measure’s inclusion requirements when
occurring during the reporting period.

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Terms

G-codes
for PQRS
ICD-9-CM
Diagnosis Codes
ICD-10-CM
Diagnosis Codes

Line-Item
Diagnosis

Measure

Definitions

A set of CMS-defined temporary HCPCS codes used to report quality measures on a claim. Gcodes are maintained by CMS.
The International Classification of Diseases, 9th Revision, Clinical Modification5 is used in
assigning codes to diagnoses associated with inpatient, outpatient, and physician office visits
for reporting in PQRS.
ICD-10-CM is a clinical modification of the World Health Organization’s ICD-10, which consist
of a diagnostics classification system. ICD-10-CM includes the level of detail needed for
morbidity classification and diagnostics specificity in the United States.9
ICD-10-CM diagnosis codes have been incorporated into the 2013 PQRS Measures
Specifications. These codes are for REFERENCE ONLY and will not count toward
satisfactorily reporting the measures within PQRS in the 2013 program year.
Six service lines in Section 24 of the CMS-1500 claim form to accommodate submission of the
rendering NPI and supplemental information to support the billed service, including the pointed
diagnosis from Item 21.
QDCs are submitted on the line item in section 24 for PQRS.
Performance Measure
• A quantitative tool (e.g., rate, ratio, index, percentage) that provides an indication of
performance in relation to a specified process or outcome.
• See also process measure and outcome measure.1,6
Measure Types
• Process measure: A measure which focuses on a process which leads to a certain
outcome, meaning that a scientific basis exists for believing that the process, when
executed well, will increase the probability of achieving a desired outcome. 6
• Outcome measure: A measure that indicates the result of the performance (or nonperformance) of a function(s) or process(es). 6
• Structure measure: A measure that assesses whether organizational resources and
arrangements are in place to deliver health care, such as the number, type, and
distribution of medical personnel, equipment, and facilities.6

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Terms

Measure
Reporting
Frequency
(Measure Tag)

Definitions
•

•

Patient-Process: Report a minimum of once per reporting period per individual
eligible professional (NPI).
o If the measure is reported more than once during the reporting period,
performance rates are calculated using the most advantageous QDC submitted.
o Reflect quality actions performed throughout the reporting period or other
timeframe.
Patient-Intermediate: Report a minimum of once per reporting period per individual
eligible professional (NPI).
o If the measure is reported more than once during the reporting period,
performance rates are calculated using the most recent QDC submitted.
o Often reflects lab or other test value, so the most recent measurement is desired.
Patient-Periodic: Report once per timeframe specified in the measure for each
individual eligible professional (NPI) during the reporting period.
o Examples include once per month and three times per year.
Episode: Report once for each occurrence of a particular illness/condition by each
individual eligible professional (NPI) during the reporting period.
o Usually reflects a clinical episode, difficult to determine from a single Part B claim.
o Requires specialized analytics to determine the episode.
Procedure: Report each time a procedure is performed by the individual eligible
professional (NPI) during the reporting period.

Visit: Report each time the patient is seen by the individual eligible professional (NPI)
during the reporting period.
Medicare Improvements for Patients and Providers Act of 2008.
Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of
2007.
National Provider Identifier of the individual eligible professional billing under the Tax ID (“NPI
within the Tax ID”).
The upper portion of a fraction used to calculate a rate, proportion, or ratio.
•

MIPPA
MMSEA
NPI
Numerator

A clinical action to be counted as meeting a measure’s requirements (i.e., patients who
received the particular service or obtained a particular outcome that is being measured). 6
Numerator
Statement

Performance
Timeframe
Performance
Measure
Exclusion
Modifiers

PQRS measure numerators are CPT Category II codes and G-codes.
A statement that describes the clinical action that satisfies the conditions of the performance
measure.
For example, “Patients who were assessed for the presence or absence of urinary
incontinence.”
A designated timeframe within which the action described in a performance measure should be
completed. This timeframe is generally included in the measure description and may or may
not coincide with the measure’s data reporting frequency requirement.
Modifiers developed exclusively for use with CPT Category II codes to indicate documented
medical (1P), patient (2P), or system (3P) reasons for excluding patients from a measure’s
denominator.2

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Terms

Performance
Measure
Reporting Modifier
8P
Place of Service
Quality-Data Code
(QDC)
Rationale
Remittance
Advice (RA)
Reporting
Frequency

Reporting Options
Reporting Period

TRHCA

Definitions

The 8P reporting modifier is intended to be used as a “reporting modifier” to allow the reporting
of circumstances when an action described in a measure’s numerator is not performed and the
reason is not otherwise specified.
8P performance measure reporting modifier - action not performed, reason not otherwise
specified 2
References Place of Service Codes (POS) from the list provided in section 10.5 of the
Medicare Claims Processing Manual.
Specified CPT Category II codes with or without modifiers and G-codes used for submission of
PQRS data. The 2013 Physician Quality Reporting System (PQRS) Measure Specifications
Manual for Claims and Registry contains all codes associated with each PQRS measure and
instructions for data submission through the administrative claims system.
A brief statement describing the evidence base and/or intent for the measure that serves to
guide interpretation of results.4
Means utilized by Medicare contractors to communicate to providers claims processing
decisions such as payments, adjustments, and denials.7
The number of times QDCs specified for a quality measure must be submitted on claims during
the reporting period. The reporting frequency for each measure is described in the 2013
Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and
Registry posted on the CMS Web site at http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/index.html.
2013 reporting methods available for incentive payment: claims-based; registry-based;
electronic health record (EHR); measures group; or CMS-selected group practice reporting
options. Refer to the “2013 PQRS Participation Decision Tree (Appendix C)”.
The period during which PQRS measures are to be reported for covered professional services
provided.

6-month (July 1, 2013 through December 31, 2013) or 12-month (January 1, 2013 through
December 31, 2013) time periods are available depending upon the 2013 reporting option the
eligible professional selects for submitting PQRS quality data.
Tax Relief and Health Care Act of 2006.

Sources:
1. Agency for Health Care Research & Quality (AHRQ) National Quality Measures Clearinghouse Glossary.
2. IBID, PSNet, Patient Safety Network Glossary.
3. American Medical Association (AMA), CPT® Category II Index of Alphabetic Clinical Topics.
4. Institute of Medicine (IOM), Performance Measurement Accelerating Improvement, Appendix A Glossary,
National Academies Press.
5. Joint Commission on Accreditation of Health Care Organizations (JCAHO).
6. National Center for Health Statistics (NCHS) of the Centers for Disease Control (CDC).
6. QualityNet, QMIS Specification Manual for National Hospital Quality Measures, Appendix D-3, Glossary of
Terms version 2.3b, 9-28-2007.
Version 7.0
CPT only copyright 2012 American Medical Association. All rights reserved.

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7. CMS Medicare Learning Network, Understanding the Remittance Advice: A Guide for Medicare Providers,
Physicians, Suppliers, and Billers.
8.

Medicare Claims Processing Manual: Chapter 26 – Completing and Processing Form CMS – 1500 Data Set.

9. American Health Information Management Association (AHIMA), Understanding ICD-10, retrieved from official
AHIMA website.

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This symbol (asterisk) represents the Measure Developer (as noted in
the Symbol and Copyright Information section following the 2013
Physician Quality Reporting System (PQRS) Measure Specifications
Manual for Claims and Registry). The NQF number is also listed.

Appendix B: Sample 2013 PQRS Measure

Official measure title.

Measure #19 (NQF 0089): Diabetic Retinopathy: Communication with the Physician Managing
On-going Diabetes Care
2013 PHYSICIAN QUALITY REPORTING OPTIONS FOR INDIVIDUAL MEASURES:
CLAIMS, REGISTRY

This segment
includes a
high-level
description of
the measure.

Details when the
measure should
be reported and
who should
report.

Each individual
measure specification
identifies the available
reporting option(s).

DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed with documented communication to the physician who
manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or
fundus exam at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with diabetic
retinopathy seen during the reporting period. It is anticipated that clinicians who provide the primary
management of patients with diabetic retinopathy (in either one or both eyes) will submit this measure.

Measure Reporting via Claims:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are
included in the measure’s denominator. CPT Category II and/or G-codes are used to report the
numerator of the measure.
Measure #19 can
be reported via
claims and
registry.

Refer to PQRS
measure
specification
#33 to view a
registry only
specification.

Review patient
demographics, DX,
and encounter codes
to determine if the
patient meets
denominator criteria.
Review other PQRS
measures for which
the patient meets
denominator
inclusion.
Enter the correct
combination of
codes on the claim.

When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the modifier
AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons,
8P- reason not otherwise specified. All measure-specific coding should be reported on the claim(s)
To ensure satisfactory reporting, submit all measure-specific coding for
representing the eligible encounter.
the beneficiary on the claim(s) representing the eligible encounter. If
criteria are met, claims may be reconnected based on
TIN/NPI/Beneficiary/Date of Service.

Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are
included in the measure’s denominator. The numerator options as described in the quality-data codes
are used to report the numerator of the measure. The quality-data codes listed do not need to be
submitted for registry-based submissions; however, these codes may be submitted for those registries
that utilize claims data.
Denominator statement describes the population evaluated by the performance measure.

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular
or fundus exam performed
Patient population that may be counted

Denominator Criteria (Eligible Cases):
as eligible to meet a measure’s inclusion
requirements.
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for diabetic retinopathy (ICD-9-CM): 362.01, 362.02, 362.03, 362.04, 362.05,
362.06
Identified by ICD-9-CM,
Version 7.0
CPT only copyright 2012 American Medical Association. All rights reserved.

CPT Category I, and HCPCS codes,
as well as patient demographics (age,
gender, etc), and place of service
(if applicable).

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ICD-10-CM codes are
included in the 2013
PQRS Measure
Specifications for
reference purposes
only. These codes can
not be used for 2013
reporting purposes.

Diagnosis for diabetic retinopathy (ICD-10-CM) [REFERENCE ONLY/Not Reportable]: E08.311,
E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.311,
E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.311,
E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.311,
E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.311,
E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359

AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014, 99201,
99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
A clinical action counted as meeting the measure’s requirements (i.e., patients who received the
particular service or obtained a particular outcome that is being measured).

NUMERATOR:
Patients with documentation, at least once within 12 months, of the findings of the dilated macular or
fundus exam via communication to the physician who manages the patient’s diabetic care
Measures may or may
not contain definitions.

Measure #19 is an
example of a complex
measure. Review
carefully to submit the
quality-data codes
(QDCs) that meet the
quality action being
reported.

Section 1:
Satisfactory
Reporting and
Performance.

Section 2:
Satisfactory
Reporting and
Excluded from
Performance.

Definition:
Communication – May include documentation in the medical record indicating that the findings
of the dilated macular or fundus exam were communicated (e.g., verbally, by letter) with the
clinician managing the patient’s diabetic care OR a copy of a letter in the medical record to the
clinician managing the patient’s diabetic care outlining the findings of the dilated macular or
fundus exam.
Findings – Includes level of severity of retinopathy AND the presence or absence of macular
edema
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on the
claim form in order to properly report this measure. The “correct combination” of codes may
require the submission of multiple numerator codes.

Numerator section outlines
applicable quality-data
coding options for reporting
the numerator.

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Macular or Fundus Exam Findings Communicated
(One CPT II code & one G-code [5010F & G8397] are required on the claim form to submit this
numerator option)
CPT II 5010F: Findings of dilated macular or fundus exam communicated to the physician
managing the diabetes care
Examples of QDCs.
AND
G8397: Dilated macular or fundus exam performed, including documentation of the presence or
absence of macular edema AND level of severity of retinopathy
Modifiers developed
exclusively for use with
Dilated Macular or Fundus Exam Findings not Communicated for Medical
(One
CPTReasons
II codes to indicate
documented
medical this
(1P),
CPT II code & one G-code [5010F-1P & G8397] are required on the claim form
to submit
patient (2P), or system
numerator option)
(3P) reasons for excluding
patients from a measure’s
Append a modifier (1P) to CPT Category II code 5010F to report documented
denominator.

circumstances that appropriately exclude patients from the denominator

Some measures allow no

performance exclusions;
5010F with 1P: Documentation of medical reason(s) for not communicating
the findings
some have only one or
of the dilated macular or fundus exam to the physician who manages
the
two.
on-going care of the patient with diabetes

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AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
OR

Measure #19 has two
performance exclusion sections.

Dilated Macular or Fundus Exam Findings not Communicated for Patient Reasons
(One CPT II code & one G-code [5010F-2P & G8397] are required on the claim form to submit
this numerator option)
Append a modifier (2P) to CPT Category II code 5010F to report documented circumstances
that appropriately exclude patients from the denominator.
5010F with 2P: Documentation of patient reason(s) for not communicating the findings of
the dilated macular or fundus exam to the physician who manages the
on-going care of the patient with diabetes
AND
G8397: Dilated macular or fundus exam performed, including documentation of the presence or
absence of macular edema AND level of severity of retinopathy

Section 2:
Satisfactory
Reporting and
Excluded from
Performance.

OR
Section 3:
Satisfactory
Reporting and
Performance Not
Met.

A brief statement
describing the
evidence base
and/or intent for
the measure that
serves to guide
interpretation of
results.
Questions or
comments
regarding how
the measure is
constructed or
suggestions for
changes to a
measure should
be submitted to
the measure’s
developer/owner.

If patient is not eligible for this measure because patient did not have dilated macular or
fundus exam performed, report:
(One G-code [G8398] is required on the claim form to submit this numerator option)
G8398: Dilated macular or fundus exam not performed
Dilated Macular or Fundus Exam Findings not Communicated, Reason not Specified
(One CPT II code & one G-code [5010F-8P & G8397] are required on the claim form to submit
this numerator option)
Append a reporting modifier (8P) to CPT Category II code 5010F to report circumstances when
the action described in the numerator is not performed and the reason is not otherwise
specified.
5010F with 8P: Findings of dilated macular or fundus exam was not communicated to the
physician managing the diabetes care, reason not otherwise specified
AND
G8397: Dilated macular or fundus exam performed, including documentation of the presence or
absence of macular edema AND level of severity of retinopathy

RATIONALE:
The physician that manages the on-going care of the patient with diabetes should be aware of the
patient’s dilated eye examination and severity of retinopathy to manage the on-going diabetes care.
Such communication is important in assisting the physician to better manage the diabetes. Several
studies have shown that better management of diabetes is directly related to lower rates of development
of diabetic eye disease. (Diabetes Control and Complications Trial – DCCT, UK Prospective Diabetes
Study – UKPDS)

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Summary of clinical recommendations
based on best practices.

CLINICAL RECOMMENDATION STATEMENTS:
While it is clearly the responsibility of the ophthalmologist to manage eye disease, it is also the
ophthalmologist’s responsibility to ensure that patients with diabetes are referred for appropriate
management of their systemic condition. It is the realm of the patient’s family physician, internist or
endocrinologist to manage the systemic diabetes. The ophthalmologist should communicate with the
attending physician. (Level A: III Recommendation) (AAO, 2003)
Although the ophthalmologist will perform most of the examination and all surgery, certain aspects of
data collection may be conducted by other trained individuals under the ophthalmologist's supervision
and review. Because of the complexities of the diagnosis and surgery for PDR, the ophthalmologist
caring for patients with this condition should be familiar with the specific recommendations of the DRS,
ETDRS, UKPDS, and DCCT/EDIC (see Appendices 3 and 5).[A:III] The ophthalmologist should also
have training in and experience with the management of this particular condition.[A:III] (AAO, 2008)

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Appendix C: 2013 PQRS Participation for Incentive Payment Decision Tree

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2013 Program Reporting Options
Number assigned coordinates with appropriate box on the Appendix C: 2013 PQRS Participation for Incentive Payment Decision Tree.
1. Claims-based reporting of individual measures (12 months)
2. Claims-based reporting of at least one measures group for 20 unique Medicare Part B FFS patients (12 months)
3. Registry-based reporting of at least 3 individual PQRS measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
4. Registry-based reporting of at least one measures group for 20 patients, the majority of which must be Medicare Part B FFS patients (12 months)
5. Registry-based reporting of at least one measures group for 20 patients, the majority of which must be Medicare Part B FFS patients (6 months)
6. Direct EHR-based reporting of at least 3 individual PQRS measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
7. Direct EHR-based reporting of a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures (12 months)
8. EHR Data Submission Vendor reporting of at least 3 individual PQRS measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
9. EHR Data Submission Vendor reporting of a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures (12 months)
10. GPRO-based reporting (2+ eligible professionals) of at least 3 individual PQRS measures via registry for 80% or more of the practice’s applicable Medicare Part B FFS patients (12
months)
11. GPRO-based reporting (25-99 eligible professionals) of all applicable measures included in the submission web interface provided by CMS for consecutive, confirmed, and completed
patients for each disease module and preventive care measures (12 months)
12. GPRO-based reporting (100+ eligible professionals) of all applicable measures included in the submission web interface provided by CMS for consecutive, confirmed, and completed
patients for each disease module and preventive care measures (12 months)

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Appendix D: CMS-1500 Claim PQRS Example
Example of an individual NPI reporting on a single CMS-1500 claim. See http://www.cms.gov/manuals/downloads/clm104c26.pdf for more information.

The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease (CAD), and urinary incontinence:
•
Measure #2 (LDL-C) with QDC 3048F + diabetes line-item diagnosis (24E points to DX 250.00 in Item 21);
•
Measure #3 (BP in Diabetes) with QDCs 3074F + 3078F + diabetes line-item diagnosis (24E points to Dx 250.00 in Item 21);
•
Measure #6 (CAD) with QDC 4011F + CAD line-item diagnosis (24E points to Dx 414.00 in Item 21); and
•
Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRS, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter.
•
Note: All diagnoses listed in Item 21 will be used for PQRS analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21.
•
NPI placement: Item 24J must contain the NPI of the individual provider who rendered the service when a group is billing.
•
If billing software limits the line items on a claim, you may add a nominal amount such as a penny to one of the QDC line items on that second claim. PQRS analysis will subsequently join both claims
based on the same beneficiary, for the same date-of-service, for the same TIN/NPI and analyze as one claim.

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Appendix E: Satisfactory Reporting Scenarios

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Appendix F: PQRS Claims-Based Process for Incentive

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File Type	application/pdf
File Title	2013 Physician Quality Reporting System (PQRS) Implementation Guide - Claims-Based Reporting for Incentive
Subject	2013 Claims-Based Implementation Guide
Author	CMS
File Modified	2013-09-16
File Created	2012-11-07