Physician Quality Reporting System

The PQRS program encourages eligible professionals to report quality measures intended to improve care and show opportunities for improvement. Participation in the program, which informs value-based modifier calculations, is required to avoid payment reductions.

How Do I Get Started?

  1. Determine whether you are an eligible professional (EP). Based on the Physician Fee Schedule, EPs include physicians, practitioners and therapists.
  2. Select reporting measures relevant to radiology, as listed below.
  3. Decide whether you will report as an individual EP or group.
  4. Select your PQRS reporting option, as listed below.
  5. If you select the traditional PQRS registry reporting option, determine whether you will report individual or group measures.
  6. Review the options to avoid the 2018 PQRS Payment Adjustment.

How Do I Submit Data?

Reporting Options

Individual Measures

Measures Groups

Group Practice Reporting Option

See 2016 Measures

Measures may be submitted via the following methods:

See 2016 Measures Groups

A CMS-qualified traditional registry is required for measures group reporting.

Groups of two or more may register as a GPRO and submit measures through one of the following methods:

  • CMS-qualified registry
  • Qualified clinical data registry
  • Web interface (groups of 25+ eligible professionals)
  • Electronic health record
  • Data submission vendor
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Avoiding Penalties

Requirements to avoid the 2018 payment adjustment (-2.0% for all eligible professionals) based on 2016 reporting are the same as those for the 2015 incentive, with several additional requirements.

Individual EPs and physician group practices can avoid penalties by doing any one of the following:

  • Successfully report on nine individual measures across three National Quality Strategy domains for at least 50% of your eligible patients
    • One of the nine measures must be a cross-cutting measure, if you have face-to-face encounters
    • If you are unable to report nine measures, follow the Measures Applicability Validation Process
  • Successfully report on one measure group for at least 20 eligible patients, more than 50% of whom must be Medicare beneficiaries
  • Successfully participate in a Qualified Clinical Data Registry or a traditional registry

Quality Measures Most Relevant to Radiology

Diagnostic

Interventional

Radiation Oncology

MIPS Qualified Clinical Data Registry

QCDR_320

A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of improvement in the quality of care furnished to patients. CMS has approved the ACR National Radiology Data Registry as a QCDR for MIPS for 2017.

How to Participate