Physician Quality Reporting System | Choosing PQRS Measures
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PQRS – Choosing Measures

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What PQRS measures are available for reporting through IM’s quality module?

5 – Heart Failure: ACE Inhibitor or ARB Therapy for LVSD (R)
6 – Coronary Artery Disease: Oral Antiplatelet Therapy Prescribed
20 – Perioperative Care: Timing of Antibiotic Prophylaxis
21 – Perioperative Care: Selection of Prophylactic Antibiotics
22 – Perioperative Care: Discontinuation of Prophylactic Antibiotics
23 – Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis
31 – Stroke and Stroke Rehab: DVT Prophylaxis for Ischemic Stroke or Intercranial Hemorrhage
32 – Stroke and Stroke Rehab: Discharged on Antiplatelet Therapy
33 – Stroke and Stroke Rehab: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge (R)
35 – Stroke and Stroke Rehab: Screening for Dysphagia
36 – Stroke and Stroke Rehab: Consideration of Rehabilitation Services
47 – Advance Care Plan
76 – CVC Insertion Protocol: Sterile Barriers
111 – Preventive Care and Screening: Pneumonia Vaccination for Patients 65 and Older
130 – Documentation of Current Medications in the Medical Record
134 – Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
173 – Preventive Care and Screening: Unhealthy Alcohol Use – Screening

How many measures should we activate?

The minimum reporting requirement for successful participation is 3 measures. IM recommends activating at least 4 or 5 measures in order to allow for variation among your combinations of providers and patients throughout the year and afford the best opportunity for each of your providers to trigger at least three measures. Activation of more than 5 measures is typically not necessary if appropriate measures are selected.

Will it overwhelm my physicians if we turn on more than the required minimum of 3 measures?

Not likely. Even when activating closely related measures, each measure typically triggers on a different subset of CPTs, so it is rare for more than a measure or two to trigger on a patient on any given day. Since many measures also require an ICD component to trigger, the majority of patients seen throughout the day will typically not result in any measure triggering either. With most measures, providers typically see an extremely low number of triggers during the course of any given week (or month).

How can we determine which quality measures are best for our practice to report?

IM has extensive experience identifying collections of measures that apply to typical hospitalist and various specialist practices. Based on your billing patterns, we can recommend an assortment of reporting options to meet your participation needs.

Why can’t we just activate any measure that seems like it would apply to our practice?

In many cases, the title of PQRS measures can be misleading. References to clinical conditions that a practice typically deals with does not necessarily mean that the measures will apply to the specific billing patterns typical to that practice.

Can IM analyze our billing to determine which measures best apply to my group?

Yes. Typically, IM has conducted analyses on enough groups within each of the major specialties that we can recommend a predetermined list of applicable measures based on specialty alone. In cases where groups may have unusual specialties or unique billing patterns, an analysis specific to that group can be performed.

Why does IM specifically recommend against using certain measures?

Some measures are reportable only by registry (claims data submitted for those measures will be ignored by CMS). Those measures are not recommended for groups that do not intend to submit their participation data through IM’s registry service. Other measures have specific aspects of their definitions (as adopted by CMS) that make answering the measure questions difficult for many providers. One example of this type of situation would be stroke measures that ask clinical questions related to discharge orders, but trigger (and, therefore, require answers in order to meet reporting requirements) on admission or follow-up codes. Relying on the provider to remember a measure triggered on admission still needs answering at discharge can be problematic (especially when they may not end up being the discharging physician). Charge lag settings for concurrent billing practices and/or registry participation can mitigate some of these effects, but cannot automatically correct for all of them. Other measures are defined in ways that don’t allow the physician to indicate a valid reason for a measure action not having been performed, other than take the blame themselves as simply not having done it, which damages their individual performance ratings. As each year’s measures are defined and updates by CMS, IM will review the measure options and make specific recommendations about measures that have favorable and unfavorable definitions for participating groups.

Can IM build custom measures for our practice if we would like to report a measure not currently offered?

IM can create custom measures, but we would need to analyze the group’s billing history to validate their ability to participate with the requested measure. In the event we determine measures already available through the application better meet the participation requirements of the group, there may be a fee associated with the custom development of any additional measures. We have yet to find a practice, hospitalist or specialty, that require measures outside of the list already offered within IM.

What are the questions and triggering codes associated with each of the available measures?

The definitions for measures potentially change with the start of each participation period. We keep this information in a separate document so it can be updated whenever measure definitions change or new measure choices are added.


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