The Physician Quality Reporting System measures quality based on four factors:

1. Eligibility for a measure.
2. Performance in meeting the measure.
3. Reporting rate
4. Performance rate.

Eligibility

Each measure has a set of criteria to determine if the patient data is eligible for the particular measure. The criteria are generally specific to:

• Time frame (in the last year, two years etc)
• Age range
• Procedure (CPT) code
• Diagnosis (ICD-9) code
• Place of service
• Other disease-specific factors.

Usually, the eligibility data can be determined from the Practice Management System. There are some measures where the eligibility cannot be determined without reviewing the patient record.The number of patients eligible becomes the denominator (D) of the PQRS Quality Equation.

Performance

Performance is the number of eligible patients who meet the performance criteria or for whom the quality action was performed.

The performance is described as

• Met:  Performance criteria met or quality action performed.
• Not Met:  Performance criteria not met or quality action not performed.
• Excluded: There is a medical, patient or system reason documented in the patient record for not meeting the performance criteria (not all measures allow exclusions)

The determination of Met, Not Met or Excluded, must come from a review of the patient record, either paper or electronic.

Reporting Rate (RR)

The Reporting Rate is the number of patients reported (Performance Met (A) + Performance Not Met (B) + Performance Exclusions(C))
divided by the total number of Eligible Patients (D) expressed in percent.

RR=(A + B+ C)/D*100

In order to qualify for an incentive payment, you must have a Reporting Rate of 50% or above.

Performance Rate (PR)

The number of patients who meet the performance criteria (or for whom the quality action was performed) (A) divided by the number of patients.reported (E) minus the number excluded (C).

PR=A/(E-C)

Example

Measure 6: Coronary Artery Disease (CAD) Antiplatelet Therapy

Patient data that is eligible for this measure includes all patients in your practice who are age 18 or older with a diagnosis of CAD (410.00, 410.01, 410.02 etc) and  a CPT code of 99201, 99202, 99203 etc.

The performance criteria is the number of eligible patients who were prescribed aspirin or clopidogrel.

Patients who could not be prescribed aspirin or clopidogrel for medical, patient or system reasons (e.g. allergy, patient declined or lack of drug availability) are excluded from the measure.

Assumptions:

There are 75 patients in your practice who meet eligibilty criteria. D=75

67 of the eligible patients were given aspirin.(A=67)

2 were not given aspirin or clopidogrel and there was no documentation as to why. (B=2)

5 of the 75 patients are allergic to aspirin and clopidogrel.(C=5)

1 patient chart could not be found.

RR=(67+2+5)/75*100=98.66%
PR=67/(74-5)*100=97.10%

MIPS and ACO Reporting under the Quality Payment Program

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