Urology PQRS Measure Recommendations (2016)

2016 Reporting Options

Read a brief overview about the three options to successfully report PQRS measures in 2016, and access links to learn more.

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Measures Groups Recommendations

Report 20 Patient Visits and be done with PQRS reporting for the year! Cannot be reported by practices that have self-nominated for GPRO.

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Individual Measure Recommendations

Report 50% of the eligible patient visits 9 measures across 3 NQS domains, with 1 measure being a cross-cutting measure.

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MAV Cluster Recommendations

If you cannot identify a Measures Group or 9 Individual Measures across 3 NQS domains, then MAV is for you!

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Simple PQRS reporting starts with PQRSPRO.

2016 Reporting Options

4 Options for Successful 2016 PQRS Registry Reporting

 

1. Measures Group

There are 25 2016 Measures Groups available for individual provider reporting. To meet the reporting requirement, enter data from a minimum of 20 unique patient visits, a majority of which (at least 11) must be Medicare Part B patients. Successfully reporting one Measures Group will qualify you to avoid the -2% PQRS and associated VM payment adjustments in 2018. Note that measures with a 0% Performance Rate (unless an inverse measure) will not count – you must meet the quality action at least once for the selected measures or measures group to successfully avoid the -2% payment adjustment in 2018. As in previous years, dependent on a practice’s specialty and patient population, PQRS 2016 Measures Group reporting is the least time-consuming, most straightforward, efficient, and effective form of registry reporting available; however not all specialties and practices will have an applicable measures group.

(Note: individual providers in practices that registered with CMS for the Group Practice Reporting Option (GPRO) cannot report a measures group.)

2. Individual Measures

There are 281 individual 2016 PQRS measures available for reporting.  Submit at least 50% of your eligible Medicare Part B patient visits for at least 9 individual measures, from at least 3 of the National Quality Strategy (NQS) domains, including at least one cross-cutting measure if you have at least one face-to-face visit, to successfully avoid the -2% Payment Adjustment in 2018. Note that measures with a 0% Performance Rate will not count – you must meet the quality action at least once for the selected measures to successfully avoid the -2% payment adjustment in 2018.

3. CAHPS for PQRS survey in conjunction with Individual Measures

Groups of 2 or more with face-to-face encounters in 2016 that register for the Group Practice Reporting Option (GPRO) can elect to report the CAHPS for PQRS survey measures (representing three (3) PQRS measures) via a qualified CAHPS for PQRS certified survey vendor AND report at least 6 additional measures, covering at least 2 NQS domains, to successfully avoid the -2% PQRS payment adjustment and associated Value-Modifier payment adjustments in 2018. Note that measures with a 0% Performance Rate will not count – you must meet the quality action at least once for the selected measures to successfully avoid the -2% PQRS payment adjustment and associated Value-Modifier payment adjustments in 2018.  If less than 6 measures apply to the group practice and patient population, the group practice must report on at least one MAV Cluster or all applicable measures to successfully the -2% PQRS payment adjustment and associated Value-Modifier payment adjustments in 2018. Note: of the non-CAHPS for PQRS measures reported, if any provider in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the GPRO is also required to report at least 1 cross-cutting measure. If elected, PQRS Measure #321 (Person and Caregiver-Centered Experience and Outcomes) CAHPS for PQRS Clinician/Group Survey will submit the following practice group-level, patient-reported performance considerations to CMS:

  • Getting timely care, appointments, and information;
  • How well providers Communicate;
  • Patient’s Rating of Provider;
  • Access to Specialists;
  • Health Promotion & Education;
  • Shared Decision Making;
  • Health Status/Functional Status;
  • Courteous and Helpful Office Staff;
  • Care Coordination;
  • Between Visit Communication;
  • Helping Your to Take Medication as Directed; and
  • Stewardship of Patient Resources
Strategic Considerations for CAHPS for PQRS
  • Practice groups of 100 or more with face-to-face claims in 2016 that register for the GPRO must report all CAHPS for PQRS survey measures, via a qualified CAHPS for PQRS certified survey vendor, and report at report at least 6 additional measures, covering at least 2 NQS domains, including at least one cross-cutting measure, to successfully avoid the -2% Payment Adjustment and associated VM adjustments in 2018.
  • Practices of 100 or more providers that do not register for GPRO are exempt from reporting CAHPS for PQRS survey measures, as the sample patients for the CAHPS survey are drawn and reported at the aggregate TIN-level, but must then ensure that at least 50% of the providers in the group successfully report PQRS at the individual (NPI/TIN) levelvia another method (registry, claims, EHR, QCDR) to successfully avoid the 2018 PQRS payment adjustment and associated VM adjustments in 2018.

4. Measures Applicability Validation (MAV) Process for Individual Measures reporting

If a patient population/practice/specialty does not meet the required criteria for reporting 9 individual measures and/or cannot cover 3 NQS domains, the submission will be subject to the CMS Measures Applicability Validation (MAV) Process. If a provider or GPRO reports less than 9 measures, the MAV Process allows CMS to conduct a claims audit, applying a ‘clinical relation/domain test’ comparing ‘clusters,’ or sets of closely related measures, to determine whether additional measures and/or domains are applicable to the practice and could/should have been reported. If CMS finds that there are additional measures applicable to the practice within the reporting group or individual providers’ claims for the reporting period, the PQRS submission will fail and will not avoid the -2% Payment Adjustment and associated VM adjustments in 2018.  There are a number of educational resources available on the CMS website regarding the MAV Process.

Note: if a MAV Cluster does not include a cross-cutting measure(s), at least one cross-cutting measure must be also be satisfactorily reported for those individual providers or group practices with face-to-face encounters in order to successfully avoid the -2% Payment Adjustment and associated VM adjustments in 2018.

Measures Group Recommendations

Report 20 Eligible Patients
 One group is successful reporting
Not for GPRO Practices
Must report all measures in group

PRO Tip: For best results, report at least 25 unique patients to accommodate any potential calculation errors.

Individual Measures Recommendations

Report 50% of eligible patient visits for each
Select 9 Individual Measures Covering 3 NQS domains
 At least 1 of the 9 selected measures must be a cross-cutting measure
Must meet numerator requirements at least once for each selected measure.

PRO Tip: For best results, report at least 60% of eligible visits to accommodate any potential calculation errors.

MEASURES

It is also recommended that you review other measures for potential applicability, keeping in mind that claims will be audited by CMS if reporting less than 9 measures in 3 NQS domains.

Individual Measures

21 Perioperative Care: Selection of Prophylactic Antibiotic–First OR Second Generation Cephalosporin

22 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)

23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

*48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

*50 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

*102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

*104 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients

113 Colorectal Cancer Screening

*119 Diabetes: Medical Attention for Nephropathy

143 Oncology: Medical and Radiation–Pain Intensity Quantified

144 Oncology: Medical and Radiation–Plan of Care for Pain

145 Radiology Exposure Time Reported for Procedures Using Fluoroscopy

147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

181 Elder Maltreatment Screen and Follow-Up Plan

238 Use of High-Risk Medications in the Elderly

*265 Biopsy Follow-Up

342 Pain Brought Under Control Within 48 Hours

343 Screening Colonoscopy Adenoma Detection Rate

*358 Patient-Centered Surgical Risk Assessment and Communication

408 Opioid Therapy Follow-up Evaluation

412 Documentation of Signed Opioid Treatment Agreement

414 Evaluation or Interview for Risk of Opioid Misuse

NOTE: Please also review MAV clusters to ensure 2016 CMS PQRS compliance!

Cross-cutting Measures

46 Medication Reconciliation

47 Care Plan

110 Preventive Care and Screening: Influenza Immunization

111 Pneumonia Vaccination Status for Older Adults

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

130 Documentation of Current Medications in the Medical Record

131 Pain Assessment and Follow-Up

134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

236 Controlling High Blood Pressure

317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

321 CAHPS for PQRS Clinician/Group Survey

402 Tobacco Use and Help with Quitting Among Adolescents

*431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

* CMS Proposed 2016 Urology Preferred Specialty Measure Set

MAV Cluster Recommendations

Report 50% of eligible patient visits for each selected measure
Select 1 MAV Cluster
 At least 1 of the selected measures must be a cross-cutting measure
Must meet numerator requirements at least once for each selected measure.

PRO Tip: For best results, report all measures that apply to your practice when applying for MAV.

Cluster 42: Preventive Care

ID Name Cross-Cutting?
#112 2016 PQRS Measure #112: Breast Cancer Screening Yes
#113 2016 PQRS Measure #113: Colorectal Cancer Screening No
#130 2016 PQRS Measure #130: Documentation of Current Medications in the Medical Record Yes
#317 2016 PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Yes

Note: When submitting #130 or #317, they are not subject to MAV for this clinical cluster. It is expected to submit these measures if #112 and/or #113 are submitted. There is no requirement to report both #112 and #113.