Quality Measures

FAQ 8. Can you explain the difference between clinical quality measures and PQRS and how they may cross over with the different physician reporting programs?

CQMs are taken from the PQRS measures, but are reported separately. For 2014 and 2015, you will need to report on 9 CQMs across 3 of the 6 NQS domains:

  1. Patient and family engagement
  2. Patient safety
  3. Care coordination
  4. Population/public health
  5. Efficient use of health care resources
  6. Clinical process/effectiveness

FAQ 9. As of now, we must manually enter our PQRS data. Do you know if there are any options to upload it electronically?

At this time, if you are not using a registry or submission center, you will need to manually submit claims-based data. You may report CQMs by attestation through the EHR registration and attestation system or by e-reporting through the PQRS portal. For further information visit CMS.

FAQ 10. For 2015, does one of the menu objectives need to be a public health measure?

All providers are required to report on at least one measure from the public health menu set for Stage 1. If you do not submit to a public registry, you will have to file exclusions in both public registry categories. An exclusion does not count as one of the 5 menu measures you need to report on in Stage 1.

FAQ 11. What are the 5 best core measures for retina specialists to report on?

Medicare removed the core objective to report on a core set of CQMs. However, reporting on CQMs is still required to demonstrate MU. Medicare provides a list of its recommended CQMs that are most aligned with its goals. If the Medicare-recommended CQMs do not suit your needs you can select from a comprehensive list of approved CQMs to meet the reporting requirement. You can review the complete list of meaningful use CQMs under columns U and V in Medicare’s complete list of quality measures.

Every provider is required to report on all the core objectives. Exclusions may be applicable to each provider based on specialty; these must be discussed on a case-by-case basis.

FAQ 12. Which are the best CQMs for retina?

Because CQMs are not specialty-specific (they are only classified as pediatric or adult), some may be more or less applicable to retina practices. You should carefully select the measures to report on to best position yourself for success.

FAQ 13. Is there a performance requirement for CQMs in 2015, or do we just submit the data as we did in 2014?

Many quality-reporting programs implemented by Medicare have a requirement to both report and meet certain performance goals. Medicare has not yet designated any specific threshold requirement for reporting CQMs in 2015.

FAQ 14. My EHR has measures that do not really pertain to retina specialists, like glaucoma CQMs. Can we report zero CQMs when we attest?

CQMs have no threshold that providers are required to meet. If a CQM is showing zero, then a provider can report zero with no adverse effect.

Providers can only submit CQMs for which your vendor is certified. Regardless of how many CQMs you report on, you must still meet Medicare’s goal number of core and menu objectives.

FAQ 15. As retina specialists, it seems we are generally able to meet only 7 of the 9 CQMs. Does this increase our risk of an audit? Is it better to registry report?

There is no requirement to meet any specific threshold for CQMs. The CQMs the provider is able to attest to are based on those for which their vendor is certified. This does not negatively affect the provider or instigate an audit. This is true whether providers submit the CQMs themselves or have a registry submit on their behalf.

FAQ 16. When is the attestation deadline for 2014?

Providers who participated in 2014 have until February 28, 2015 to submit their 2014 attestation.

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