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2016 Physician Quality Reporting System (PQRS)Measures Groups Specifications ManualUtilized by Individual Eligible ProfessionalsRegistry ONLY ReportingThis manual contains specific guidance for reporting 2016 Physician Quality Reporting System (PQRS) MeasuresGroups. Measures Groups are a subset of four or more PQRS measures that have a particular clinical condition orfocus in common. Only those measures groups defined in this document can be utilized when reporting themeasures group options. All other individual measures that are included in PQRS but not defined in this manual asincluded in a measures group cannot be grouped together to define a measures group.Version 9.112/18/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 1 of 471
Twenty-five (25) measures groups have been established for 2016 PQRS: Diabetes, Chronic Kidney Disease (CKD),Preventive Care, Coronary Artery Bypass Graft (CABG), Rheumatoid Arthritis (RA), Hepatitis C, Heart Failure (HF),Coronary Artery Disease (CAD), HIV/AIDS, Asthma, Chronic Obstructive Pulmonary Disease (COPD), InflammatoryBowel Disease (IBD), Sleep Apnea, Dementia, Parkinson’s Disease, Cataracts, Oncology, Total Knee Replacement(TKR), General Surgery, Optimizing Patient Exposure to Ionizing Radiation (OPEIR), Sinusitis, Acute Otitis Externa(AOE), Cardiovascular Prevention, Diabetic Retinopathy, and Multiple Chronic Conditions. As required by applicablestatutes, through formal notice-and-comment rulemaking in 2015, these 25 measures groups consist of individualmeasures established for use in the 2016 PQRS. An eligible professional may choose to report one or moremeasures groups through registry-based submission. Note that denominator coding has been modified whennecessary from the original individual measures specified by the measure developer to allow for implementation inPQRS as a measures group. An overview for each measures group is included in this manual followed by specificreporting instructions for each measure within the group.Please note, eligible professionals may choose to pursue more than one 2016 PQRS option. This manual describeshow to implement 2016 reporting of PQRS measures groups to facilitate satisfactory reporting of quality-data byeligible professionals who wish to participate under this reporting alternative. Additional information describing how toimplement 2016 measures groups can be found in the 2016 Physician Quality Reporting System (PQRS) GettingStarted with Measures Groups at: 2016 Physician Quality Reporting System (PQRS) Getting Started with MeasuresGroups.Note: Additional information on how to avoid PQRS payment adjustments can be found through supportingdocumentation available on the CMS website at: Payment Adjustment Information.Measures Groups Reporting Method:20 Patient Sample Method via Registry – 12-month reporting period January 1 through December 31: A participating eligible professional must report on all applicable measures within the selected measuresgroup for a minimum sample of 20 unique patients (or procedures as applicable), a majority of which mustbe Medicare Part B FFS patients, who meet patient sample criteria for the measures group. If the eligibleprofessional does not have at least 11 unique Medicare Part B FFS patients who meet patient samplecriteria for the measures group, the eligible professional will need to choose another measures group orchoose another reporting option. Please refer to the 2016 Physician Quality Reporting System (PQRS)Implementation Guide to determine the proper reporting option.The patient sample for the 20 Patient Sample Method is determined by diagnosis and/or specific encounterparameters common to all measures within a selected measures group. All applicable measures within agroup must be reported for each patient within the sample that meets the criteria (e.g., age or gender)required in accordance with this manual. For example, if an eligible professional is reporting on thePreventive Care Measures Group, the Screening for Osteoporosis for Women Aged 65 -85 Years of Agemeasure would only need to be reported on women age 65-85 years within the eligible professional’s patientsample.Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting themeasures group unless the measure is an inverse measure in which case a 0% would be considered satisfactorilyreporting. An inverse measure with a 100% performance rate will not be counted as satisfactorily reporting themeasures group.Version 9.112/18/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 2 of 471
Table 1 – Table of 176177178Version 9.1Measure TitlePageDiabetes Measures GroupDiabetes: Hemoglobin A1c Poor ControlPreventive Care and Screening: Influenza ImmunizationDiabetes: Eye ExamDiabetes: Medical Attention for NephropathyDiabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – NeurologicalEvaluationPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionChronic Kidney Disease (CKD) Measures GroupCare PlanPreventive Care and Screening: Influenza ImmunizationAdult Kidney Disease: Laboratory Testing (Lipid Profile)Adult Kidney Disease: Blood Pressure ManagementDocumentation of Current Medications in the Medical Record91213141516Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention30Preventive Care Measures GroupScreening for Osteoporosis for Women Aged 65 -85 Years of AgeUrinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence inWomen Aged 65 Years and OlderPreventive Care and Screening: Influenza ImmunizationPneumonia Vaccination Status for Older AdultsBreast Cancer ScreeningColorectal Cancer ScreeningPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanPreventive Care and Screening: Screening for Clinical Depression and Follow-Up PlanPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPreventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingCoronary Artery Bypass Graft (CABG) Measures GroupCoronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patientswith Isolated CABG SurgeryCoronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with IsolatedCABG SurgeryCoronary Artery Bypass Graft (CABG): Prolonged IntubationCoronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection RateCoronary Artery Bypass Graft (CABG): StrokeCoronary Artery Bypass Graft (CABG): Postoperative Renal FailureCoronary Artery Bypass Graft (CABG): Surgical Re-ExplorationRheumatoid Arthritis (RA) Measures GroupRheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD)TherapyPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanPain Assessment and Follow-UpRheumatoid Arthritis (RA): Tuberculosis ScreeningRheumatoid Arthritis (RA): Periodic Assessment of Disease ActivityRheumatoid Arthritis (RA): Functional Status Assessment37404112/18/2015CPT only copyright 2015 American Medical Association. All rights 6676873767880828384Page 3 of 471
Version 9.1Measure TitlePageRheumatoid Arthritis (RA): Assessment and Classification of Disease PrognosisRheumatoid Arthritis (RA): Glucocorticoid ManagementTuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patientson a Biological Immune Response ModifierHepatitis C Measures GroupHepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating TreatmentHepatitis C: HCV Genotype Testing Prior to TreatmentHepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 WeeksAfter Initiation of TreatmentDocumentation of Current Medications in the Medical RecordHepatitis C: Hepatitis A VaccinationPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionHepatitis C: Discussion and Shared Decision Making Surrounding Treatment OptionsHepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisHeart Failure (HF) Measures GroupHeart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin ReceptorBlocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)Care PlanPreventive Care and Screening: Influenza ImmunizationDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCoronary Artery Disease (CAD) Measures GroupCoronary Artery Disease (CAD): Antiplatelet TherapyCoronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) orLeft Ventricular Systolic Dysfunction (LVEF 40%)Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCoronary Artery Disease (CAD): Symptom ManagementHIV/AIDS Measures GroupCare PlanPreventive Care and Screening: Screening for Clinical Depression and Follow-Up PlanHIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) ProphylaxisHIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionHIV Viral Load SuppressionPrescription of HIV Antiretroviral TherapyHIV Medical Visit FrequencyAsthma Measures GroupAsthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care SettingPreventive Care and Screening: Influenza ImmunizationPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionTobacco Use and Help with Quitting Among Adolescents85868812/18/2015CPT only copyright 2015 American Medical Association. All rights 56163165166167169170171Page 4 of 471
MeasureNumberMeasure TitlePageOverview4751Chronic Obstructive Pulmonary Disease (COPD) Measures 82283284286287288Overview47289290291292Version 9.1Care PlanChronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation180181Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy182Preventive Care and Screening: Influenza ImmunizationPneumonia Vaccination Status for Older AdultsDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionInflammatory Bowel Disease (IBD) Measures Group183184185186192Preventive Care and Screening: Influenza Immunization194Pneumonia Vaccination Status for Older AdultsPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionInflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy195196197Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury– Bone Loss AssessmentInflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before InitiatingAnti-TNF (Tumor Necrosis Factor)TherapyInflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status BeforeInitiating Anti-TNF (Tumor Necrosis Factor) TherapySleep Apnea Measures GroupPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionSleep Apnea: Assessment of Sleep SymptomsSleep Apnea: Severity Assessment at Initial DiagnosisSleep Apnea: Positive Airway Pressure Therapy PrescribedSleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapyDementia Measures GroupCare PlanPreventive Care and Screening: Screening for Clinical Depression and Follow-Up PlanDementia: Staging of DementiaDementia: Cognitive AssessmentDementia: Functional Status AssessmentDementia: Neuropsychiatric Symptom AssessmentDementia: Management of Neuropsychiatric SymptomsDementia: Counseling Regarding Safety ConcernsDementia: Counseling Regarding Risks of DrivingDementia: Caregiver Education and SupportParkinson’s Disease Measures GroupCare PlanParkinson’s Disease: Annual Parkinson’s Disease Diagnosis ReviewParkinson’s Disease: Psychiatric Disorders or Disturbances AssessmentParkinson’s Disease: Cognitive Impairment or Dysfunction AssessmentParkinson’s Disease: Querying about Sleep Disturbances19912/18/2015CPT only copyright 2015 American Medical Association. All rights 1232233234236237239240250252253254255256Page 5 of 471
Version 9.1Measure TitlePageParkinson’s Disease: Rehabilitative Therapy OptionsParkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment OptionsReviewedCataracts Measures GroupDocumentation of Current Medications in the Medical RecordCataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryCataracts: Complications within 30 Days Following Cataract Surgery Requiring AdditionalSurgical ProceduresPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCataracts: Improvement in Patient’s Visual Function within 90 Days Following CataractSurgeryCataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryCataract Surgery with Intra-Operative Complications (Unplanned Rupture of PosteriorCapsule Requiring Unplanned Vitrectomy)Cataract Surgery: Difference Between Planned and Final RefractionOncology Measures GroupBreast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ProgesteroneReceptor (ER/PR) Positive Breast CancerColon Cancer: Chemotherapy for AJCC Stage III Colon Cancer PatientsPreventive Care and Screening: Influenza ImmunizationDocumentation of Current Medications in the Medical RecordOncology: Medical and Radiation – Pain Intensity QuantifiedOncology: Medical and Radiation – Plan of Care for PainPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionTotal Knee Replacement (TKR) Measures GroupDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionTotal Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical)TherapyTotal Knee Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationTotal Knee Replacement: Preoperative Antibiotic Infusion with Proximal TourniquetTotal Knee Replacement: Identification of Implanted Prosthesis in Operative ReportGeneral Surgery Measures GroupDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionAnastomotic Leak InterventionUnplanned Reoperation within the 30 Day Postoperative PeriodUnplanned Hospital Readmission within 30 Days of Principal ProcedureSurgical Site Infection (SSI)Patient-Centered Surgical Risk Assessment and CommunicationOptimizing Patient Exposure to Ionizing Radiation (OPEIR) Measures GroupOptimizing Patient Exposure to Ionizing Radiation: Utilization of a StandardizedNomenclature for Computed Tomography (CT) Imaging DescriptionOptimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose RadiationImaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesOptimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose IndexRegistry12/18/2015CPT only copyright 2015 American Medical Association. All rights 31332333335344346347348Page 6 of 471
on 9.1Measure TitlePageOptimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) ImagesAvailable for Patient Follow-up and Comparison PurposesOptimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography(CT) Studies Through a Secure, Authorized, Media-Free, Shared ArchiveOptimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imagingfor Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesSinusitis Measures GroupDocumentation of Current Medications in the Medical RecordPain Assessment and Follow-UpPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionAdult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without ClavulanatePrescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)Acute Otitis Externa (AOE) Measures GroupAcute Otitis Externa (AOE): Topical TherapyAcute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of InappropriateUseDocumentation of Current Medications in the Medical RecordPain Assessment and Follow-UpFalls: Risk AssessmentFalls: Plan of CarePreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPreventive Care and Screening: Screening for High Blood Pressure and Follow-UpDocumentedCardiovascular Prevention Measures GroupDocumentation of Current Medications in the Medical RecordIschemic Vascular Disease (IVD): Use of Aspirin or Another AntithromboticPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionControlling High Blood PressurePreventive Care and Screening: Screening for High Blood Pressure and Follow-UpDocumentedStatin Therapy for the Prevention and Treatment of Cardiovascular DiseaseDiabetic Retinopathy Measures GroupDiabetes: Hemoglobin A1c Poor ControlDiabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Levelof Severity of RetinopathyDiabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareDiabetes: Eye ExamDocumentation of Current Medications in the Medical RecordPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPreventive Care and Screening: Screening for High Blood Pressure and Follow-UpDocumentedMultiple Chronic Conditions Measures GroupCare PlanPreventive Care and Screening: Influenza ImmunizationPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan34912/18/2015CPT only copyright 2015 American Medical Association. All rights 21422423432435436437Page 7 of 471
MeasureNumber130131134154155238Version 9.1Measure TitleDocumentation of Current Medications in the Medical RecordPain Assessment and Follow-UpPreventive Care and Screening: Screening for Clinical Depression and Follow-Up PlanFalls: Risk AssessmentFalls: Plan of CareUse of High-Risk Medications in the Elderly12/18/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page439440442444446447Page 8 of 471
DIABETES MEASURES GROUP OVERVIEW2016 PQRS OPTIONS FOR MEASURES GROUPS:2016 PQRS MEASURES IN DIABETES MEASURES GROUP:#1Diabetes: Hemoglobin A1c Poor Control#110 Preventive Care and Screening: Influenza Immunization#117 Diabet
measure would only need to be reported on women age 65-85 years within the eligible professional’s patient sample. Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group unless the measure is an inverse measure in which case a 0% would be considered satisfactorily
