Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

PQRS: Getting Started for 2016


Ready to begin another year of PQRS reporting? Here are a few steps to get you started for 2016.

Step 1: Select Individual or Group Reporting

Determine whether you will participate as individual providers or as a group with other members of your practice (grouped by Tax ID Number [TIN]). (Remember, to avoid the automatic value-based payment modifier (VBPM) payment adjustment for 2018, your group must avoid the 2018 PQRS payment adjustment as a group or 50 percent or more of the individual providers in your group must avoid the 2018 PQRS payment adjustment as individuals.)

Step 2: Choose Your Reporting Option

As you are determining whether you will participate as a group or individual, remember the following reporting options are available for each. Keep in mind that there are no hardship or low volume exemptions from the PQRS program. All providers must report PQRS via one of the options below. If you are participating as a group, select measures that broadly cover your practice’s services. If you are reporting as individuals, be sure to choose individual measures for each physician that will be applicable to that provider’s practice. Reporting no measures under any reporting option will result in a 2 percent negative payment adjustment as well as put that individual and/or the group at risk for the additional 2 or 4 percent VBPM negative payment adjustment.


  • Claims
  • Qualified Registry (requires choosing a registry vendor to submit on your behalf, usually at a cost per provider)
  • EHR (EHR product must be certified for the PQRS program)
  • Qualified Clinical Data Registry (QCDR) (requires choosing a clinical data registry vendor to submit on your behalf, often at a cost per provider)

Group (GPRO):

Step 3: Note Special Reporting Guidelines

Generally, for all reporting options except web interface, to avoid the 2 percent payment adjustment in 2018, individual or group providers will need to report on 9 or more quality measures covering 3 or more National Quality Strategy Domains (NQSD).


  • If a group or individual reporting via claims or qualified registry sees at least one Medicare patient in a face-to-face encounter, as least one measure of the required nine must be chosen from the list of cross-cutting measures.
  • The Measure Applicability Validation will apply for groups or individuals who successfully report only 1-8 measures or 9 or more measures in 1 or 2 NQSDs in either the claims or qualified registry reporting options.
  • Measures or measures groups reported with a 0 percent performance rate will not be counted for groups or individuals reporting via claims or qualified registry.
  • Measures groups are reportable only via qualified registry for individual providers. Providers choosing this option must report at least 1 measures group and report each measures group for at least 20 patients, the majority (11 patients) of which are required to be Medicare Part B FFS patients.


  • If an individual is reporting via QCDR, then at least 2 of the measures must be outcome measures. If 2 outcome measures are not available, individuals should report on at least 1 outcome measure and at least 1 of the following types of measures – resource use, patient experience of care, efficiency/appropriate use, or patient safety.


  • If groups choose to report the CAHPS for PQRS measures with a CMS Certified Survey Vendor in addition to EHR, Qualified Registry, or QCDR, then the number of measures reported via EHR, Qualified Registry, or QCDR drops to 6 over 2 NQSD.


  • For groups or individuals choosing the EHR option, if the direct EHR product or EHR data submission vendor product does not contain patient data for at least 9 measures covering at least 3 domains, then the group practice or individual must report the measures for which there is patient data. A group practice must report on at least 1 measure for which there is Medicare patient data.


  • Groups choosing the web interface must report all measures included in the web interface and populate data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, then the group practice must report on 100 percent of assigned beneficiaries.
  • Groups of 100 or more participating as a group must report the CAHPS for PQRS regardless of which GPRO option they choose. CAHPS is optional for groups of 25-99.

Step 4: Choose Your Measures

To help with choosing measure, the Centers for Medicare and Medicaid Services (CMS) is collaborating with specialty societies to provide suggested Specialty Measure Sets that identify measures associated within a particular clinical area. The Specialty Measure Sets are to be utilized as a guide to assist eligible professionals in choosing measures applicable to their specialty in 2016. The Specialty Measure Sets are NOT required measures but are suggested measures for a specific specialty. (NOTE: CMS published the proposed specialty sets with measures that were proposed for 2016, but they have not yet updated the lists to reflect the finalized measures for 2016. As you are selecting measures for your specialty from the proposed lists, be sure to compare them with the overall finalized lists of measures linked below.)

Lists and information about 2016 PQRS measures are available on the CIPROMS website. One list contains all claims and registry measures and can be sorted and/or filtered by denominator codes and reporting option. A second list contains all measures and can be sorted and/or filtered by reporting option and NQS domain. Check all measures chosen with the specifications outlined by CMS in their 2016 individual measures specifications, available for download from the CMS PQRS web page.

Step 5: Take the Next Steps

  • Work with all stakeholders in your practice to specify what actions need to be taken and how data will be collected for your chosen measures.
  • For the claims option, determine how the data you collect will be passed along to coders and billing specialists for inclusion on the claims immediately for 2016 dates of service.
  • If you are reporting via a qualified registry, qualified clinical data registry, or EHR, begin researching vendors and contacting them for reporting costs and specifications. Those specifications may guide how you will collect data beginning in January.
  • If you are participating in any of the GPRO options, make sure you are registered for the physician value portlet at the CMS.gov Enterprise Portal. For the 2016 reporting year, groups must register for GPRO before June 30, 2016.

Remember, 2016 is the last reporting year for PQRS, and 2018 will be the last year for PQRS payment adjustments. Beginning with the 2017 reporting year (which will affect the 2019 payment year), physicians will be subject to the guidelines of the Merit-Based Incentive Payment System (MIPS), mandated through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) back in April 2015.

For more information about the 2016 PQRS reporting year for the 2018 payment adjustment, visit CMS’s PQRS webpage. Resources are being updated regularly for the new program year. Also, you can review the slides from a recent MLN Connects National Provider Call on the 2016/2018 PQRS and VBPM Programs.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by Stephen Kruso via Flickr used with permission under the Creative Commons License.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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