As a national coding and reimbursement expert for nearly twenty years, multiple coding/billing certification and credentials, and commercial payer work experience to boot, I thought learning PQRS would be, well, pretty easy. I mean becoming a national expert in E&M coding, mastering ICD-9 and now ICD-10, understanding community health center coding and billing amidst a combination of ANSI 837s (I, P, and D) as well as remits via 835 files… certainly a few weeks of quick study should get me pretty up to speed. Wow, was I wrong. The system is complex and onerous. And it’s not just learning the system; collecting and reporting is challenging.

Here is a quick Q&A format to show what I think I’ve learned (and think you should know) about the basic ABCs of PQRS:

Q: What is PQRS?

A: A quality program initiated by CMS in 2007 focused on lowering health care expenses per beneficiary, elevating care quality, and improving the patient experience.

Q: Who does it impact?

A1: Eligible Professionals or EPs. EPs are essentially any provider using an individual NPI to be paid from Medicare Part B via the fee-for-service (FFS) physician/professional fee schedule (PFS).

A2: If you are part of a Medicare Shared Savings Program (MSSP) or an Accountable Care Organization (ACO) you may not need to submit PQRS if these entities are doing so on your behalf:

Q: Why should EPs care?

A1: PQRS is part of CMS responding to a congressional mandate to see 50% of all payments (by 2019) be distributed/impacted by Alternate Payment Methodologies.

A2: EPs who don’t meet PQRS requirements see their FFS dollars penalized; e.g., 2% in 2018 for failure to successfully report in 2016 escalating up to 9% by 2022.

A3: Opportunity to share in monies recovered from unsuccessful EPs… some in 2016 seeing as much as a 30% increase.  In short, those who do well keep more of the fixed pool of federal money, those who don’t report well get paid less.

A4: We led with the money in this questions because, as they say “it’s never money, but it’s always the money…” yet the ability to positively impact quality of care is essential to PQRS (and MIPS moving forward) as it reflects the true program intent.

Q: What is a PQRS measure?

A: Each measure is a distinct clinical scenario with a defined denominator and numerator whose quotient is used to determine whether a measure has been successfully met (passed) or not (failed).

Q: How many measures are there?

A: There are more than 400 measures.

Q: How should an EP select optimal measures?

A: First, an EP must decide how they will report choosing from 3 options:

  1. Measures Group (these are clusters of measures centered around a disease state) reported individually by each provider on 20 patient encounters for the reporting period.
  2. Individual Measures: Choose 9 and report on greater than 50% of the EP’s Medicare Part B FFS patient population for the reporting period
  3. Group Practice Reporting Option (GPRO; best for practice with 2+ EPs and easiest in terms of compliance)

Q: What are the requirements for the reporting options?

A: Depending options selected, following are the requirements:

  1. Measures Group: Report only 20 patients with 50% (at least 11) being Medicare Part B FFS. This is the easiest and recommended option for most practices
  2. Individual measures: EPs, like GPRO, 9 measures across 3 NQS domains
    NOTE: NQS = National Quality Service domains are the categories under which measures are classified.
  3. Group Practice Reporting Option (GPRO): Select 9 measures with three 3 NQS domains for > 50% of ALL Medicare Part B patients in the group practice in the reporting season. The entire group reports just once vs. once for each EP. Great news except i f the measures fail, ALL group members fail. Most of P360’s GPRO submitters pass but want folks aware of the risk.

Q: How do EPs submit data?

A: Through a CMS approved registry like Patient360 ( You can’t (except through CEHRT) submit directly so find a partner you trust and make it happen.

Q: What if an EP cannot find measures that work for his/her practice?

A: This should be rare but if it does happen, EPs may enter the Measure Applicability Validation (MAV) process. In short, it is a process to determine whether there really were no measures that worked for you OR you are just filing late and want a “get out of jail free” card. The former often works but the latter, not. Remember, MAV is a last resort and once an EP or a group of EPs enter MAV, there are no guarantees that PQRS penalty will be avoided.

There are always more questions, but these are the ones that seem most important for neophytes. If you have more questions, call us at Patient360 or any other registry. You can also research mountains of information online. Regardless of how, start learning now so your practice may master quality data submission to see improved patient care and optimize income from CMS and other early-adopting third party payers.