PQRS: Your Questions Answered

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Each year, the Academy and AAOE receive scores of questions from members about the reporting requirements of the Physician Quality Reporting System (PQRS). While some of the more general questions were answered in last month’s EyeNet—which provided an overview of how you can use the IRIS Registry to report PQRS—the answers to some specific queries are provided here.

Cross-Cutting Measures

Q. What are cross-cutting measures?

A. These are primary care measures that are intended to represent core competencies that apply to multiple specialties.

Q. What measures are considered cross-cutting?

A. The Centers for Medicare & Medicaid Services (CMS) included 19 cross-cutting measures in 2015 PQRS, but not all of them will be an option for ophthalmology practices.

Furthermore, the cross-cutting measures that you can use will also depend on your choice of reporting method—13 of these measures can be reported by claims, 16 by registry (and eight of those are included in the IRIS Registry), 11 by electronic health records (EHR), 10 by the Group Practice Reporting Option (GPRO), two by the Cataracts Measures Group, and one by a CMS-certified survey vendor (CSV).

The eight cross-cutting measures included in the Academy’s IRIS Registry are the following:

• 111 Pneumonia vaccination status for older adults  (claims, registry, EHR, or GPRO)
• 130 Documentation of current medications in the medical record (claims, registry, EHR, or GPRO)
• 226 Preventive care and screening: tobacco use: screening and cessation intervention (claims, registry, EHR, or as part of the Cataracts Measures Group)
• 236 Controlling high blood pressure (claims, registry, or EHR)
• 318 Falls screening for falls risk (EHR or GPRO)
• 374 Closing the referral loop (EHR only)
• 402 Tobacco use and helping with quitting among adolescents (registry).

Note: Two of the measures listed above—318 and 374—are available if you are integrating your EHR with the IRIS Registry, but they are not an option if you are reporting measures manually via the IRIS Registry Web portal.

The 11 other cross-cutting measures are:

• 1 Diabetes hemoglobin A1c poor control (claims, registry, EHR, or GPRO)
• 46 Medication reconciliation (claims or registry)
• 47 Care plan (claims or registry)
• 128 Preventive care and screening: Body mass index screening and follow-up plan (claims, registry, EHR, or GPRO)
• 131 Pain assessment and follow-up (claims or registry)
• 134 Preventive care and screening: Screening for clinical depression and follow-up plan (claims, registry, EHR, or GPRO)
• 182 Functional outcome assessment (claims or registry)
• 240 Childhood immunization status (EHR only)
• 317 Preventive care and screening: Screening for high-blood pressure and follow-up documented (claims, registry, EHR, or GPRO)
• 321 The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for PQRS clinician/ group survey (CSV)
• 400 Hepatitis C: One-time screening for hepatitis C virus for patients at risk (registry only)

Q. What do the immunization and vaccination measures involve?

A. Measure 110 (influenza immunization) requires you to report the percentage of infants aged 6 months and older who either received or reported previous receipt of an influenza immunization.

Measure 111 (pneumonia vaccination status of older adults) requires you to report the percentage of your patients aged 65 or older who have ever received a pneumococcal vaccine. 

Staff members can ask about influenza immunization or pneumonia vaccination when patients in the relevant age group are seen.

Cataracts Measures Group

Q. If I plan to report the Cataracts Measures Group through the IRIS Registry, can I report surgical cases this month?

A. Yes, but it would be preferable to wait until the IRIS Registry Web portal reopens. CMS reapproves the IRIS Registry annually, and once this year’s approval is granted—which is expected to happen in March or April—the Web portal will reopen and you’ll be able to use it to start reporting the Cataracts Measures Group. 

You will need to provide patients with the preoperative visual function survey to fill out prior to surgery, and they will also need to receive the postoperative visual function survey and postoperative satisfaction survey after surgery.

Q. I practice under multiple Tax Identification Numbers (TINs). Do I need to report PQRS from each of my locations?

A. Yes. You must meet the required threshold of patients at each location used to bill Medicare.

Q. If I move to a new practice partway through the year, how do I avoid the PQRS penalty?

A. As with the previous query, you must meet the required threshold of patients for each combination of National Provider Identifier (NPI) and TIN that you are using to bill Medicare.

Performance Evaluation

Q. Is there a way to track your PQRS performance during the year?

A. If you use the IRIS Registry, you will get feedback on your PQRS performance.

If you report via claims this year, you will have access to quarterly reports to keep track of your data submissions status. These will be available via the QualityNet website using your IACS (Individuals Authorized Access to the CMS Computer Services) account, with the first reports available this summer.

Q. What is the Measure-Applicability Validation (MAV) process?

A. If you are reporting individual measures via claims or the IRIS Registry Web portal and you report fewer than the nine measures that are required, the MAV process is used to determine whether you could have reported on any additional measures. At time of press, CMS hadn’t updated the MAV criteria, but it was expected to do so in January and February. CMS stated that it would post a document explaining the 2015 MAV process.

Q. If CMS tells me that I failed to satisfy the reporting requirements for PQRS, is there a way to appeal that decision?

A. There is a process for informal reviews. Typically, requests for these reviews are accepted during the first two months of the penalty year—for 2015 reporting, that would be January and February 2017. These requests can be made on the QualityNet website.

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The authors are Academy staff members from the Governmental Affairs division, Quality of Care department, AAOE, and EyeNet.