Top 10 questions on 2016 PQRS answered

ivy_lee.jpgBy Ivy Lee, MD

The Physician Quality Reporting System (PQRS) had been a voluntary federal program offering bonus Medicare payments to physicians who report on a designated set of quality measures. While PQRS technically remains voluntary, the 2007 legislation that established the program requires CMS to phase out incentive payments and, instead, apply penalties to physicians who fail to satisfy PQRS reporting requirements. Beginning with the 2015 reporting year, the program transitioned to penalties only.

That can mean incurring a penalty of up to 4-6 percent in Medicare charges (depending on practice size) if you don’t report in 2016! So it’s more important than ever to participate in PQRS. Unfortunately, CMS doesn’t make it simple. Trying to unravel the intricacies of reporting can be daunting. Fortunately, the Academy has many resources to take the pain out of the process. The AAD offers free resources on PQRS and, most importantly, is about to launch a fantastic new member benefit, DataDerm™, a robust clinical data registry that can streamline the PQRS reporting process.

Below are some of the most important things you need to know about 2016 PQRS.

1. Which patients do I actually have to report?
You are only reporting on Medicare Part B patients for PQRS. This can be confusing because the measure specifications often say “regardless of age” in reference to which patients need to be reported. However, this language exists only to account for younger patients (e.g., people with disabilities) who may be on Medicare.

2. How much will I be penalized if I don’t report PQRS in 2016?
The potential payment reduction for not reporting PQRS in 2016 could be up to 6 percent of Medicare charges, depending on the size of the practice (reduction to be applied in 2018). The penalties are broken down as such:
2 percent PQRS payment reduction plus an additional 2 percent value-based payment modifier (VBM) reduction for solo practitioners and groups of up to nine providers. Group practices with 10 or more providers, on the other hand, will automatically receive a 4 percent VBM reduction.

3. How do I know which measures are eligible for PQRS?
The Academy has created a table that lists measures eligible for PQRS.

4. What is a cross-cutting measure and why do I have to report one?
Cross cutting measures are broadly applicable measures that are meant to drive quality and improvement across the house of medicine. Cross-cutting measures are required for all eligible professionals that have a face to face encounter. You should choose the most applicable cross-cutting measure to your practice, but per PQRS requirements, at least one cross-cutting measure must be reported in order to satisfactorily report. For example, if you already ask whether your patients are tobacco users, then measure 226, Tobacco Use; Screening and Cessation Intervention, may be a good cross-cutting measure to report. The AAD staff can help you think about how to integrate at least one cross-cutting measure into your practice or how to capture one that you may already be doing.

5. Do I really have to report nine quality measures?
In 2016, eligible professionals (EPs) must report at least nine quality measures that cover at least three of the National Quality Strategy Domains (NQS), one of which must be a cross-cutting measure.

Confused? Here’s a table to help you avoid penalties:

NQS domains
(report 3 of 6)
Patient Safety  Patient and
Family Engagement
Care Coordination 
Clinical Processes
and Effectiveness
and Public Health
 Efficient Use of
Healthcare Resources

Cross-cutting measures
(report at least 1)
#130: Documentation of
Current Medications
in the Medical Record
 #131: Pain Assessment
and Follow-Up
#226: Preventive Care and Screening:
Tobacco Use:
Screening and Cessation Intervention
#46: Medication Reconciliation Post-Discharge
#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
#47: Care Plan
#317: Preventive Care and Screening:
Screening for High Blood Pressure and Follow-Up Documented
#431: Preventive Care and Screening:
Unhealthy Alcohol Use:
Screening & Brief Counseling

6. Oh, no! I can’t reach the required nine measures. Now what?
If you cannot reach the required nine measures, the Measure Applicability Validation (MAV) exception will apply to you. CMS uses this process to evaluate whether or not EPs could have reported on additional measures, and determines whether or not reporting requirements have been satisfied. Medicare encourages providers to report measures that are relevant to them and that work within the flow of their practice. Only you can consider a measure applicable or relevant to your practice. However, some measures may require clinic flow adjustments that are more efficient and effective in order to accurately reflect the measure.

7. How many measures do I have to meet?
You must have greater than a 0% performance rate for all reported measures in order to report successfully.  However, not every reported patient needs to meet every measure. In addition, each of the quality measures must have at least one eligible instance in order for you to report that measure. For example, since the only applicable diagnosis for measure 138 is a new diagnosis of melanoma, you must see at least one patient with a new diagnosis of melanoma (that is also a Medicare patient) to report measure 138 successfully.

8. What are all of these percentages I keep hearing about? 50% >0%?
The “50%” figure refers to the minimum percentage of patients, or patient visits (depending on the measure), that one must report per measure. This number of patients must be reported whether you successfully perform the measure or not. For example, measure 138, Melanoma: Coordination of Care, only applies to patients with a new diagnosis of melanoma. Therefore, you would report at least 50% of however many patients you had with that diagnosis. Measure 226, Tobacco Use; Screening and Cessation Intervention, on the other hand, applies to all patients who had an office visit in 2016. If choosing to report that measure, you would still have to report at least 50% of those patients, even though it will inevitably be a larger number than for measure 138.

The “0%” figure you may have heard about is the measure performance rate that will not count as successful reporting. If reporting a measure, the measure must be successfully performed at least once.

9. Can I report as a group practice?
Yes, Medicare allows practices of two or more eligible providers to report PQRS as a group (known as the Group Practice Reporting Option or GPRO). To participate, registration with CMS must be completed between April 1 and June 30, 2016. More information about participating as a group is available on the CMS website

10. What is the easiest way to report these measures?
 AAD’s new DataDerm offers an easy, streamlined reporting experience with its PQRS submission option (available for purchase from the AAD Store March 3). The PQRS option is replacing the AAD’s QRS submission tool for 2016 reporting.

DataDerm is a Web-based system  all you need is an Internet connection to use it. Additionally, DataDerm will support group reporting. DataDerm registration will launch in March 2016.

DataDerm additionally provides EHR-facilitated data collection to streamline reporting and minimize your practice’s administrative burden. To take advantage of this opportunity, however, you must register for DataDerm by July 1, 2016. There is also a more streamlined process for paper-based practices that participate in PQRS.  


Dr. Lee is chair of the AAD’s Telemedicine Task Force and a member of the Core Curriculum Task Force.