The Centers for Medicare & Medicaid Services (CMS) has continued the Physician Quality Reporting System (PQRS) program into 2013 as required under the Medicare Improvements for Patients and Providers Act of 2008. PQRS is the first CMS-crafted national program to link the reporting of quality data to physician payment. Eligible professionals (EPs) who successfully participate in the PQRS program receive incentive payments.
The incentive payment for the 2013 and 2014 reporting years is 0.5 percent of the total allowed charges for Medicare Part B professional services covered in the physician fee schedule and furnished during the respective reporting period. There are penalties for nonparticipation, which are imposed two years following a calendar year of participation. For example, EPs who are unsuccessful PQRS participants in 2013 may be subject to a penalty in 2015. Table 1 illustrates the incentive and penalties for 2013–2015.
Table 1. PQRS payment incentives and penalties
| Reporting year | Incentive | Penalty |
| 2013 | 0.50% | – |
| 2014 | 0.50% | – |
| 2015 | – | 1.50% |
| 2016 and beyond | – | 2.00% |
EPs who previously reported to the PQRS program should note that 2013 PQRS now includes 259 individual quality measures and 22 that are part of a 2013 measures group. Although some 2012 PQRS quality measures and measures groups have been continued under the 2013 PQRS, measures specifications may have been updated for 2013. Surgeons who currently are reporting to the 2013 PQRS are encouraged to review the 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures for updates and changes to the individual measures. The manual is available at this website. EPs may also refer to the 2013 PQRS Measures Groups Specifications Manual for updates and changes in the measures groups. The measures are available here.
This column focuses on the perioperative care PQRS measures group because it is the one surgeons use most frequently. It is important to note that although the perioperative measures group includes individual quality measures, the denominator coding has been modified from the individual measures to allow for implementation as a group. The 2013 PQRS Measures Groups Specifications Manual serves as an essential resource when reporting a PQRS measures group, and the April issue of the Bulletin provides an overview of the changes in PQRS for 2013.* Measures in the perioperative care group may be reported using the claims or registry method. This column focuses on the claims-based method.
First steps in reporting
The first step in reporting to PQRS is to identify applicable measures groups for professional services routinely provided using the 2013 PQRS Measures Groups Specifications Manual. Next, select the measures group that makes sense based on prevalence and volume, as well as individual or practice performance analysis and improvement priorities.
The perioperative measures group includes the following 2013 PQRS measures†:
- #20—Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician
- #21—Perioperative Care: Selection of Prophylactic Antibiotic – First or Second Generation Cephalosporin
- #22—Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
- #23—Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in All Patients)
The instructions in the 2013 PQRS Measures Groups Specifications Manual explain when, how, and who should report. CMS specifically requires that group code G8492 be reported to indicate the intention to report the perioperative measures group. The code should be reported at least once during the January 1–December 31, 2013, reporting period. However, this code is only used when billing a claim for the 20 Medicare patients claims-based option. It is recommended that surgeons report G8492 more than once during the reporting period in the event a claim with the intent code does not go through. The instructions also include the patient sample criteria. Table 2 lists the specific surgical procedure codes that can be reported for the perioperative measures group.†
Table 2. Perioperative measures group surgical procedural codes3
| 0236T, 15734, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 19260, 19271, 19272, 19300, 19305, 19306, 19307, 19316, 19318, 19324, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 21627, 21632, 21740, 21750, 21805, 21825, 22558, 22600, 22612, 22630, 27080, 27125, 27130, 27132, 27134, 27137, 27138, 27158, 27202, 27235, 27236, 27244, 27245, 27269, 27280, 27282, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27880, 27881, 27882, 27884, 27886, 27888, 31760, 31766, 31770, 31775, 31786, 31805, 32096, 32097, 32098, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32215, 32220, 32225, 32310, 32320, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32491, 32505, 32506, 32507, 32800, 32810, 32815, 32900, 32905, 32906, 32940, 33020, 33025, 33030, 33031, 33050, 33300, 33310, 33320, 33877, 33880, 33881, 33883, 33886, 33889, 33891, 34051, 34800, 34802, 34803, 34804, 34805, 34812, 34820, 34825, 34830, 34831, 34832, 34833, 34834, 34900, 35011, 35013, 35021, 35081, 35082, 35091, 35092, 35102, 35103, | 35131, 35141, 35142, 35151, 35152, 35206, 35216, 35246, 35266, 35271, 35276, 35301, 35311, 35363, 35371, 35372, 35460, 35512, 35521, 35522, 35523, 35525, 35526, 35533, 35537, 35538, 35539, 35540, 35556, 35558, 35565, 35566, 35570, 35571, 35572, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 36830, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37235, 37616, 37617, 38100, 38101, 38115, 38120, 38381, 38571, 38572, 38700, 38720, 38724, 38740, 38745, 38746, 38747, 38760, 38765, 38770, 38780, 39000, 39010, 39200, 39220, 39545, 39561, 43020, 43030, 43045, 43100, 43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43130, 43135, 43279, 43280, 43281, 43282, 43300, 43305, 43310, 43312, 43313, 43314, 43320, 43325, 43327, 43328, 43330, 43331, 43332, 43333, 43334, 43335, 43336, 43337, 43340, 43341, 43350, 43351, | 43352, 43360, 43361, 43400, 43401, 43405, 43410, 43415, 43420, 43425, 43496, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43635, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43800, 43810, 43820, 43825, 43830, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880, 44005, 44010, 44020, 44021, 44050, 44055, 44120, 44125, 44126, 44127, 44130, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 45000, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45395, 45397, 45400, 45402, 45540, 45541, 45550, 45560, 45562, | 45563, 45800, 45805, 45820, 45825, 47100, 47120, 47122, 47125, 47130, 47140, 47141, 47142, 47350, 47400, 47420, 47425, 47460, 47480, 47560, 47561, 47562, 47563, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47630, 47700, 47701, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47802, 47900, 48000, 48001, 48020, 48100, 48102, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 48554, 48556, 49000, 49002, 49010, 49020, 49021, 49040, 49041, 49060, 49203, 49204, 49205, 49215, 49220, 49250, 49320, 49321, 49322, 49323, 49505, 49507, 49568, 50320, 50340, 50360, 50365, 50370, 50380, 57267, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58951, 58953, 58954, 58956, 60521, 60522, 61312, 61313, 61315, 61510, 61512, 61518, 61548, 61697, 61700, 62230, 63015, 63020, 63047, 63056, 63081, 63267, 63276, 64746. |
Denominator, frequency, and numerator
The Current Procedural Terminology (CPT)‡ codes and patient demographics outlined in the patient sample criteria identify the patients who are included in the measures group, otherwise known as the “denominator.” The instructions further note that “CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, i.e., dual procedures), will be included in the denominator population. Both surgeons participating in PQRS will be fully accountable for the clinical action described in the measure.”†
“Frequency” refers to how often the measure should be reported. To successfully report the perioperative measures group, quality data codes (QDCs) must be reported for all four measures, #20, #21, #22, and #23, for each patient each time a surgical procedure is performed during the reporting period. QDCs are CPT II codes that are used to report the clinical action required by the measure on the claims form, otherwise known as the “numerator.” The specifications include instructions for reporting each measure.
The specifications for the perioperative measures group indicate that QDCs must be reported on all measures within the group. The specifications include a description and numerator for all four measures. When encountering a patient in the denominator, a QDC for each measure should be reported. If all quality actions for the patient are performed for each measure, G8501 may be reported on the claim instead of the individual QDCs. G8501 may not be used when reporting on a patient with a G8631 or G8632 for measure #20, or an 8P or 1P modifier for measures #21, #22, and #23. For claims-based reporting of measure groups, all measures within the group must be reported for each of the unique 20 Medicare Part B fee-for-service patients within the sample population seen by the EP from January 1 through December 31, 2013, reporting period.
Likewise, measures groups containing a measure with a 0 percent performance rate will not be counted as satisfactorily reporting the measures group. A 0 percent performance rate can result if a single measure is reported with all 8P modifiers, for measures #21, #22, and #23, or all G8632, for #20, or a combination of 8P or G8632 with 1P or G8631 for a single measure for the 20 Medicare patient sample. Beginning on page 64 of the 2013 PQRS Measures Groups Specifications Manual, the numerators are listed for measures #20, #21, #22, and #23. Refer to Table 3 for QDCs associated with each measure.
Table 3. QDCs for #20, #21, #22, and #23 PQRS Perioperative Measures Groups5
| #20—Perioperative Care: Timing of Prophylactic Parenteral Antibiotic—Ordering Physician | |
| Report one code for timing of prophylactic parenteral antibiotic ordered or given, or report one code for not ordered within specified time frame. | |
| Documentation of order for prophylactic parenteral antibiotic (written order, verbal order, or standing order/protocol) | G8629 |
| Documentation that prophylactic parenteral antibiotic has been given within one hour prior to the surgical incision (or start of procedure when no incision is required) | G8630 |
| Order for prophylactic parenteral antibiotic not given for documented reasons | G8631 |
| Order for administration of prophylactic parenteral antibiotic not given, reason not given | G8632 |
| #21—Perioperative Care: Selection of Prophylactic Antibiotic—First or Second Generation Cephalosporin | |
| Report one code for selection of prophylactic antibiotic, or report one code for not ordered/given. | |
| Documentation of order for cefazolin OR cefuroxime for antimicrobial prophylaxis (written order, verbal order, or standing order/protocol) | 4041F |
| Order for first or second generation cephalosporin not ordered for medical reasons | 4041F-1P |
| Order for first or second generation cephalosporin not ordered, reason not otherwise specified | 4041F-8P |
| #22—Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | |
| Report one code for timing of prophylactic parenteral antibiotic. If prophylactic parenteral antibiotic given intraoperatively or within four hours prior to surgical incision, report one code for discontinuation of prophylactic parenteral antibiotics or one code for not ordered to be discontinued. | |
| Documentation that prophylactic antibiotics were given neither within four hours prior to surgical incision nor given intraoperatively | 4042F |
| Documentation that prophylactic antibiotics were given within four hours prior to surgical incision or given intraoperatively and documentation that order was given to discontinue prophylactic antibiotics within 24 hours of surgical end time, noncardiac procedure | 4046F and 4049F |
| Documentation that prophylactic antibiotics were given within four hours prior to surgical incision or given intraoperatively and documentation of medical reason(s) for not discontinuing prophylactic antibiotics within 24 hours of surgical end time | 4046F and 4049F-1P |
| Documentation that prophylactic antibiotics were given within four hours prior to surgical incision or given intraoperatively and order was not given to discontinue prophylactic antibiotics within 24 hours of surgical end time, noncardiac procedure, reason not otherwise specified | 4046F and 4049F-8P |
| #23—Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in All Patients) | |
| Report one code for VTE prophylaxis or one code for not ordered or given. | |
| Appropriate VTE prophylaxis ordered | 4044F |
| VTE prophylaxis not ordered for medical reasons | 4044F-1P |
| VTE prophylaxis not ordered, reason not otherwise specified | 4044F-8P |
Step-by-step guide to submitting a claim form
CPT II codes may be reported on claim form CMS 1500 or via electronic form ASC X 12N Health Care Claim Transaction, Version 5010.
Step 1: If your Medicare patient is age 18 or older on the date of the encounter, look in the measure specifications for the perioperative measures group to see if the CPT code is listed in the table of surgical procedures for which there are indications for a prophylactic antibiotic (including first or second generation cephalosporin) and VTE prophylaxis. If so, continue to step 2.
Step 2: On the CMS 1500 claim form, list, for example, the CPT procedure code 44120 on line 1.
Step 3: On lines 2 through 5, list the CPT II codes, or QDCs, based on the numerator actions.
Step 4: On the following lines, list CPT II codes that correspond to PQRS measures #20, #21, #22, and #23. (Refer to Table 3.) Or, if all quality actions for the patient have been performed for each of the four measures, G8501 may be reported. However, G8501 may not be reported if any of the QDCs with the 8P modifier, 1P modifier, G8631, or G8632 have been selected.
Step 5: Be sure billing software and clearinghouse can correctly submit PQRS CPT II codes or QDCs.
Step 6: Regularly review the remittance advice notice from the carrier to ensure the denial remark code N365 is listed for each QDC submitted. This notification indicates that claims have made it to the CMS national claims history file. If a remittance advice does not display the N365 denial remark code, make sure to check to see that the QDC line items are listed.
Surgical practices that follow these steps should be able to successfully report to PQRS 2013 using the claims-based methodology and receive incentive payments. Along with this approach, there are six other options for reporting to PQRS 2013 (see Table 4).
Table 4. PQRS reporting options matrix
| Claims-based methods | Registry-based methods | Electronic health record (EHR)-based methods (via a qualified direct EHR product or data submission vendor) | ||
| Full-year period | Individual measures | 1. At least three PQRS measures for 50% of applicable Medicare Part B fee-for-service (FFS) patients of each EP. Allowed to report one or two if less than three apply. | 3. At least three PQRS measures for 80% of applicable Medicare Part B FFS patients of each EP. | 6. (A) Report on all three PQRS EHR measures that are also Medicare EHR Incentive Program core measures.If the denominator for one or more of the Medicare EHR Incentive Program core measures is 0, report on up to three PQRS EHR measures that are also Medicare EHR Incentive Program alternate core measures; and Report on three additional PQRS EHR measures that are also measures available for the Medicare EHR Incentive Program (note that not all PQRS EHR measures are available in the EHR Incentive Program. To see a breakdown of the measures, visit: www.facs.org/ahp/pqrs/2013/ehr-based-report.pdf); or (B) At least three PQRS measures for 80% of applicable Medicare Part B FFS patients of each EP. |
| Measures groups | 2. One measures group for at least 20 Medicare Part B FFS patients. | 4. One measures group for at least 20 Medicare Part B FFS patients, a majority of whom should be Medicare patients (at least 11 Medicare patients). | N/A | |
| Half-year period | Individual measures | N/A | N/A | N/A |
| Measures groups | N/A | 5. One measures group for at least 20 Medicare Part B FFS patients, a majority of whom should be Medicare patients (at least 11 Medicare patients). | N/A |
For additional information regarding the PQRS program, visit www.cms.hhs.gov/pqri/ and access the resources posted at www.facs.org/ahp/pqrs. For information on how to get started with reporting measure groups, visit www.facs.org/ahp/pqrs/2013/measure-groups-started.pdf. For PQRS-related questions, contact Sana Gokak at 202-337-2701 or sgokak@facs.org or call the CMS PQRS help desk at 1-866-288-8912.
†Centers for Medicaid & Medicare Services. 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual. Available at: www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_MeasuresGroupsSpecs_ReleaseNotes_SupportingDocs_03042013.zip. Accessed July 29, 2013.
‡All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2012 American Medical Association. All rights reserved.
