Criteria for Determination of Satisfactory Reporting of Individual

70.1.1 – Criteria for Determination of Satisfactory Reporting of Individual Measures for Claims-based Reporting (Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12) As discussed in §60 above, eligible professionals have the option of reporting on individual quality measures or on measures groups. The criteria for determining whether an eligible professional satisfactorily reports data on Physician Quality Reporting System quality measures for reporting individual quality measures are different from the criteria for satisfactory reporting of measures groups. To qualify for a Physician Quality Reporting System incentive payment through claims-based reporting of individual measures prior to the 2011 program year, each eligible professional must meet the following criteria for satisfactory reporting during the applicable reporting period: 23 • Report at least 3 Physician Quality Reporting System measures for the relevant program year, or 1-2 measures, if less than 3 measures apply to an eligible professional; and • Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the measure applies. For years prior to the 2011 Physician Quality Reporting System, if an eligible professional reports less than 3 measures, the eligible professional must: • Report on all measures that apply to the services furnished by the professional, and • Report each measure for at least 80% of the eligible professional’s Medicare Part B FFS patients for whom services were furnished during the reporting period to which the measure(s) applies. The eligible professional may also be subject to a Measure Applicability Validation (MAV) process, which would allow CMS to determine whether an eligible professional should have reported QDCs for additional measures. For the 2007 Physician Quality Reporting System, these criteria applied to the 6-month reporting period beginning July 1st only. For the 2008 and 2009 Physician Quality Reporting System, these criteria applied to the 12- month reporting period beginning January 1st only. For the 2010 Physician Quality Reporting System, these criteria apply to both the 12-month reporting period beginning January 1st and the 6-month reporting period beginning July 1st for claims-based reporting of individual measures. This results in a total of 2 reporting options for claims-based reporting of individual measures for the 2010 Physician Quality Reporting System. The 2011 Physician Quality Reporting System retained the 2 reporting options established in the 2010 Physician Quality Reporting System. However, the 2011 Physician Quality Reporting System reduced the percentage of instances eligible professionals must report per measure. Eligible professionals need only report on 50% instead of 80% of the Medicare Part B FFS patients to whom each measure applies. The 2012 Physician Quality Reporting System retains 1 of the 2 reporting options established in the 2011 Physician Quality Reporting System. The reporting option established for a 6-month reporting period was eliminated. In addition, under all 2012 claims-based reporting options for the 2012 Physician Quality Reporting System, measures reported with a zero percent performance rate will not be counted. The 2012 Physician Quality Reporting System criteria for satisfactorily reporting individual quality measures through claims-based reporting that each eligible professional must meet under these 2 reporting options are summarized in Table 1 below along with the relevant reporting period for each reporting option. 24 Table 1: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through Claims Reporting Criteria Reporting Period • Report at least 3 Physician Quality Reporting System measures, or • 1-2 measures if less than 3 measures apply to an EP; and • Report each measure for at least 50% of Medicare Part B FFS patients to whom the measure applies. If reporting less than 3 measures, the eligible professional must: • Report on all measures that apply to the services furnished by the professional, and • Report each measure for at least 50% of the eligible professional’s Medicare Part B PFS patients for whom services were furnished during the reporting period to which the measure(s) applies. • May also be subject to a MAV process January 1, 2012– December 31, 2012 Eligible professionals who report on fewer than three individual Physician Quality Reporting System individual quality measures may be subject to a two-step measure-applicability validation (MAV) process. The purpose of the MAV is to determine whether the eligible professional should have submitted quality-data codes for additional measures. If CMS finds that eligible professionals who have reported fewer than three quality measures have not reported additional measures that are also applicable to the services they furnished during the reporting period, then those eligible professionals cannot earn the incentive payment. More information on the MAV process for a specific program year is available in the Analysis and Payment section of the CMS PQRS website at http://www.cms.hhs.gov/PQRS. When claims-based reporting of measures groups was introduced in the 2008 Physician Quality Reporting System program, the only reporting period available for claims-based reporting of measures groups was the 6-month reporting period beginning July 1, 2008. However, there were 2 reporting options for claims-based reporting of measures groups for 2008. The first reporting option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting System consisted of the following criteria for satisfactory reporting: • Report at least 1 measures group; and • Report each measure in the measures group on at least 15 consecutively seen Medicare Part B FFS patients to whom the measures in the measures group apply for each participating eligible professional. The term “consecutive” refers to the manner in which the patients are seen by the eligible professional and are selected for inclusion in the eligible professional’s patient sample. The patient sample must consist of at least 15 unique Medicare Part B FFS patients seen consecutively, or in order, by date of service, by the eligible professional. 25 The second reporting option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting System consisted of the following criteria for satisfactory reporting: • Report at least 1 measures group; and • Report each measure in the measures group on at least 80% of Medicare Part B FFS patients for whom the measures in the measures group apply for each participating eligible professional. Beginning with the 2009 Physician Quality Reporting System, CMS implemented two reporting periods for claims-based reporting of measures groups: a 12-month reporting period beginning January 1st and a 6-month reporting period beginning July 1st. For the 2009 Physician Quality Reporting System, there were 3 reporting options for claims- based submission of measures groups. Whereas for the 2008 Physician Quality Reporting System only the 6-month reporting period was available for claims-based submission of measures groups, both the 12-month and the 6-month reporting periods are available for claims- based submission of measures groups for the 2009 Physician Quality Reporting System. In addition, CMS eliminated the option of reporting on at least one measures group on 15 consecutive patients for the 6-month reporting period but added the option of reporting on at least 30 consecutive Medicare Part B FFS patients during the 12-month reporting period instead. We also added a minimum sample size requirement for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients. Eligible professionals reporting on 80% of applicable Medicare Part B FFS patients for the 12-month reporting period must have at least 30 applicable patients. Eligible professionals reporting on 80% of applicable Medicare Part B FFS patients for the 6-month reporting period must have at least 15 applicable patients. CMS implemented the following changes to the 2009 Physician Quality Reporting System for the 2010 Physician Quality Reporting System: (1) eliminated the requirement that the 30 patients be seen consecutively to allow an eligible professional to report on any 30 patients seen at any time during the reporting period; and (2) reduced the minimum patient sample size threshold for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively. With respect to the reporting options for claims-based submission of measures groups, the 2011 Physician Quality Reporting System is largely identical to the 2010 Physician Quality Reporting System. However, CMS implemented the following change in 2011: eligible professionals need only report at least 50% (instead of the 80% that was required in the 2010 Physician Quality Reporting System) of their Medicare Part B FFS patients seen during the reporting period to which the measures group applies. For the 2012 Physician Quality Reporting System, CMS retained the two 2011 reporting options for the 12-month reporting period. However, CMS implemented the following change for 2012: measures within a measures group with a zero percent performance rate will not be counted. Therefore, the 2012 Physician Quality Reporting System criteria for satisfactorily reporting measures groups through claims-based reporting that each eligible professional must meet under 26 these 2 reporting options are summarized in Table 2 below along with the relevant reporting period for each reporting option. Table 2: 2012 Criteria for Satisfactory Reporting of Measures Groups through Claims Reporting Criteria Reporting Period • Report at least one measures group; and • Report each measure within the measures group for at least 30 Medicare Part B FFS patients to whom the measures group apply • Measures within a measures group with a zero percent performance rate will not be counted. January 1, 2012 – December 31, 2012 • Report at least one measures group; and • Report each measure within the measures group for at least 50% of Medicare Part B FFS patients to whom the measures in the measures group apply; but • Report each measures group on at least 15 patients during the reporting period for which the measures group applies. • Measures within a measures group with a zero percent performance rate will not be counted. January 1, 2012– December 31, 2012 Eligible professionals choosing to participate in the Physician Quality Reporting System through the claims-based reporting mechanism, regardless of whether they choose to report on individual measures or measures groups, must have their own individual-level NPI and must consistently use their individual NPI to correctly identify their services, procedures, and QDCs for an accurate determination of satisfactory reporting. As stated in §30 above, the analysis of whether an eligible professional has satisfactorily reported is performed at the individual eligible professional level using the individual-level NPI. The eligible professional’s individual NPI must be listed correctly along with the HCPCS codes for services, procedures, and QDCs on the claim. More information on reporting options for a specific program year is available on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS.