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PQRS reporting based on Claims

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If you have not yet read “Getting Started” please refer to Steps 1-5 here, which describe initial steps for PQRS reporting.

Step 6: Decide which reporting option you will use

If you begin reporting after July 1, 2011 the following options are available for reporting through Claims:

  • Report three individual measures for 50% of your Medicare Part B PFS patients seen for 6 months (7/1/2011 through 12/1/2011).
  • Report one Measures Group for 50% of your Medicare Part B PFS patients seen for 6 months (7/1/2011 through 12/1/2011—at least 8 patients).
  • Report one Measures Group for at least 30 unique Medicare Part B PFS patients seen between January 1 and December 31, 2011.

Step 7: Read the CMS PQRS Implementation Guides

Step 8: Select your measures.

Primaris is providing assistance with the following eight individual PQRS measures related to Preventive and Cardiac Care:

You may track and report more than three measures.

Primaris will also help with reporting the Preventive Care Measures Group.

Step 9: Review the Measure Specifications

The measure specifications for the above individual measures can be found here. Specifications for the Preventive Care Measures Group can be found here. The Numerator section contains the quality performance action codes. The Denominator section defines the patient population for inclusion in the measure. Some measures also have exclusions listed. To qualify for the incentive, the correct quality action or exclusion codes will need to be reported on eligible Medicare Part B PFS cases to meet the reporting threshold. Each measure also has a reporting frequency or timeframe requirement. Ensure all members of the team understand their role in addressing services and capturing information in the clinical record.

STEP 10: Flag eligible cases

If your software has the capability, turn-on alerts/flags to help identify eligible PQRS patients as they are seen. Many vendors have pre-defined alerts that align with PQRS measures. If flags can’t be set electronically, determine another method to alert providers.

STEP 11: Record the correct diagnosis, CPT, and Quality Data Codes (QDC) for each measure on the patient bill and submit the bill as usual

Refer to the 2011 PQRS Implementation Guide for details.

QDCs should be submitted on the line item as a zero charge, or with a nominal amount if billing software does not permit a zero charge line item. The charge field cannot be left blank. QDCs will be denied and then passed on for PQRS analysis and payment. You will see a denial code N365 on the Remittance Advice. This code does not mean the data was submitted correctly, only that it was passed on for PQRS analysis. You cannot submit a bill for the sole purpose of PQRS reporting or to correct a PQRS code.

STEP 12: If possible, run monthly monitoring reports on the status of your PQRS patients.

If possible, track your performance by running monthly reports for each of the measures from your Practice Management or EHR software. Your I.T. consultant may be able to schedule a task to automatically run the reports on the same day every month. After identifying patients that have not met the measure, follow-up using reminders. Discuss results among staff and physicians, possibly at monthly meetings, and establish a plan and process for improvement. Performance in quality measures will soon be publicly reported, so you’ll want your rates to be as high as possible.

STEP 13: Log-on to the Primaris website and report numerators and denominators for each provider.

Primaris is hosting a website that will allow you to track your performance, establish benchmarks and compare your performance with other physicians in Missouri and nationwide. Such data will be useful for identifying opportunities for improvement and may be helpful when applying for ACO, medical home, or preferred provider status with payers. This website is free of charge and providers will be de-identified. Contact Primaris to obtain log-in information: aray@primaris.org.


Primaris is providing assistance to Missouri providers with reporting preventive and cardiac care measures in 2011 and 2012. Missouri providers may contact Sandy Pogones, Program Manager Physician Services at spogones@primaris.org phone (573) 673-4531 for assistance.

Providers may also contact the Quality Net Help Desk for assistance: 866-288-8912 TTY/TDD at 877-715-6222 (Monday – Friday 7:00 a.m.-7:00 p.m. CST) email at qnetsupport@sdps.org for assistance.