1. A guide for last minute 2016 PQRS reporting
PQRS: Are You Ready?
A guide for last minute 2016 PQRS reporting
Sandy Pogones, MPA, CPHQ
Senior Strategist, Health Care Quality
Welcome, and thank you for joining today’s webinar. The webinar is PQRS: Are you Ready? Sponsored by the American Academy of Family Physicians. My name is Tracey Allen-Ehrhart and I’m the manager for the Center for Quality of the AAFP. I will serve as your moderator today. Also with me is my colleague from the AAFP Erin Solis, Regulatory Compliance Strategist. Erin will help field questions at the end of the webinar.
Before we get started I want to review a few housekeeping items and let you know how you can participate in today’s webinar. You’ll notice that the GoTo Webinar interface has two parts: the viewer window on the left which allows you to see everything the presenter will share on her screen; and the control panel at the right. So let’s take a look at the Control panel on the right side of your screen. Click the orange arrow to open and close your Control Panel. Throughout the presentation, you may type any questions into the text box titled “Questions”. We’ll address questions at the end of the webinar. All lines are automatically muted. Please note that we will only be addressing questions related to PQRS 2016 reporting. While we realize the MACRA law was just finalized and is at the top of mind for everyone, we will not be able to address questions related to MACRA.

2. Conflict of Interest Disclosure
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.
Next slide: Here is the Conflict of Interest Disclosure for your review. There are no conflicts of interest to disclose.
This presentation has been approved for 1.0 CME prescribed credits by the AAFP. You will receive an by Monday that will include instructions for claiming your CME and will provide information on how to access the slides and the webinar recording.

3. Senior, Strategist, Health Care Quality
Sandy serves as the American Academy of Family Physician’s Senior Strategist, Health Care Quality, with expertise in quality improvement, performance measurement, federal quality programs, and advanced primary care transformation. In this role, she works to assist family physicians in adopting care delivery capabilities to better prepare them for success in value-based payment models. Prior to the AAFP, Sandy was with Primaris Healthcare Business Solutions where she led the physician services task providing “hands-on” technical assistance to physicians to support PQRS, Meaningful Use, value-based purchasing and patient medical home transformation. She facilitated practice improvement using advanced capabilities of EHRs for population management, care coordination, health information exchange and patient engagement.   
Sandy Pogones, MPA, CPHQ
Senior, Strategist, Health Care Quality
Next slide: Now onto today’s speaker: It’s my honor and pleasure to introduce Sandy Pogones. Sandy serves as the American Academy of Family Physician’s Senior Strategist for Health Care Quality, with expertise in quality improvement, performance measurement, federal health care quality reporting programs, MACRA and advanced primary care transformation. In this role, she works to assist family physicians in adopting care delivery capabilities to better prepare them for success in value-based payment models. We are pleased to have Sandy present for us today. Sandy, it’s all yours.

4. A guide for last minute 2016 PQRS reporting
PQRS: Are You Ready?
A guide for last minute 2016 PQRS reporting
Sandy Pogones, MPA, CPHQ
Senior Strategist, Health Care Quality
Thank you for the introduction, Tracey. And, thank you to the audience for taking time out of your busy day to learn more about 2016 PQRS reporting.
See if this sounds familiar to you: you’re a family physician… you’re seeing patients all day, everyday. After a full day you have charts to finish, prior authorizations to submit, and now you have complete your 2016 PQRS reporting. Rules and instructions are confusing, your staff is unsure of where to begin, the 2016 PQRS deadline is fast approaching, and you’re frustrated. Sound familiar to anyone?
Well, We’re here to help. I’ve had the opportunity to work with family physicians over many years to make sense of the constant changes and requirements of the Medicare quality programs. The AAFP exists to help you with these changes and requirements, and today we’ll help you better understand what’s required to report for 2016 PQRS.

5. Learning Objectives
List the requirements and available options for PQRS compliance.
Explain the benefits of reporting by the deadline and the implications if reporting is not completed by the deadline.
Articulate a plan for improved PQRS reporting.
After this webinar, you’ll be able to understand the reporting requirements and options for 2016 PQRS.
You’ll know why reporting in 2016 will be of benefit to you.
And, you’ll have a plan in place to report quality measures for 2016.

6. What is PQRS? Physician Quality Reporting System
Quality reporting program for Medicare
Report quality measures on Part B Professional FFS patients
Negative payment adjustments for non-reporting
So, what is PQRS? PQRS stands for the Physician Quality Reporting System, which is a program where physicians and other Eligible Professionals (EPs) report data on quality measures for services you provide to your patients. The goal is to improve population health and quality of care, while lowering the cost of health care—known as the Triple AIM.
To participate in value-based purchasing programs your must successfully report PQRS. Failure to report results in automatic negative payment adjustments applied to your Medicare Part B payments.

7. When to Report PQRS? Eligible Professionals (EPs) must report annually
Deadline depends on selected reporting option
Quality measures are reported once annually for most reporting methods. The data you’ll report for 2016 PQRS will come from patients you saw between January 1 and December 31, 2016.
The deadline for PQRS submission is set by CMS and depends on the reporting option you choose. We’ll address this later.
[Note: 2/28/2017: PQRS EHR-based submission (eCQMs) and QCDR (QRDA files)
3/31/2017: QCDR (xml files) and QR]

8. Why Report? Avoid payment adjustments Value-based Payment Modifier
-2% payment adjustment applies to all Medicare Part B FFS in 2018 based on 2016 reporting
Value-based Payment Modifier
CMS pay-for-performance program
PQRS measures used in VBPM calculation
VBPM penalties % - 4% (depends on size of practice)
Changing payment environment
Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA)
Alternative payment models
Merit-Based Incentive Payment System
2017 performance year for 2019 payment
There are three main reasons to report for 2016 and in future years.
First, and we’ve already mentioned this--to avoid a negative payment adjustment under the PQRS program, which is -2% and is applied to your 2018 medicare part b payments.
The second reason is CMS’s value-based payment modifier. The Value Based modifier program applies an upward, downward or no adjustment using performance on the PQRS measures you report, along with other quality and resource use measures.
Payment adjustments under the Value modifier are in addition to those under PQRS. So, if you don’t report for PQRS, you’ll receive negative adjustments under both programs.
Total Payment adjustments under these 2 programs can add up to 4%-6% in 2018 depending on the size of your group. And keep in mind there is an additional penalty for non-participation in the Meaningful Use program of -3%.
The third reason is the replacement of the Sustainable Growth Rate or SGR methodology with a value-based payment system—this transition was solidified by the passage of the Medicare Access & CHIP Reauthorization Act of 2015, known as MACRA. Elements of PQRS are part of the Merit-Based Incentive Payment System and Alternative Payment Models, with 2017 as the initial reporting period. So Quality reporting will play an ever-increasing role in payment.

9. Develop a PQRS Plan Choose reporting option Select quality measures
Gather data and report
With all this in mind, we’ll cover the following during this presentation to help you develop your plan for reporting.
We’ll review the reporting options that are still available to you for 2016 and the pros and cons of each.
We’ll take a look at quality measures that are appropriate for family practice, the reporting requirements and examples of measures that are applicable to family medicine.
And we’ll talk about considerations when gathering your data and reporting to CMS. You’ll then have the tools you need to report your data.

10. Reporting Options
First, you’ll need to determine which reporting option is right for you, given your practice size and available reporting options.

11. Reporting Options Individual reporting
One physician reports individually
Group practice reporting option (GPRO)
Two or more physicians or providers
Registration has closed for this option
The first decision is to determine if you’ll report as an individual or as part of a group. Reporting as a group is also referred to as the Group Practice Reporting Option, or GPRO. The size of your group may impact this decision. Larger groups may find that it’s much easier to report as a group versus reporting individually for each provider. Group reporting is always done at the Tax Identification Number-level.
However, in order to report as a Group, you first must register with CMS, and the registration deadline for group reporting was June 30, So if your group didn’t register, then at this point your only option will be to report individually. Registration isn’t required to report as an individual. While many of the requirements and options are the same for individual and group reporting, but today we’re going to focus on reporting as an individual.

12. Individual Provider Option
Report at the TIN/NPI combination Level
Options available
Electronic Health Record (EHR) Direct
EHR Data Submission Vendor (DSV)
Qualified Registry
Medicare Part B Claims
Qualified Clinical Data Registry (QCDR)
Individual EPs
EHR-DSV
Qualified Registry
Claims
QCDR
EHR-Direct
Next, we’ll look at the reporting options you may use to submit your data.
With individual reporting, Quality measures are reported and analyzed at the TIN/NPI combination level. You have several options available:
You can use your certified EHR technology to report electronic clinical quality measures (eCQMs)—this option is referred to as EHR-Direct.
You can use a vendor to report eCQMs from your EHR—this option is referred to as an EHR Data Submission Vendor or DSV
You can use a qualified registry
You can submit codes on your Medicare claims
Or, you can use a Qualified Clinical Data Registry or QCDR.

13. Electronic Health Record (EHR) Direct & Data Submission Vendor (DSV)
Must use Certified Electronic Health Record Technology (CEHRT)
Upload batch information directly from EHR CEHRT to CMS
Data Submission Vendor (DSV)
Contract with outside vendor to submit data to CMS on their behalf
Vendor extracts data directly from provider’s CEHRT
Reporting once option
Report once and satisfactorily meet PQRS requirements and Clinical Quality Measure (eCQM) component of the EHR Incentive Program
Must select measures from an approved list of 64 eCQMs
Reporting deadline: February 28, 2017
The first option we’ll discuss is the EHR options available to you—Direct and DSV. To use either of these methods you must be using a certified EHR and you must capture structured data in your EHR for all the data elements in the measures you select. Your vendor will have instructions for how and where to capture this data.
There are a total of 64 possible electronic Clinical Quality Measures, or “eCQMs” in 2016 that can be submitted using the EHR—these are the same eCQMs offered through the MU program. However, your particular EHR may not offer all 64 measures--so it’s important to determine upfront what measures are offered and how to capture needed data before choosing the EHR option.
After the close of the year, you can then submit data directly from your EHR to CMS—thus the term “EHR-Direct”. You create a standard file using software within your EHR. The file is called a “QRDA” file—which stands for “Quality Reporting Document Architecture”. You should check with your EHR vendor to make certain your product is capable of producing this file and and that your vendor will support to you during Direct Submission. Experience shows you will encounter errors and questions during the process and you’ll need your vendor’s help to resolve them. EHR Direct Submission must be completed by February 28, 2017.
For Direct Submission, you must also have an account within CMS’ Enterprise Identity Management system, or EIDM—along with the proper roles. This will allow you to to upload your data through the CMS portal. So there’s two steps in EHR Direct submission—you first create the QRDA files using your EHR, then you log into the CMS portal with your EIDM credentials and upload the file. Obtaining an EIDM role can be time consuming, so start this process as soon as possible.
The other EHR option is the EHR Data Submission Vendor. The DSV option is identical to the EHR-Direct option, except that a third party vendor does all the work with the exception of data capture. The DSV extracts data from your EHR and creates the standard QRDA file, obtains the EIDM roles and uploads the data to CMS on your behalf. Many of the EHR vendors themselves offer the DSV option as do other third parties. You’ll need to identify and hire your DSV on your own and meet the vendor’s deadline dates-- and you will be charged a fee.
Note that if you submit PQRS data using either EHR option, this MAY also satisfy the portion of Meaningful Use that requires you to “report Clinical Quality Measures”. This is called the “report once” option. However, it does not satisfy ALL MU requirements. There are other caveats to the “Report Once” option that are important to understand. Meaningful Use isn’t the focus of this webinar, but we want you to know there is such an option if you’re interested.
So to sum up, if you’re using an EHR that is Certified, this may be a good option. There is a learning curve but it can pay off in the long run. Using your EHR for quality reporting can help make the most of your investment in technology. Using your EHR allows you to generate your own feedback reports throughout the year to track your performance and take action using real time data. There’s still time to report using the EHR, but some preparation should have been done by now. Please contact your EHR vendor ASAP for more information.

14. EIDM Accounts for EHR-Direct Submissions
Solo Practice
(Submit EHR data under SSN or TIN)
Group Practice
(Submit EHR data under a TIN)
REQUIRED: Individual Practitioner
Approve other roles
Access PQRS and QRUR Feedback Reports
Submit EHR-Direct PQRS Data
Individual Practitioner Representative
Access PQRS and QRUR Reports
REQUIRED: Security Official
Approve other Roles
Self-Nominate as GPRO
Group Representative
REQUIRED: PQRS Submitter
This slide is for your reference—I’m not going to read it. It shows the various roles that should be established within the EIDM system for solo providers and for groups that plan to submit using EHR-Direct.

15. Qualified Registry Submit data to registry – registry uploads to CMS
Provider must enter into contract with 2016 Qualified Registry
Report either Individual Measures or a Measures Group
Reporting deadline: March 31, 2017, but…
Registry vendors have their own internal deadlines prior to 3/31/16!
Example of a Qualified Registry: PQRS Wizard (CE City)
The next mechanism for reporting is using a Qualified registry. With a registry, you select measures from an approved list and then submit the data either manually or through an electronic upload to the registry. The registry is then responsible for submitting the data to CMS on your behalf.  CMS qualifies registries every year and you can find a list of qualified registries on the CMS PQRS website. We’ve also provided a link.
Qualified registries simplify reporting by walking you through the process step-by-step. You still have time to report using a registry—the CMS deadline for registry reporting is March 31, But be aware that you will need to get your data to your registry prior to this time. Check with the registry for their specific requirements.
Registries allow you to report either individual measures or a Measure Group. We’ll discuss the difference later.
I want to mention that the AAFP has contracted with PQRSwizard, a Qualified Registry, and they are giving a substantial discount for AAFP members. You can receive the discount by registering with PQRS Wizard from the AAFP website. Please see the link at the end of this presentation. Data submission can begin immediately.

16. Qualified Clinical Data Registry (QCDR)
Collects data for patient and disease tracking
Not limited to PQRS data
Regular exchange of data
Analyzes data and provides more frequent feedback
The next option is reporting through a Qualified Clinical Data Registry or QCDR. A QCDR is a CMS-approved entity that collects clinical data for the purpose of patient and disease tracking and is designed to support population management and quality improvement efforts. QCDRs are often run by specialty societies.
The QCDR reporting option is different from a traditional registry because it isn’t limited to traditional PQRS measures—QCDRs can create their own measures with approval from CMS. Normally a QCDR is mapped to your EHR and data is transmitted to the QCDR on a regular basis—for instance nightly or weekly or quarterly. The QCDR must provide feedback reports to you at least 4x/year—but many allow you to pull reports more frequently or even at will. After the close of the year, the QCDR reports your data to CMS to satisfy PQRS requirements. QCDR participation has been given considerable attention under MACRA to help satisfy both quality and performance improvement categories. There may be upfront and ongoing costs to build and maintain an interface and to map data to the QCDR.
Often QCDRs require that you begin participation earlier in the year due to set-up needs—so it may be too late to select this option for But you might still investigate using a QCDR for future quality reporting and improvement. A link to the 2016 listing of QCDRs is included in this slide deck.
All the reporting mechanisms we’ve discussed to this point are also available to GPROs.

17. Claims-Based Select measures from a specified list
Include qualified-data codes (QDC) on each claim for eligible patient in denominator population
Not an option if you did not document QDC codes throughout 2016
The last option is Claims-based reporting which is only available for individual reporting. Claims-based reporting requires that you submit Quality Data Codes (QDCs) which are CPT Category II, or G-codes, on Medicare Part B claims for your measures. In order to be successful, you must add QDC codes to each claim at the time it is submitted throughout the reporting year. So if you haven’t been doing this throughout 2016, it’s too late for you to report this way now as you can’t add codes retroactively. The advantage of Claims-based reporting is it’s free and it’s a good choice for providers that have very small Medicare Part B populations. The disadvantage is the time commitment and complexity of reporting 9 measures. Your billing software may have capabilities to help you with claims-based reporting.

18. Selecting Measures
Now that you have a better idea of the reporting mechanism available , we’ll move on to selecting quality measures for reporting.

19. Selecting Measures Reporting method determines measures reported
In general 9 measures covering at least 3 National Quality Strategy (NQS) domains
Patient Safety
Effective Clinical Care
Community/Population Health
Communication and Care Coordination
Efficiency and Cost Reduction
Person and caregiver-centered Experience Outcomes
At least one cross-cutting measure for Claims and QR; At least 2 outcome measures for QCDR
Reporting period is January 1 – December 31, 2016
The reporting method that you choose will determine which measures you can report.
As a general rule, CMS requires you to report 9 measures covering at least three of the National Quality Strategy Domains, including a cross-cutting for Qualified Registry and Claims and an outcome measure for QCDR reporting. We’ll look at more specific requirements of each.
If you need help selecting measures, CMS offers a measures search tool—we’ve provided a link at the end of this webinar.

20. Selecting Measures Review the CMS 2016 measure list
Consider the following factors:
Clinical conditions treated
Practice priorities
Quality improvement goals
Other quality programs in use or being considered
Your use of the EHR to collect and report data
What should you consider when selecting measures?
You’ll need to review the Measure List to see what measures are available for Many measures apply to family medicine.
When reviewing the list, think about the conditions you often treat—chronic, acute and preventive.
Think about your practice priorities, quality goals, other quality programs in which you participate, and how you use your EHR.
Also, because performance on these measures will be used to calculate the Value Modifier, you’ll want to report measures on which you are doing well.

21. Selecting Measures Method matters when selecting measures to report
Individual measures vs Measures Group
0% performance does not count
Each reporting mechanism has its own list of measures available to report. All mechanisms require you to report individual measures, although the Qualified Registry gives you an additional option of reporting a Measures Group.
Remember, measures with 0% performance won’t count toward your 9 required measures.
Let’s look closer at reporting individual measures.

22. Individual Measures: Reporting Thresholds
Claims & Qualified Registry
9 measures across 3 NQS domains plus 1 cross-cutting for 50% of eligible Medicare Part B patients
EHR-Direct & EHR DSV
9 measures across 3 domains for ALL eligible patients regardless of payer
QCDR
9 measures across 3 domains including 2 outcome measures for 50% of ALL eligible patients regardless of payer
Here’s the specific reporting requirements for each mechnism.
For Claims and Qualified Registry, you must report 9 measures across 3 domains plus one cross-cutting. You report only on Medicare Part B patients. And you must report for at least 50% of the patients to which the specific measure applies. So for example, if you’re reporting a diabetes measure, and you have 100 Medicare Part B diabetes patients that meet the measure denominator criteria, then you must report on at least 50 of them. It is best to report for more than 50% to account for any patients you might overlook.
For EHR-Direct and EHR DSV, you must also report 9 measures across 3 domains. But here you’re reporting on ALL eligible patients, regardless of payer. So you’re reporting on all patients contained in your EHR to which the measure applies. There is no cross-cutting measure requirement.
For the QCDR option, the reporting requirements are a little different yet. You must still report 9 measures across 3 domains, including two outcome measures. You include all patients regardless of payer and must report for 50% of them.
[If two outcome measures aren’t available, then you may report 1 outcome plus one measure from resource use, patient experience of care, efficiency/appropriate use, or patient safety]

23. Individual Measure Domains
Falls plan of care (#155)
Functional assessment (#182)
Medication Reconciliation (#046) (crosscutting)
Communication and care coordination
BMI screening (#128) (crosscutting)
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (#226) (crosscutting)
Community / population health
Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use (#116)
Efficiency and cost reduction
Documentation of Current Medications in the Medical Record (#130) (cross cutting)
Falls Risk Assessment (#154) (crosscutting)
Patient Safety
Diabetes HbA1c Poor Control (#1) (crosscutting)
CAD Antiplatelet Therapy (#006)
Controlling High Blood Pressure (#236) (crosscutting)
Effective clinical care
Osteoarthritis (OA): Function and Pain Assessment (#050)
Person- and caregiver- centered experience and outcomes
Earlier, we spoke about the National Quality Strategy domains. This table is for your reference and lists the six National Quality Strategy domains with examples of corresponding quality measures.

24. Measures Group
Only available through a Qualified Registry and only for individual reporting (not GPRO)
Measures Group include a set of related measures for a single patient sample
Report on 20 of your patients seen in 2016, 11 of which must be Medicare part B patients
Use same 20 patients for each measure included in the group
We mentioned earlier that if you report using a Qualified Registry, you also have the option of reporting a Measures Group. A measures group is a group of 6-10 related measures that address one disease, such as diabetes or asthma, or preventive measures. There’s 25 different Measures Groups, several of which are appropriate for family medicine.
You will select 20 patients you’ve seen in 2016 that meet the patient sample criteria for the measures group. At least 11/20 patients must be Medicare Part B FFS—the rest can be any payer. You’ll report every measure in the Measures Group for each of those 20 patients. You may report more than 20 patients to allow for any unintended errors.
Reporting via a measures group can simplify the data collection process as you’re only looking at 20 patients, and is often seen as the easiest way to report PQRS individually, especially if you don’t have an EHR.
You can’t have 0% performance on ANY of the measures within the group.
Also, you must have at least 20 patients that fall into the patient sample. If you don’t, you must choose a different measures group or report individual measures.

25. Measures Groups #1 Diabetes: Hemoglobin A1c Poor Control
Preventive
#1 Diabetes: Hemoglobin A1c Poor Control
#110 Preventive Care and Screening: Influenza Immunization
#117 Diabetes: Eye Exam
#119 Diabetes: Medical Attention for Nephropathy
#126 Diabetes: Foot and Ankle Care-Neurological Exam
#226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
#39 Screening for Osteoporosis for Women Aged years #48 Urinary Incontinence women 65+ #110 Influenza Immunization #111 Pneumonia Vaccination for Older Adults #112 Breast Cancer Screening #113 Colorectal Cancer Screening #128 BMI Screening and Follow-Up Plan #134 Screening for Clinical Depression and Follow-Up Plan #226 Tobacco Use: Screening and Cessation #431 Unhealthy Alcohol Use Screening and Brief Counseling
Here are two examples of measures groups that are often selected by family physicians. The diabetes measure group is the most popular among your peers.
When you report a measures group you don’t have to worry about covering 3 domains or including a cross-cutting measure, because that work is done for you.

26. Review Measure Specifications
Diabetes: Hemoglobin A1c Poor Control
Report once per reporting period for patients with diabetes seen during the reporting period.
Measure Description
Numerator
Denominator
Exclusions
Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%
Patients years of age with diabetes with a visit during the measurement period
none
Once you’ve selected your measures, review the current measure specifications for 2016 for the reporting mechanism you plan to use. Specifications are updated every year and give you the details of what is being measured.
Here is an example of a quality measure and specifications that may look familiar to you. This measure requires you to report the measure once during the reporting period. Some measures require you to report at every visit. For example, Measure #130 Documentation of Current Medications requires reporting at every visit.
This particular measure also requires a diagnosis. Some measures don’t, such as preventive measures or use of high risk medications in the elderly.
The measure description will give you an overview of what is being measured. This measure looks at the Percentage of patients with diabetes who had a Hb A1c greater than 9 during the measurement period.
The first measure component is the denominator, which describes the eligible cases for a measure or the eligible patient population. So in this case, it’s patients with diabetes who had a visit during the measurement year. The denominator is used to determine whether or not you met the reporting threshold—for example reporting 50% of eligible cases.
The numerator describes the specific clinical action or outcome required by the measure. So in this case, a diabetic patient whose most recent HbA1c is greater than 9 would be in the numerator.
Now note that this particular measure is an inverse measure, meaning the lower the score, the better. There are only a few inverse measures. For most measures, the higher the score the better. For inverse measures, like this one, if your performance rate is 100% it won’t count.
Reviewing the measure specifications allows you to see exactly who is included in the measure, the clinical action targeted, and any exclusions.

27. Additional Considerations
Not enough individual measures to report
Only have measures across two domains
Measures Applicability Process
Here are some additional things to consider.
What happens if you don’t have enough measures to report or only have measures that cover two domains?
If there aren’t enough measures that apply to your practice, you should report all that DO apply. You will then be subject to Measures Applicability Validation or MAV. This is where CMS determines if you COULD have reported more measures or domains. The findings of the MAV will determine if you have satisfactorily reported.
It would be VERY RARE that a family physician could not find enough measures to report, so MAV isn’t something you will need to worry about.

28. Carry Out Your Plan Select method Identify measures
Gather data and report
Now that you have this information, it’s time to carry out your plan for reporting.
First: Determine your reporting method. Determine if you’ll report as an individual or group.
Next Determine your measures and whether you’ll report a measures group or individual measures. And finally use your EHR, billing system and/or paper charts to gather the patient data on the measures selected. Work closely with your registry or EHR vendor to complete reporting.

29. Plan for the Future
2016 is the last reporting period for the PQRS and Value Modifier programs
MACRA—Quality Reporting will continue under MIPS and APMs
Six Individual Measures or Web Interface
QR, QCDR and EHR: 50% patients across all payers first year and increasing thereafter
Payment Adjustments on a Sliding Scale
Plan for Improvement
As you work through reporting for 2016, use what you learn to plan for the future. PQRS reporting ends in 2016 but quality reporting will continue under MACRA through MIPS and APMs and begins in We’ve included a link to the AAFP’s MACRAready program for more information.
The final MACRA-MIPS rule only allows reporting of individual measures—not Measures Groups. For registries, QCDRs and EHR-based reporting, patient across all payers are included and you must report 6 measures. The threshold for complete reporting is 50% the first year, but reporting thresholds will increase in subsequent years
Begin looking at measures—for example, the Core Measures for Primary Care-- and streamline your process for capturing data, whether manually or electronically. Now is the time to investigate EHR-based reporting or QCDR reporting so you’ll have enough time to prepare for 2017 and beyond.
As performance increasingly affects payment, find a way to measure and improve your performance throughout the year using near real-time data—EHRs and QCDRs are able to generate real time reports. Keep in mind that payment adjustments under MIPS will be made on a sliding scale, so nearly ALL physicians will see either negative or positive adjustments. So you’ll want your performance to be as high as possible.
QI plans don’t have to be complex—but make certain to involve the entire staff and make improvement a routine part of everyone’s work.

30. Resources General PQRS Resources Measures List AAFP website
CMS’ PQRS How to Get Started
Measures List
2016 Measures List
PQRS Measure Search Tool
CMS Reporting Guides
Claims Reporting
EHR Reporting
Registry Reporting
Reporting Options
List of 2016 Qualified Registries
List of Qualified Clinical Data Registries
PQRSwizard
This concludes the formal presentation. The next 3 slides include resources we’ve mentioned throughout the presentation. We have General PQRS resources and some CMS reporting guides that can walk you step-by-step through the reporting option. Here’s a link to the PQRSwizard and other Qualified registries and QCDRs.

31. Resources CMS QualityNet Help Desk Phone: 1-866-288-8912
General PQRS information
Quality Reporting Portal
Problems with EIDM account
EIDM Accounts
CMS Enterprise Portal
EIDM Quick Reference Guides
MACRA Assistance
AAFP MACRAready
CMS Quality Payment Program
CMS’ QualityNet Help Desk can help with your specific questions and will provide help with EIDM accounts. MACRA information is provided on the AAFP MACRA Ready site and CMS has launched a new website for their Quality Payment Program. You may also call the AAFP with your questions.
(This slide was updated 10-5)

32. Resources CMS PQRS Analysis and Payment Physician Value Help Desk:
General Information PQRS Feedback Reports
PQRS Informal Review
MAV Process
Negative Payment Adjustments
Physician Value Help Desk:
Phone: (select option 3)
Trouble downloading PQRS Feedback Report
Information on QRUR, VBPM
VBPM Informal Review
You can find information on PQRS Feedback reports, Informal Review, the MAV process and payment adjustments on the CMS website. And the Physician Value Helpdesk can assist you with problems downloading the feedback reports and general information about the QRUR, Value modifier and Informal Review.
(This slide was added 10-5)

33. Resources
For questions and feedback, contact: Erin Solis Regulatory Compliance Strategist
Please remember that AAFP staff is a resource you can use. If you have questions, please contact Erin Solis.

34. QUESTIONS?
The AAFP knows you’re feeling the crunch right now and we hope this information equips you with a plan for quality reporting in 2016 and beyond. Thank you for your time today. Now, I’ll hand it back over to Tracey to start the Q and A session.
Tracey: “Just a quick reminder for people that may have logged in late: you will receive an no later than Monday with instructions for claiming your CME, and will provide information on how to access the slides and the webinar recording.
And now we’ll open it up for questions. Again, please limit your questions to 2016 PQRS reporting. To submit a question, please type into the textbox titled “Questions” on the control panel, which is on the right side of your screen. We’ll answer as many as we can within the allotted time today. If we can’t get to all questions today, please feel free to contact Erin Solis at the AAFP, or for more information on PQRS please visit the web pages that were referenced earlier.”
[If no questions or lull in questions: ] “We did receive a few additional questions that we weren’t able to get to, so we’ll follow-up with those of you with those questions.”
Next Slide

35. We hope you found the information valuable
We hope you found the information valuable. Instructions for claiming your CME, presentation slides and a link to the recording will be provided to you by . In the meantime, if you want to claim you CME now, follow the link you see in the chat box.
On behalf of the AAFP, thank you for joining us today. We hope you found today’s webinar on PQRS to be informative on how to report for 2016.