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Physician Quality Reporting System Checklist for Wound Care Providers: The Art of Documentation and Reporting

This article offers a go-to resource for quality measures reporting methods and guidelines for 2016. 

The Physician Quality Reporting System (PQRS)1 was created under the Tax Relief and Health Care Act of 2006 as a Medicare quality incentive program. In 2008, the Medicare Improvements for Patients and Providers Act made the program permanent. It was this act that included increased PQRS incentive payments. Over time, the program has expanded its opportunities for reporting and is aligning with other governmental initiatives including Physician Compare, Value-Based Payment Modifier (VBM), Electronic Health Record (EHR) Incentive Programs, Million Hearts,® Medicare Shared Savings Program, Pioneer Accountable Care Organization (ACO) model, and Comprehensive Primary Care (CPC) Initiative. Once an incentive program, PQRS is now a reporting program that applies negative payment adjustments to promote reporting of quality information by individual eligible professionals (EPs) and group practices identified by their individual national provider identifier (NPI) and tax identification number (TIN).

Beginning in calendar year (CY) 2015, the program applied a (negative) -2% payment adjustment to individual EPs and PQRS group practices that did not satisfactorily report data on quality measures for the Medicare Part B Physician Fee Schedule (MPFS)-covered professional services in 2013. Those EPs who reported satisfactorily for the 2015 program year avoided the 2017 PQRS negative payment adjustment.2 Turning to this reporting year, there is a (negative) -2% adjustment applied in CY 2018 (based on program year 2016 data submission) to individual EPs and PQRS group practices that do not satisfactorily report data on quality measures for MPFS-covered professional services. Additionally, the VBM program was added to measure cost and quality, with associated penalties and incentives as well.3 To that end, PQRS reporting and the VBM program are complex and require thoughtful attention and engagement on behalf of the EP. 

The key to successful reporting is one’s engagement in the process. As the program year moves forward, it is important to know how one’s patient population influences measure selection. Equally important is to understand how measure selection directly impacts documentation captured for reporting. Next, checking the progress of one’s reporting often to gauge progress in meeting the measure’s performance rate and reporting rate is important. Finally, EPs should seek assistance early in the PQRS process to ensure reporting is done accurately and timely. (See Figure 1) Each year, the Centers for Medicare & Medicaid Services (CMS) provides educational information to assist EPs and group practices in understanding requirements for reporting.4 Based on this information, review the following four checklist items to assist in understanding the art of PQRS documentation and measure selection. twc_0416_hess_figure1

1. Determine Eligibility 

Medicare physicians, practitioners, and therapists providing covered professional services paid under or based on MPFS are considered EPs under PQRS. To the extent that EPs are providing services that get paid under or based on MPFS, those services are eligible for PQRS negative payment adjustments. Individual EPs and EPs in PQRS group practices, ACOs reporting PQRS via the Group Practice Reporting Option (GPRO) Web Interface, and CPC practice sites are eligible to participate in PQRS.5 

2.  Determine PQRS Participation as Individual EP or Group

Providers can determine whether they want to participate in PQRS as individual EPs or as part of a group practice. Individual EPs are identified on claims by their individual NPI and TIN. A group practice (under 2015 PQRS) is defined as a single TIN with two or more individual EPs who have reassigned their billing rights to the TIN.6 Group practices can register to participate in PQRS via the group practice reporting option (referred to as “PQRS group practices”) to be analyzed at the group TIN level.

3. Choose Reporting Mechanism 

Depending on whether one is participating in PQRS as an individual EP or as part of a PQRS group practice, several reporting mechanisms by which to submit PQRS data are available. These include:

  • reporting electronically through an EHR,
  • a qualified registry,
  • a qualified clinical data registry (QCDR),
  • a PQRS group practice via GPRO Web Interface,
  • a CMS-certified survey vendor, and
  • claims.

Once the reporting mechanism is chosen, providers should become familiar with their registry’s requirements (including the measure selection). Understanding the differences between reporting as individuals or through GPRO is crucial. Providers should know their documentation and reporting requirements as well as reporting deadlines. Reach out to the registry for assistance early in the process. 

4.  Determining Quality Measures to Report

According to CMS, quality measures are indicators of the quality of care provided by physicians.7 They are tools that help CMS measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare. Important reminder: All PQRS measure specifications are updated annually and EPs will need to review the measure specifications for revisions or measure retirement for the current program year. It’s the responsibility of the EP to review and understand each measure specification, especially as it pertains to a specific reporting mechanism.

Individual EPs and group practices participating in the GPRO can avoid the 2018 PQRS negative payment adjustment by satisfactorily reporting 2016 quality measures data to a participating registry. Each EP or group participating in GPRO via registry must satisfactorily report on at least 50% of eligible instances for at least nine measures covering three National Quality Strategy (NQS) domains to avoid the negative payment adjustment. If fewer than nine measures or three NQS domains are reported via a qualified registry, CMS will apply a measure-applicability validation (MAV) process.8 Based on the participating registry, individual EPs can also report on a 20-patient sample (if reporting measures groups) to avoid the negative payment adjustment. Individual EPs or group practices reporting via GPRO should work directly with the participating registry for more information on how to submit data on the selected measures or measures group. According to the 2016 PQRS Implementation Guide, the 2016 PQRS measures address various aspects of care.4 EPs and PQRS group practices are not required to report on all PQRS measures and must select which measures they would like to report. Based on the implementation guide, use the following three steps to determine measure selection:

Step 1:  Review Measures List

Review the 2016 PQRS Measures List, the PQRS online measures search tool,9 and 2016 PQRS Single Source Code Master10 to determine which measures, associated domains, and reporting mechanism(s) may be of interest and applicable to the individual EP or group practice participating in PQRS via GPRO. NOTE: Not all measures are available under each PQRS reporting mechanism. EPs or PQRS group practices should avoid individual measures that do not or may infrequently apply to the services they provide to Medicare patients. NOTE: With alignment of quality measures across CMS quality reporting programs, some measures from the EHR Incentive Programs may have been updated or modified during the National Quality Forum endorsement process. This may result in different measurement titles, number versions, or NQS domains from the corresponding PQRS specification. Refer to program-specific documentation for accurate interpretation of measures and reporting criteria. NOTE: The GPRO Web Interface reporting mechanism has established measures, all of which must be reported.

Individual EPs and PQRS group practices should choose at least nine individual measures across three NQS domains or one measures group as an option to report on measures to CMS (with the exception of the GPRO). Individual EPs or PQRS group practices are also required to report one cross-cutting measure if they have at least one Medicare patient with a face-to-face encounter.

Here are some helpful hints to assist with narrowing quality measure code selection:

  • Review current billing codes. This will assist in identifying the quality measure tied to applicable denominator codes based on applicable billing codes.
  • Use the PQRS Single Source Code Master, referencing the excel spreadsheet entitled “Individual Measures Single Source.”
  • Using the search tool features within the excel spreadsheet, select Current Procedural Terminology codes that apply to the appropriate place of service to determine the quality measures for reporting and the reporting method available (eg, claims versus registry). Follow Step No. 2 within the instructions of the Excel document to learn “How to Search Measure by Code.”
  • If there are fewer than nine measures across three domains given this process, review the MAV process to determine the evaluation methods based on the measures being submitted. 

Step 2:  Consider Important Factors When Selecting Measures to Report

  • clinical conditions usually treated;
  • types of care typically provided (eg, preventive, chronic, acute);
  • settings where care is usually delivered (eg, office, emergency department, surgical suite;
  • quality improvement goals for 2016; and
  • other quality reporting programs in use or being considered by NQS. 

Step 3:  Review Measure Specifications

After making a selection of potential measures, providers should review the specifications for the selected reporting mechanism for each measure under consideration. Select those measures that apply to services most frequently provided to Medicare patients by the EP or PQRS group practice. NOTE: EPs or PQRS group practices should review each measure’s denominator coding to determine which patients may be eligible for the selected PQRS measure(s). EPs can report individual measures or measures groups while PQRS group practices can only report individual measures or all of the measures within the GPRO Web Interface, if that mechanism is chosen. NOTE: Group practices must report using an EHR, registry, QCDR, or GPRO Web Interface in order to select their measures. 

Finally, to be empowered in the PQRS reporting process, remember four important points:

  1. Engage in the process.
  2. Determine patient population and know the services provided in the facility.
  3. Choose and understand measure selection and how each measure supports patient population and services provided.
  4. Map documentation to PQRS workflow and review PQRS reports often to keep track for timely reporting. 

Cathy Thomas Hess is vice president, chief clinical officer for wound care at Net Health, Pittsburgh, PA. Net Health Specialty Care Registry is a qualified CMS PQRS registry.


1. Physician Quality Reporting System. Centers for Medicare & Medicaid Services. Accessed online:

2. Payment Adjustment Information. Centers for Medicare & Medicaid Services. Accessed online: 

3. Value-Based Payment Modifier. Centers for Medicare & Medicaid Services. Accessed online: 

4. 2016 Physician Quality Reporting System Implementation Guide. Centers for Medicare & Medicaid Services. Accessed online:

5. 2015 Physician Quality Reporting System List of Eligible Professionals. Centers for Medicare & Medicaid Services.  Accessed online:

6. Physician Quality Reporting System Group Practice Reporting Option 2015 Criteria. Centers for Medicare & Medicaid Services. Accessed online:

7. 2016 Physician Quality Reporting System Payment Adjustment. Centers for Medicare & Medicaid Services. Accessed online: 

8. Analysis and Payment. Centers for Medicare & Medicaid Services. Accessed 

9. Measures Codes. Centers for Medicare & Medicaid Services. Accessed online:

10. 2016 Physician Quality Reporting System (PQRS) Single Source Code Master. Centers for Medicare & Medicaid Services. Accessed online:

Cathy Thomas Hess, BSN, RN, CWOCN
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