CMS Measures Groups & Individual Measures

  1. Measure details for 2016 now available
  2. View available Measures Group and Individual Measures
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PQRSPRO Measures

To learn more about how to begin the measure selection process, review our Getting Started page.  If you are ready to select measures for reporting, continue on this page to discover measures that best reflect your patient population. Be sure to note the measures you would like to use for later selection on your PQRSPRO Dashboard.

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CMS Measures Groups

To meet the reporting requirement, enter data from a minimum of 20 unique patient visits, a majority of which (at least 11) must be Medicare Part B patients. Successfully reporting one Measures Group will qualify you to avoid the -2% PQRS and associated VM payment adjustments in 2018. Note that measures with a 0% Performance Rate (unless an inverse measure) will not count – you must meet the quality action at least once for the selected measures or measures group to successfully avoid the -2% payment adjustment in 2018. As in previous years, dependent on a practice’s specialty and patient population, PQRS 2016 Measures Group reporting is the least time-consuming, most straightforward, efficient, and effective form of registry reporting available; however not all specialties and practices will have an applicable measures group. (Note: individual providers in practices that registered with CMS for the Group Practice Reporting Option (GPRO) cannot report a measures group.)

APAPO provides PQRS registry reporting for psychologists and other mental health professionals. Register for 2015 now!

Measures List

Individual Measures – 2016 Reporting for 2018 Payment Adjustment Avoidance:

Submit at least 50% of your eligible Medicare Part B patient visits for at least 9 individual measures, from at least 3 of the National Quality Strategy (NQS) domains, including at least one cross-cutting measure if you have at least one face-to-face visit , to successfully avoid the -2% Payment Adjustment in 2018. Note that measures with a 0% Performance Rate will not count – you must meet the quality action at least once for the selected measures to successfully avoid the -2% payment adjustment in 2018.

Measures Applicability Validation (MAV) Process for Individual Measures reporting:*

If a patient population/practice/specialty does not meet the required criteria for reporting 9 individual measures and/or cannot cover 3 NQS domains, the submission will be subject to the CMS Measures Applicability Validation (MAV) Process. If a provider or GPRO reports less than 9 measures, the MAV Process allows CMS to conduct a claims audit, applying a ‘clinical relation/domain test’ comparing ‘clusters,’ or sets of closely related measures, to determine whether additional measures and/or domains are applicable to the practice and could/should have been reported. If CMS finds that there are additional measures applicable to the practice within the reporting group or individual providers’ claims for the reporting period, the PQRS submission will fail and will not avoid the -2% Payment Adjustment and associated VM adjustments in 2018. There are a number of educational resources available on the CMS website regarding the MAV Process. Note: if a MAV Cluster does not include a cross-cutting measure(s), at least one cross-cutting measure must be also be satisfactorily reported for those individual providers or group practices with face-to-face encounters in order to successfully avoid the -2% Payment Adjustment and associated VM adjustments in 2018.

*The CMS Proposed 2016 Behavioral/Mental Health Professionals Preferred Specialty Measure Set Includes the following Measures: 134, 181, 226, 317, 325, 383, 391, 402

Note: Measures 342 and 391 are linked to evaluation and management (E&M) codes. For this reason most psychologists will not be able to report these two measures.

CMS MAV Training Course MAV Training course

CMS MAV Presentation 2016_PQRS_MAV_ProcessforRegistryBasedReporting

IDDomainNameDescription
#46Communication and Care CoordinationMedication Reconciliation Post-DischargePercentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.
#47Communication and Care CoordinationCare PlanPercentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
#110Community/Population HealthPreventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
#111Community/Population HealthPneumonia Vaccination Status for Older AdultsPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
#128Community/Population HealthPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanPercentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 65 years and older BMI ? 23 and < 30 kg/m2; Age 18 – 64 years BMI ? 18.5 and < 25 kg/m2
#130Patient SafetyDocumentation of Current Medications in the Medical RecordPercentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
#131Communication and Care CoordinationPain Assessment and Follow-UpPercentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
#134Community/Population HealthPreventive Care and Screening: Screening for Clinical Depression and Follow-Up PlanPercentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
#181Patient SafetyElder Maltreatment Screen and Follow-Up PlanPercentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
#226Community/Population HealthPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPercentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
#317Community/Population HealthPreventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedPercentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
#325Communication and Care CoordinationAdult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid ConditionsPercentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
#370Effective Clinical CareDepression Remission at Twelve MonthsAdult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment
#383Patient SafetyAdherence to Antipsychotic Medications for Individuals with SchizophreniaThe percentage of individuals 18 years of age or greater as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who are prescribed an antipsychotic medication, with adherence to the antipsychotic medication [defined as a Proportion of Days Covered (PDC)] of at least 0.8 during the measurement period (12 consecutive months).
#391Communication and Care CoordinationFollow-up After Hospitalization for Mental Illness (FUH)The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.
#402Community/Population HealthTobacco Use and Help with Quitting Among AdolescentsThe percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user
#411Communication and Care CoordinationDepression Remission at Six MonthsAdult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
#431Community/Population HealthPreventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingPercentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user

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CMS Disclaimer

If reporting for Physician Quality Reporting System (PQRS) through another Centers for Medicare and Medicaid Services’ (CMS) program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to earn a PQRS incentive and/or avoid the PQRS payment adjustment.

Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, eligible professionals (EPs) should look to the respective quality program to ensure they satisfy the PQRS, Electronic Health Record (EHR) Incentive Program, Value-based Payment Modifier (VM), etc. requirements of each of these programs.

You should not select that you participate in the Medicare PQRS-EHR Incentive Pilot when you attest to this question on the CMS website. The Healthmonix Registry is NOT a qualified submission vendor for clinical quality measures for purposes of meaningful use.