PQRI - Reporting by Group Practices

Physician Quality Reporting Initiative

2010_PQRI_MeasuresGroups_Specifications_Manual_111309

PQRI - Reporting by Group Practices

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2010 Physician Quality Reporting Initiative
Measures Groups Specifications Manual
This manual contains specific guidance for reporting 2010 Physician Quality Reporting Initiative (PQRI)
Measures Groups. Measures Groups are a subset of four or more PQRI measures that have a particular clinical
condition or focus in common. Only those measures groups defined in this document can be utilized when
reporting the measures group options. All other individual measures that are included in PQRI but not defined in
this manual as included in a measures group cannot be grouped together to define a measures group.
Thirteen measures groups have been established for 2010 PQRI: Diabetes Mellitus, Chronic Kidney Disease
(CKD), Preventive Care, Coronary Artery Bypass Graft (CABG), Rheumatoid Arthritis, Perioperative Care, Back
Pain, Hepatitis C, Heart Failure, Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), HIV/AIDS,
and Community-Acquired Pneumonia (CAP). These thirteen groups, combined, include a total of 82 measures
established for use in the 2010 PQRI, as required by applicable statutes, through formal notice-and-comment
rulemaking in 2009. An eligible professional (EP) may choose to report one or more measures groups through
claims-based and/or registry-based submission. Note that denominator coding has been modified from the
original individual measures specified by the measure developer to allow for implementation in PQRI as a
measures group. An overview for each measures group is included in this manual followed by specific reporting
instructions for each measure within the group.
There are two reporting periods available to EPs to report 2010 PQRI measures groups: a) 12-month reporting
period from January 1 through December 31, 2010 OR b) a six-month reporting period from July 1 through
December 31, 2010. The six month reporting period allows those EPs who may have decided to participate later
in the year to begin reporting. Those EPs who satisfactorily report quality data under the measures groups
reporting option may earn an incentive payment equal to 2.0% of their total estimated allowed charges for
Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished during the applicable
reporting period.
Please note, EPs may choose to pursue more than one 2010 PQRI reporting option. However, an EP who
satisfactorily reports under more than one reporting option will earn a maximum of one incentive payment equal
to 2.0% of their total estimated allowed charges for Medicare Part B PFS covered professional services
furnished during the longest reporting period for which he or she satisfied reporting requirements. This manual
describes how to implement 2010 reporting of PQRI measures groups to facilitate satisfactory reporting of
quality-data by EPs who wish to participate under this reporting alternative. Additional information describing
how to implement 2010 measures groups can be found in the Getting Started with 2010 PQRI Reporting of
Measures Groups and the PQRI Made Simple - Reporting the Preventive Care Measures Group at:
http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOfPage.
Measures Group Reporting via Claims:
The Diabetes Mellitus, CKD, Preventive Care, Rheumatoid Arthritis, Perioperative Care, Back Pain, Hepatitis C,
IVD and CAP Measures Groups can be submitted through claims or a qualified registry. To select a measures
group reporting option via claims, the first step requires that EPs identify their intent to report a measures group
by submitting a measures group-specific intent G-code on a claim for covered professional services furnished to
a patient enrolled in Medicare Part B PFS. The submission of the intent G-code serves as the indication that an
EP is choosing to report on a measures group and will initiate measures group analysis. It is not necessary to
submit the measures group-specific intent G-code on more than one claim. If the G-code for a given group is
submitted multiple times during the reporting period, only the submission with the earliest date of service will be
included in the PQRI analyses; subsequent submissions of that code will be ignored.
G8485: I intend to report the Diabetes Mellitus Measures Group
G8487: I intend to report the Chronic Kidney Disease (CKD) Measures Group
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G8486: I intend to report the Preventive Care Measures Group
G8490: I intend to report the Rheumatoid Arthritis Measures Group
G8492: I intend to report the Perioperative Care Measures Group
G8493: I intend to report the Back Pain Measures Group
G8545: I intend to report the Hepatitis C Measures Group
G8547: I intend to report the Ischemic Vascular Disease (IVD) Measures Group
G8546: I intend to report the Community-Acquired Pneumonia (CAP) Measures Group
Measures Group Reporting via Registry:
The CABG, HF, CAD and HIV/AIDS Measures Groups can only be submitted through a qualified registry. It is
not necessary to submit the measures group-specific intent G-code for registry-based submissions. However,
the measures group specific intent G-codes have been created for registry only measures groups for use by
registries that utilize claims data.
G8544: I intend to report the Coronary Artery Bypass Graft (CABG) Measures Group
G8548: I intend to report the Heart Failure (HF) Measures Group
G8489: I intend to report the Coronary Artery Disease (CAD) Measures Group
G8491: I intend to report the HIV/AIDS Measures Group
Measures Groups Reporting Methods:
There are two reporting methods for submission of measures groups:
1) 30 Patient Sample Method:
• For claims-based submissions, a participating EP must report on all applicable measures
within the selected measures group when billing measure-eligible claims for a minimum
sample of 30 unique Medicare Part B PFS patients who meet patient sample criteria for the
measures group (include Medicare Secondary Payer claims and claims for Railroad
Retirement beneficiaries; exclude Medicare Advantage beneficiaries). If the EP does not have
a minimum of 30 unique patients who meet patient sample criteria for the measures group, the
EP will need to choose another measures group or choose another reporting option. Please
refer to the Getting Started with 2010 PQRI Reporting of Measures Groups to determine the
proper reporting option.
o For claims-based submissions, the measures group-specific intent G-code must be
submitted once during the reporting period to indicate the EP’s selection of the
measures group.
• For registry-based submissions, a participating EP must report on all applicable measures
within the selected measures group for a minimum sample of 30 unique patients (which may
include non-Medicare Part B PFS patients) who meet patient sample criteria for the measures
group.
• For both claims-based and registry-based submissions, all the applicable measures within the
group must be reported at least once for each patient within the sample population seen by the
EP during the reporting period (January 1 through December 31, 2010), according to each
measures group’s reporting instructions contained within each group’s overview section.
OR
2) 80% Patient Sample Method:
• A participating EP must report on all applicable measures within the selected measures group
on claims for at least 80% of all Medicare Part B PFS patients seen during the entire reporting
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•

•

period (January 1 through December 31, 2010 OR July 1 through December 31, 2010) who
meet the measures group patient sample criteria.
o For claims-based submissions, the EP must report the measures group-specific
intent G-code once during the reporting period to indicate the EP’s selection of the
measures group that the EP intends to report.
Minimum Patient Sample Size
o For the 12-month reporting period, a minimum of 15 patients must meet the measures
group patient sample criteria to report satisfactorily. For the six-month reporting period, a
minimum of 8 patients must meet the measures group patient sample criteria to report
satisfactorily. If an EP does not have the minimum number of patients for inclusion in the
patient sample for the reporting period that EP should report either another measures
group or select reporting of individual measures that are applicable to the EP’s practice. If
the minimum number of patients does not meet the measures group patient sample
criteria, the EP is not incentive eligible.
For both claims-based and registry-based submissions, all applicable measures within the
group must be reported according to each measures group’s reporting instructions contained
within each group’s overview section.

The patient sample for both the 30 Patient Sample Method and the 80% Patient Sample Method are determined
by diagnosis and/or specific encounter parameters common to all measures within a selected measures group.
All applicable measures within a group must be reported for each patient within the sample that meets the
criteria (eg, age or gender) required in accordance with this manual. For example, if an EP is reporting on the
Preventive Care Measures Group, the Screening or Therapy for Osteoporosis measure would only need to be
reported on women within the EPs patient sample.

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Table of Contents
Measure
Number
1
2
3
117
119
163

Measure Title
Diabetes Mellitus Measures Group
Diabetes Mellitus Measures Group Overview
Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes
Mellitus
Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention
for Nephropathy in Diabetic Patients
Diabetes Mellitus: Foot Exam

Reporting
Options
C, R

15
C, R

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173

Preventive Care Measures Group
Preventive Care Measures Group Overview
Screening or Therapy for Osteoporosis for Women Aged 65 Years and
Older
Urinary Incontinence: Assessment of Presence or Absence of Urinary
Incontinence in Women Aged 65 Years and Older
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50
Years Old
Preventive Care and Screening: Pneumonia Vaccination for Patients 65
years and Older
Preventive Care and Screening: Screening Mammography
Preventive Care and Screening: Colorectal Cancer Screening
Preventive Care and Screening: Inquiry Regarding Tobacco Use
Preventive Care and Screening: Advising Smokers and Tobacco Users to
Quit
Preventive Care and Screening: Body Mass Index (BMI) Screening and
Follow-Up
Preventive Care and Screening: Unhealthy Alcohol Use – Screening

43

Coronary Artery Bypass Graft (CABG) Measures Group
Coronary Artery Bypass Graft (CABG) Measures Group Overview
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery

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123
135
153

39
48
110
111
112
113
114
115
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10
11
12
13
14

Chronic Kidney Disease (CKD) Measures Group
CKD Measures Group Overview
Chronic Kidney Disease (CKD): Laboratory Testing (Calcium,
Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile)
Chronic Kidney Disease (CKD): Blood Pressure Management
Chronic Kidney Disease (CKD): Plan of Care - Elevated Hemoglobin for
Patients Receiving Erythropoiesis-Stimulating Agents (ESA)
Chronic Kidney Disease (CKD): Influenza Immunization
Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula

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27
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30
31
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33
34
35
37

R

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Table of Contents
Measure
Number
44
164
165
166
167
168
169
170
171

108
176
177
178
179
180

20
21
22
23

148
149
150

Measure Title
(IMA) in Patients with Isolated CABG Surgery
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in
Patients with Isolated CABG Surgery
Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection
Rate
Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident
(CVA)
Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at
Discharge
Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at
Discharge
Coronary Artery Bypass Graft (CABG): Lipid Management and
Counseling

Reporting
Options

41
42
43
44
45
46
47
48
49

Rheumatoid Arthritis Measures Group
Rheumatoid Arthritis Measures Group Overview
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug
(DMARD)Therapy
Rheumatoid Arthritis (RA): Tuberculosis Screening
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Rheumatoid Arthritis (RA): Functional Status Assessment
Rheumatoid Arthritis (RA): Assessment and Classification of Disease
Prognosis
Rheumatoid Arthritis (RA): Glucocorticoid Management

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Perioperative Care Measures Group
Perioperative Care Measures Group Overview
Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
Perioperative Care: Selection of Prophylactic Antibiotic – First OR
Second Generation Cephalosporin
Perioperative Care: Discontinuation of Prophylactic Antibiotics (NonCardiac Procedures)
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)

C, R

Back Pain Measures Group
Back Pain Measures Group Overview
Back Pain: Initial Visit
Back Pain: Physical Exam
Back Pain: Advice for Normal Activities

C, R

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Table of Contents
Measure
Measure Title
Number
151
Back Pain: Advice Against Bed Rest

84
85
86
87
89
90
183
184

5
8
114
115
198
199

6
114
115
196
197

114
115

Reporting
Options

Hepatitis C Measures Group
Hepatitis C Measures Group Overview
Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
Hepatitis C: HCV Genotype Testing Prior to Treatment
Hepatitis C: Antiviral Treatment Prescribed
Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of
Treatment
Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral
Therapy
Hepatitis C: Hepatitis A Vaccination in Patients with HCV
Hepatitis C: Hepatitis B Vaccination in Patients with HCV

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Heart Failure (HF) Measures Group
Heart Failure Measures Group Overview
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
Inquiry Regarding Tobacco Use (Preventive Care and Screening)
Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
Heart Failure: Left Ventricular Function (LVF) Assessment
Heart Failure: Patient Education

R

Coronary Artery Disease (CAD) Measures Group
Coronary Artery Disease (CAD) Measures Group Overview
Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for
Patients with CAD
Inquiry Regarding Tobacco Use (Preventive Care and Screening)
Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
Coronary Artery Disease (CAD): Symptom and Activity Assessment
Coronary Artery Disease (CAD): Drug Therapy for Lowering LDLCholesterol

R

Ischemic Vascular Disease (IVD) Measures Group
Ischemic Vascular Disease (IVD) Measures Group Overview
Inquiry Regarding Tobacco Use (Preventive Care and Screening)
Advising Smokers and Tobacco Users to Quit (Preventive Care and

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Measure
Number
201
202
203
204

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160
161
162
205
206
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208

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Measure Title
Screening)
Ischemic Vascular Disease (IVD): Blood Pressure Management Control
Ischemic Vascular Disease (IVD): Complete Lipid Profile
Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C)
Control
Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic

Reporting
Options

110
111
112
113

HIV/AIDS Measures Group
HIV/AIDS Measures Group Overview
HIV/AIDS: CD4 + Cell Count or CD4 + Percentage
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are
Prescribed Potent Antiretroviral Therapy
HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral
Therapy
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and
Gonorrhea
HIV/AIDS: Screening for High Risk Sexual Behaviors
HIV/AIDS: Screening for Injection Drug Use
HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis

R

Community-Acquired Pneumonia (CAP) Measures Group
Community-Acquired Pneumonia (CAP) Measures Group Overview
Community-Acquired Pneumonia (CAP): Vital Signs
Community-Acquired Pneumonia (CAP): Assessment of Oxygen
Saturation
Community-Acquired Pneumonia (CAP): Assessment of Mental Status
Community-Acquired Pneumonia (CAP): Empiric Antibiotic

C, R

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY

DIABETES MELLITUS MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN DIABETES MELLITUS MEASURES GROUP:
# 1. Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
# 2. Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
# 3. Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
#117. Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
#119. Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy
in Diabetic Patients
#163. Diabetes Mellitus: Foot Exam
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Diabetes Mellitus Measures Group by submitting the
measures group-specific intent G-code at least once during the reporting period when billing a
patient claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not
necessary to submit the measures group-specific intent G-code on more than one claim. It is
not necessary to submit the measures group-specific intent G-code for registry-based
submissions.
G8485: I intend to report the Diabetes Mellitus Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactorily. For the sixmonth reporting period, a minimum of 8 patients must meet the measures group patient
sample criteria to report satisfactorily.

•

Patient sample criteria for the Diabetes Mellitus Measures Group are patients aged 18-75
years with a specific diagnosis of diabetes accompanied by a specific patient encounter:
One of the following diagnosis codes indicating diabetes: 250.00, 250.01, 250.02, 250.03,
250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32,
250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61,
250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90,
250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07,
366.41, 648.00, 648.01, 648.02, 648.03, 648.04
Accompanied by
One of the following patient encounter codes: 97802, 97803, 97804, 99201, 99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY
•

Report quality-data codes on all measures within the Diabetes Mellitus Measures Group for
each patient within the sample.

•

Instructions for quality-data code reporting for each of the measures within the Diabetes
Mellitus Measures Group are displayed on the next several pages. If all quality actions for the
patient have been performed for all the measures within the group, the following composite Gcode may be reported in lieu of the individual quality-data codes for each of the measures
within the group. It is not necessary to submit the following composite G-code for registrybased submissions.
Composite G-code G8494: All quality actions for the applicable measures in the Diabetes
Mellitus Measures Group have been performed for this patient

•

To report satisfactorily the Diabetes Mellitus Measures Group requires all measures for each
patient within the EP’s patient sample to be reported a minimum of once during the reporting
period.

•

When using the 30 Patient Sample Method, report all measures for the 30 unique patients
seen. When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365) for the line item on the claim containing G8485 (and
G8494 if reported) as well as all other line items containing QDCs. (N365) indicates the code is
not payable and is used for reporting/informational purposes only. Other services/codes on the
claim will not be affected by the addition of a measures group-specific intent G-code or other
QDCs. The N365 remark code does NOT indicate whether the QDC is accurate for that claim
or for the measure the EP is attempting to report, but does indicate that the QDC was
processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY

Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%
NUMERATOR:
Patients with most recent hemoglobin A1c level > 9.0%
Numerator Instructions: For performance, a lower rate indicates better
performance/control.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Hemoglobin A1c Level > 9.0%
CPT II 3046F: Most recent hemoglobin A1c level > 9.0%
OR
Hemoglobin A1c not Performed
Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3046F with 8P: Hemoglobin A1c level was not performed during the performance period
(12 months)
Most Recent Hemoglobin A1c Level ≤ 9.0%
CPT II 3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0%
OR
CPT II 3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY

Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes
Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
LDL-C level in control (less than 100 mg/dl)
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent LDL-C Level < 100 mg/dL
CPT II 3048F: Most recent LDL-C < 100 mg/dL
Most Recent LDL-C Level ≥ 100 mg/dL
CPT II 3049F: Most recent LDL-C 100-129 mg/dL
OR
CPT II 3050F: Most recent LDL-C ≥ 130 mg/dL
OR
LDL-C Level not Performed
Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3048F with 8P: LDL-C was not performed during the performance period (12 months)
Note: If unable to calculate LDL-C due to high triglycerides, CPT Category II code
3048F-8P should be reported

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY

Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
NUMERATOR:
Patients whose most recent blood pressure < 140/80 mmHg
Numerator Instructions: To describe both systolic and diastolic blood pressure values,
two CPT II codes must be reported – 1) One to describe the systolic value; AND
2) One to describe the diastolic value. If there are multiple blood pressures on the same
date of service, use the lowest systolic and lowest diastolic blood pressure on that date as
the representative blood pressure.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Blood Pressure Measurement Performed
Systolic codes (Select one (1) code from this section):
CPT II 3074F: Most recent systolic blood pressure < 130 mmHg
OR
CPT II 3075F: Most recent systolic blood pressure 130 - 139 mmHg
OR
CPT II 3077F: Most recent systolic blood pressure ≥ 140 mmHg
AND
Diastolic code (Select one (1) code from this section):
CPT II 3078F: Most recent diastolic blood pressure < 80 mmHg
OR
CPT II 3079F: Most recent diastolic blood pressure 80 - 89 mmHg
OR
CPT II 3080F: Most recent diastolic blood pressure ≥ 90 mmHg
Blood Pressure Measurement not Performed
Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2000F with 8P: No documentation of blood pressure measurement

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY

Measure #117: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
DESCRIPTION:
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a
dilated eye exam
NUMERATOR:
Patients who had a dilated eye exam for diabetic retinal disease at least once within 12 months
Numerator Instructions: This measure includes patients with diabetes who had one of
the following: A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of
retinopathy) by an eye care professional in the year prior to the reporting period. For
dilated eye exams performed 12 months prior to the reporting period, an automated result
must be available.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Eye Exam Performed by an Eye Care Professional
CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or
optometrist documented and reviewed
OR
CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an
ophthalmologist or optometrist documented and reviewed
OR
CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field
stereoscopic photos results documented and reviewed
OR
CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)
Dilated Eye Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2022F or 2024F or 2026F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
2022F or 2024F or 2026F with 8P: Dilated eye exam was not performed, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #119: Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention
for Nephropathy in Diabetic Patients
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein
screening or medical attention for nephropathy during at least one office visit within 12 months
NUMERATOR:
Patients who have a nephropathy screening during at least one office visit within 12 months
Numerator Instructions: This measure is looking for a nephropathy screening test or
evidence of nephropathy.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Nephropathy Screening Performed
CPT II 3060F: Positive microalbuminuria test result documented and reviewed
OR
CPT II 3061F: Negative microalbuminuria test result documented and reviewed
OR
CPT II 3062F: Positive macroalbuminuria test result documented and reviewed
OR
CPT II 3066F: Documentation of treatment for nephropathy (eg, patient receiving dialysis,
patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a
nephrologist)
OR
G8506: Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy
Nephropathy Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3060F or 3061F or 3062F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
3060F or 3061F or 3062F with 8P: Nephropathy screening was not performed, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #163: Diabetes Mellitus: Foot Exam
DESCRIPTION:
The percentage of patients aged 18 through 75 years with diabetes who had a foot examination
NUMERATOR:
Patients who received a foot exam (visual inspection, sensory exam with monofilament, or pulse
exam)
NUMERATOR NOTE: The patients who received a foot exam at least once within the prior
12 months.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satsfactorily:
Foot Exam Performed
CPT II 2028F: Foot examination performed (includes examination through visual
inspection, sensory exam with monofilament, and pulse exam – report when any of the
three components are completed)
Foot Exam not Performed for Medical Reason
Append a modifier (1P) to CPT Category II code 2028F to report documented
circumstances that appropriately exclude patients from the denominator.
2028F with 1P: Documentation of medical reason for not performing foot exam (i.e.,
patient with bilateral foot/leg amputation)
Foot Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2028F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2028F with 8P: Foot exam was not performed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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CHRONIC KIDNEY DISEASE (CKD) MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN THE CKD MEASURES GROUP:
#121. Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid
Hormone (iPTH) and Lipid Profile)
#122. Chronic Kidney Disease (CKD): Blood Pressure Management
#123. Chronic Kidney Disease (CKD): Plan of Care: Elevated Hemoglobin for Patients Receiving
Erythropoiesis - Stimulating Agents (ESA)
#135. Chronic Kidney Disease (CKD): Influenza Immunization
#153. Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula

INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the CKD Measures Group by submitting the measures groupspecific intent G-code at least once during the reporting period when billing a patient claim for
both the 30 Patient Sample and 80% Patient Sample Methods. It is not necessary to submit
the measures group-specific intent G-code on more than one claim. It is not necessary to
submit the measures group-specific intent G-code for registry-based submissions.
G8487: I intend to report the Chronic Kidney Disease (CKD) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactorily. For the sixmonth reporting period, a minimum of 8 patients must meet the measures group patient
sample criteria to report satisfactorily.

•

Patient sample criteria for the CKD Measures Group are patients aged 18 years and older with
a specific diagnosis of CKD accompanied by a specific patient encounter:
One of the following diagnosis codes indicating CKD: 585.4, 585.5
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215

•

Report quality-data codes on all measures within the CKD Measures Group for each patient
within the EP’s patient sample. Report measures #122 and #123 once during the month the
patient is included in the patient sample population. For these measures, subsequent months
do not need to be reported.

•

Instructions for quality-data code reporting for each of the measures within the CKD Measures
Group are displayed on the next several pages. If all quality actions for the patient have been
performed for all the measures within the group, the following composite G-code may be
reported in lieu of the individual quality-data codes for each of the measures within the group.
It is not necessary to submit the following composite G-code for registry-based submissions.

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Composite G-code G8495: All quality actions for the applicable measures in the CKD
Measures Group have been performed for this patient
•

To report satisfactorily the CKD Measures Group requires all measures for each patient within
the EP’s patient sample to be reported a minimum of once during the reporting period.

•

When using the 30 Patient Sample Method, report all measures for the 30 unique patients
seen. When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #121: Chronic Kidney Disease (CKD): Laboratory Testing (Calcium,
Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]), who had the following laboratory testing ordered
within 12 months: serum levels of calcium, phosphorus and intact PTH, and lipid profile
NUMERATOR:
Patients who had the following laboratory testing ordered at least once during the 12 month
reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile Ordered
CPT II 3278F: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH)
and lipid profile ordered
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3278F to report documented
circumstances that appropriately exclude patients from the denominator
3278F with 1P: Documentation of medical reason(s) for not ordering serum levels of
calcium, phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile
3278F with 2P: Documentation of patient reason(s) for not ordering serum levels of
calcium, phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3278F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3278F with 8P: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH)
and lipid profile not ordered, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #122: Chronic Kidney Disease (CKD): Blood Pressure Management
DESCRIPTION:
Percentage of patient visits for patients aged 18 years and older with a diagnosis of advanced CKD
(stage 4 or 5, not receiving Renal Replacement Therapy [RRT]), with a blood pressure < 130/80
mmHg OR blood pressure ≥ 130/80 mmHg with a documented plan of care
MEASURES GROUPS REPORTING INSTRUCTIONS:
Report this measure one time per patient during the reporting month that brings the patient into the
CKD measures group sample population.
NUMERATOR:
Patients visits with blood pressure <130/80 mmHg OR ≥130/80 mmHg with a documented plan of
care
Numerator Instructions: If multiple blood pressure measurements are taken at a single
visit, use the most recent measurement taken at that visit.
Definition:
Documented Plan Of Care – Should include one or more of the following: recheck blood
pressure at specified future date; initiate or alter pharmacologic therapy; initiate or alter
non-pharmacologic therapy; documented review of patient’s home blood pressure log
which indicates that patient’s blood pressure is or is not well controlled.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Patient Visits with Blood Pressure < 130/80 mmHg
(One G-code [G8476] is required on the claim form to submit this numerator option)
G8476: Most recent blood pressure has a systolic measurement of <130 mmHg and a
diastolic measurement of <80 mmHg
OR
Blood Pressure Plan of Care Documented for Patient Visits with Systolic Blood
Pressure ≥ 130 mmHg and/or Diastolic Blood Pressure ≥ 80 mmHg (If either systolic
blood pressure is ≥ 130 mmHg OR diastolic blood pressure is ≥ 80 mmHg, patient
requires a plan of care)
(One G-code & one CPT II code [G8477 & 0513F] are required on the claim form to submit
this numerator option)
G8477: Most recent blood pressure has a systolic measurement of ≥130 mmHg and/or a
diastolic measurement of ≥80 mmHg
AND
CPT II 0513F: Elevated blood pressure plan of care documented
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OR

Blood Pressure Measurement not Performed, Reason not Specified
(One G-code [G8478] is required on the claim form to submit this numerator option)
G8478: Blood pressure measurement not performed or documented, reason not specified
OR
Elevated Blood Pressure Plan of Care not Documented for Patient Visits with
Systolic Blood Pressure ≥ 130 mmHg and/or Diastolic Blood Pressure ≥ 80 mmHg,
Reason not Specified
(One CPT II code & one G-code [0513F-8P & G8477] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 0513F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0513F with 8P: No documentation of elevated blood pressure plan of care, reason not
otherwise specified
AND
G8477: Most recent blood pressure has a systolic measurement of ≥130 mmHg and/or a
diastolic measurement of ≥80 mmHg

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #123: Chronic Kidney Disease (CKD): Plan of Care: Elevated Hemoglobin for
Patients Receiving Erythropoiesis-Stimulating Agents (ESA)
DESCRIPTION:
Percentage of calendar months during the 12-month reporting period in which patients aged 18
years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving Renal Replacement
Therapy [RRT]), receiving ESA therapy, have a hemoglobin < 13 g/dL OR patients whose
hemoglobin is ≥ 13 g/dL and have a documented plan of care
MEASURES GROUPS REPORTING INSTRUCTIONS:
Report this measure one time per patient during the reporting month that brings the patient into the
CKD measures group sample population.
NUMERATOR:
Number of calendar months during which patients with a hemoglobin level of < 13 g/dL OR patients
whose hemoglobin level is ≥ 13 g/dL have a documented plan of care
Definition:
Documented Plan of Care – Should include reducing the ESA dose and repeating
hemoglobin at a specified future date.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hemoglobin level < 13 g/dL
(Two CPT II codes [328xF & 4171F] are required on the claim form to submit this
numerator option)
CPT II 3281F: Hemoglobin level less than 11 g/dL
OR
CPT II 3280F: Hemoglobin level 11 g/dL to 12.9 g/dL
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
OR
Hemoglobin level ≥ 13 g/dL with a Documented Plan of Care
(Three CPT II codes [3279F & 0514F & 4171F] are required on the claim form to submit
this numerator option)
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 0514F: Plan of care for elevated hemoglobin level documented for patient receiving
Erythropoiesis-Stimulating Agent (ESA) therapy
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
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OR

OR

If patient is not eligible for this measure because, patient was not receiving
erythropoiesis-stimulating agent (ESA) therapy, report:
(One CPT II code [4172F] is required on the claim form to submit this numerator option)
CPT II 4172F: Patient not receiving Erythropoiesis-Stimulating Agents (ESA) therapy
Hemoglobin Level Measurement not Performed, Reason not Specified
(Two CPT II codes [3281F-8P & 4171F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3281F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3281F with 8P: Hemoglobin level measurement not documented, reason not otherwise
specified
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
OR
Plan of Care for Elevated Hemoglobin Level not Documented for Patient Receiving
Erythropoiesis-Stimulating Agent (ESA) Therapy, Reason not Specified
(Three CPT II codes [0514F-8P & 3279F & 4171F] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 0514F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0514F with 8P: Plan of care for elevated hemoglobin level not documented for patient
receiving Erythropoiesis-Stimulating Agent (ESA) therapy, reason not
otherwise specified
AND
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #135: Chronic Kidney Disease (CKD): Influenza Immunization
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]) who received the influenza immunization during
the flu season (September through February)
NUMERATOR:
Patients who received the influenza immunization during the flu season (September through
February)
Numerator Instructions:
• If reporting this measure between January 1, 2010 and August 31, 2010, CPT
Category II code 4037F should be reported when the influenza vaccination is ordered
or administered to the patient during the months of September, October, November,
December of 2009 or January and February of 2010 for the flu season ending
February 28, 2010.
• If reporting this measure between September 1, 2010 and December 31, 2010, CPT
Category II code 4037F should be reported when the influenza vaccination is ordered
or administered to the patient during the months of September, October, November,
and December of 2010 for the flu season ending February 28, 2011.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Ordered or Administered
CPT II 4037F: Influenza immunization ordered or administered
Influenza Immunization not Ordered or Administered for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4037F to report documented
circumstances that appropriately exclude patients from the denominator.
4037F with 1P: Documentation of medical reason(s) for patient not receiving the influenza
immunization
4037F with 2P: Documentation of patient reason(s) for patient not receiving the influenza
immunization
4037F with 3P: Documentation of system reason(s) for patient not receiving the influenza
immunization
Influenza Immunization not Ordered or Administered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4037F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4037F with 8P: Influenza immunization not ordered or administered, reason not otherwise
specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #153: Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula
DESCRIPTION:
Percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]), who were referred for AV fistula at least once
during the 12-month reporting period
NUMERATOR:
Patients who were referred for AV fistula at least once during the 12 month reporting period

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
AV Fistula Referred
CPT II 4051F: Referred for an arteriovenous (AV) fistula
AV Fistula not Referred for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4051F to report documented
circumstances that appropriately exclude patients from the denominator.
4051F with 1P: Documentation of medical reason(s) for not referring for an AV fistula
4051F with 2P: Documentation of patient reason(s) for not referring for an AV fistula
AV Fistula not Referred, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4051F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4051F with 8P: AV fistula not referred, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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PREVENTIVE CARE MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN THE PREVENTIVE CARE MEASURES GROUP:
# 39. Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
# 48. Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women
Aged 65 Years and Older
#110. Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
#111. Preventive Care and Screening: Pneumonia Vaccination for Patients 65 years and Older
#112. Preventive Care and Screening: Screening Mammography
#113. Preventive Care and Screening: Colorectal Cancer Screening
#114. Preventive Care and Screening: Inquiry Regarding Tobacco Use
#115. Preventive Care and Screening: Advising Smokers and Tobacco Users to Quit
#128. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
#173. Preventive Care and Screening: Unhealthy Alcohol Use – Screening
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Preventive Care Measures Group by submitting the
measures group-specific intent G-code at least once during the reporting period when billing a
patient claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not
necessary to submit the measures group-specific intent G-code on more than one claim. It is
not necessary to submit the measures group-specific intent G-code for registry-based
submissions.
G8486: I intend to report the Preventive Care Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (July 1 through December 31, 2008). For the 12-month
reporting period, a minimum of 15 patients must meet the measures group patient sample
criteria to report satisfactory. For the six-month reporting period, a minimum of 8 patients must
meet the measures group patient sample criteria to report satisfactory.

•

Patient sample criteria for the Preventive Care Measures Group are for patients aged 50 years
and older with a specific patient encounter:
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215

•

Report quality-data codes on all applicable measures within the Preventive Care Measures
Group for each patient within the EP’s patient sample.

Applicable measures contain patient demographic criteria specific to the measure. For
example, Screening or Therapy for Osteoporosis is applicable to women aged 65 years
and older within the sample population, while the Influenza Vaccination measure within this
group is applicable to all patients aged 50 years and older. EPs may find it more efficient to
report all measures in the group for each patient within their sample. Reporting measure(s)
from the group that are inapplicable to an individual patient will not affect the eligible
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provider’s reporting or performance rate.
Preventive Measures Group Demographic Criteria
Age

Measures for Male Patients

Measures for Female Patients

<50 years

Patient does not qualify for measures group
analysis

Patient does not qualify for measures group
analysis

50-64 years

110, 113, 114, 115, 128, 173

110, 112, 113, 114, 115, 128, 173

65-69 years

110, 111, 113, 114, 115, 128, 173

39, 48, 110, 111, 112, 113, 114, 115, 128, 173

70-75 years

110, 111, 113, 114, 115, 128, 173

39, 48, 110, 111, 113, 114, 115, 128, 173

≥76 years

110, 111, 114, 115, 128, 173

39, 48, 110, 111, 114, 115, 128, 173

•

Instructions for quality-data code reporting for each of the measures within the Preventive Care
Measures Group are displayed on the next several pages. If all quality actions for the patient
have been performed for all the measures within the group, the following composite G-code
may be reported in lieu of the individual quality-data codes for each of the measures within the
group. It is not necessary to submit the following composite G-code for registry-based
submissions.
Composite G-code G8496: All quality actions for the applicable measures in the Preventive
Care Measures Group have been performed for this patient

•

To report satisfactorily the Preventive Care Measures Group, it requires all applicable
measures for each patient within the EP’s patient sample to be reported a minimum of once
during the reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30 unique
patients seen. When using the 80% Patient Sample Method, report all applicable measures on
at least 80% of the patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and
Older
DESCRIPTION:
Percentage of female patients aged 65 years and older who have a central dual-energy X-ray
absorptiometry (DXA) measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
NUMERATOR:
Patients who had a central DXA measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
Definitions:
Pharmacologic Therapy – U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs
(raloxifene).
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Central DXA Measurement Ordered or Performed or Pharmacologic Therapy
Prescribed
G8399: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results documented
or ordered or pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed for Documented Reasons
G8401: Clinician documented that patient was not an eligible candidate for screening or
therapy for osteoporosis for women measure
Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed, Reason not Specified
G8400: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results not
documented or not ordered or pharmacologic therapy (other than minerals/vitamins) for
osteoporosis not prescribed

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary
Incontinence in Women Aged 65 Years and Older
DESCRIPTION:
Percentage of female patients aged 65 years and older who were assessed for the presence or
absence of urinary incontinence within 12 months
NUMERATOR:
Patients who were assessed for the presence or absence of urinary incontinence within 12 months
Definition:
Urinary Incontinence – Any involuntary leakage of urine.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Presence or Absence of Urinary Incontinence Assessed
CPT II 1090F: Presence or absence of urinary incontinence assessed
Presence or Absence of Urinary Incontinence not Assessed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1090F to report documented
circumstances that appropriately exclude patients from the denominator.
1090F with 1P: Documentation of medical reason(s) for not assessing for the presence or
absence of urinary incontinence
Presence or Absence of Urinary Incontinence not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1090F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1090F with 8P: Presence or absence of urinary incontinence not assessed, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #110: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50
Years Old
DESCRIPTION:
Percentage of patients aged 50 years and older who received an influenza immunization during the
flu season (September through February)
NUMERATOR:
Patients who received an influenza immunization during the flu season (September through
February)
Numerator Instructions:
• If reporting this measure between January 1, 2010 and August 31, 2010, G-code
G8482 should be reported when the influenza vaccination is ordered or administered
to the patient during the months of September, October, November, December of
2009 or January and February of 2010 for the flu season ending February 28, 2010.
• If reporting this measure between September 1, 2010 and December 31, 2010, Gcode G8482 should be reported when the influenza vaccination is ordered or
administered to the patient during the months of September, October, November, and
December of 2010 for the flu season ending February 28, 2011.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Administered
G8482: Influenza immunization was ordered or administered
Influenza Immunization not Administered for Documented Reasons
G8483: Influenza immunization was not ordered or administered for reasons documented
by clinician
Influenza Immunization not Administered, Reason not Specified
G8484: Influenza immunization was not ordered or administered, reason not specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65
Years and Older
DESCRIPTION:
Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine
NUMERATOR:
Patients who have ever received a pneumococcal vaccination

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Pneumonia Vaccination Administered or Previously Received
CPT II 4040F: Pneumococcal vaccine administered or previously received
Pneumonia Vaccination not Administered or Previously Received for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4040F to report documented
circumstances that appropriately exclude patients from the denominator.
4040F with 1P: Documentation of medical reason(s) for not administering or previously
receiving pneumococcal vaccination
Pneumonia Vaccination not Administered or Previously Received, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4040F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4040F with 8P: Pneumococcal vaccine was not administered or previously received,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #112: Preventive Care and Screening: Screening Mammography
DESCRIPTION:
Percentage of women aged 40 through 69 years who had a mammogram to screen for breast
cancer within 24 months
NUMERATOR:
Patients who had a mammogram at least once within 24 months

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Mammogram Performed
CPT II 3014F: Screening mammography results documented and reviewed
Mammogram not Performed for Medical Reasons
Append a modifier (1P) to the above CPT Category II code 3014F to report documented
circumstances that appropriately exclude patients from the denominator
3014F with 1P: Documentation of medical reason(s) for not performing a mammogram
(i.e., women who had a bilateral mastectomy or two unilateral
mastectomies).
Mammogram not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3014F with 8P: Screening mammography results were not documented and reviewed,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #113: Preventive Care and Screening: Colorectal Cancer Screening
DESCRIPTION:
Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer
screening
NUMERATOR:
Patients who had at least one or more screenings for colorectal cancer during or prior to the
reporting period
Numerator Instructions: Patients are considered to have appropriate screening for
colorectal cancer if any of the following are documented:
• Fecal occult blood test (FOBT) within the last 12 months
• Flexible sigmoidoscopy during the reporting period or the four years prior to the
reporting period
• Colonoscopy during the reporting period or the nine years prior to the reporting
period

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Colorectal Cancer Screening
CPT II 3017F: Colorectal cancer screening results documented and reviewed
Colorectal Cancer Screening not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 3017F to report documented
circumstances that appropriately exclude patients from the denominator
3017F with 1P: Documentation of medical reason(s) for not performing a colorectal cancer
screening
Colorectal Cancer Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3017F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3017F with 8P: Colorectal cancer screening results were not documented and reviewed,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #114: Preventive Care and Screening: Inquiry Regarding Tobacco Use
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tobacco Use Assessed
(Two CPT II codes [1000F & 103xF] are required on the claim form to submit this
numerator option)
CPT II 1000F: Tobacco use assessed
AND
CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user (eg, chew, snuff)
OR
CPT II 1036F: Current tobacco non-user
Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1000F with 8P: Tobacco use not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #115: Preventive Care and Screening: Advising Smokers and Tobacco Users to
Quit
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers or tobacco users who received
advice to quit smoking
NUMERATOR:
Patients who received advice to quit smoking or smokeless tobacco use
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advising Smoker or Smokeless Tobacco User to Quit
(One G-code and one CPT II code [G845x & 400xF) are required on the claim form to
submit this numerator option)
G8455: Current tobacco smoker
OR
G8456: Current smokeless tobacco user (eg, chew, snuff)
AND

OR

OR

CPT II 4000F: Tobacco use cessation intervention, counseling
OR
CPT II 4001F: Tobacco use cessation intervention, pharmacologic therapy
If patient is not eligible for this measure because patient is a non tobacco user,
report:
(One G-code [G8457) is required on the claim form to submit this numerator option)
Tobacco Non-User
G8457: Current tobacco non-user
Tobacco Smoker or Smokeless Tobacco User not Advised to Quit or Tobacco Use
not Assessed, Reason not Specified
(One CPT II code {4000F-8P} is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 4000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4000F with 8P: Tobacco use cessation intervention not counseled or tobacco use not
assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and
Follow-Up
DESCRIPTION:
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or
during the current visit documented in the medical record AND if the most recent BMI is outside
parameters, a follow-up plan is documented
Parameters: Age 65 and older BMI ≥30 or <22
Age 18 – 64 BMI ≥25 or <18.5
NUMERATOR:
Patients with BMI calculated within the past six months or during the current visit and a follow-up
plan documented if the BMI is outside of parameters
Definitions:
BMI – Body Mass Index (BMI) is a number calculated from a person’s weight and height.
BMI provides a reliable indicator of body fatness for most people and is used to screen for
weight categories that may lead to health problems. BMI is calculated by dividing a
person’s weight (in kilograms) by his/her height (in meters, squared). BMI can also be
calculated by multiplying weight (in pounds) by 705, then dividing by height (in inches)
twice. A simpler method to calculate the BMI involves the use of a chart. The weight is
plotted on one axis and the height is plotted on the other axis. The BMI can then be read
where the two points intersect. Example BMI charts are widely available via the internet.
Calculated BMI – Requires that both the height and weight are actually measured. Values
merely reported by the patient cannot be used.
Follow-up Plan – Proposed outline of treatment to be conducted as a result of abnormal
BMI measurement. Such follow-up can include documentation of a future appointment,
education, referral, prescription/administration of medications/dietary supplements, etc.
Terminal Illness – Life expectancy is 6 months or less
Not eligible/Not Appropriate for BMI Measurement – Patients can be considered not
eligible in the following situations:
• There is documentation in the medical record that the patient is over or under weight
and is being managed by another provider
• If the patient has a terminal illness
• If the patient refuses BMI measurement
• If there is any other reason documented in the medical record by the provider
explaining why BMI measurement was not appropriate
• Patient is in an urgent or emergent medical situation where time is of the essence and
to delay treatment would jeopardize the patient’s health status
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
BMI Calculated, No Follow-up Plan Needed or BMI Calculated, Follow-up Plan
Documented
G8420: Calculated BMI within normal parameters and documented
OR
G8417: Calculated BMI above the upper parameter and a follow-up plan was documented
in the medical record
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OR
OR

OR
G8418: Calculated BMI below the lower parameter and a follow-up plan was documented
in the medical record
Patient not Eligible for BMI Calculation for Documented Reasons
G8422: Patient not eligible for BMI calculation
BMI not Performed and/or Calculated BMI Outside of Normal Parameters, Follow-up
Plan not Documented, Reason not Specified
G8421: BMI not calculated
OR
G8419: Calculated BMI outside normal parameters, no follow-up plan documented in the
medical record

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use – Screening
DESCRIPTION:
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use
using a systematic screening method within 24 months
NUMERATOR:
Patients who were screened for unhealthy alcohol use using a systematic screening method within
24 months
Definition:
Unhealthy Alcohol Use – Covers a spectrum that is associated with varying degrees of
risk to health. Categories representing unhealthy alcohol use include risky use, problem
drinking, harmful use, and alcohol abuse, and the less common but more severe
alcoholism and alcohol dependence. Risky use is defined as > 7 standard drinks per week
or > 3 drinks per occasion for women and persons > 65 years of age; > 14 standard drinks
per week or > 4 drinks per occasion for men ≤ 65 years of age.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Unhealthy Alcohol Use Screening Performed
CPT II 3016F: Patient screened for unhealthy alcohol use using a systematic screening
method
Unhealthy Alcohol Use Screening not Performed, for Medical Reasons
Append a modifier (1P) to CPT Category II code 3016F to report documented
circumstances that appropriately exclude patients from the denominator.
3016F with 1P: Documentation of medical reason(s) for not screening for unhealthy
alcohol use (eg, limited life expectancy)
Unhealthy Alcohol Use Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3016F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3016F with 8P: Unhealthy alcohol use screening not performed, reason not otherwise
specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES GROUP
OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: REGISTRY ONLY
2010 PQRI MEASURES IN CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES
GROUP:
# 43. Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients
with Isolated CABG Surgery
# 44. Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated
CABG Surgery
#164. Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)
#165. Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
#166. Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident (CVA)
#167. Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
#168. Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
#169. Coronary Artery Bypass Graft (CABG): Anti-platelet Medications at Discharge
#170. Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
#171. Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling
INSTRUCTIONS FOR REPORTING: (These instructions apply to registry reporting. Do not
report this measures group via claims.)
•

It is not necessary to submit the measures group-specific intent G-code for registry-based
submissions. However, the measures group-specific intent G-code has been created for
registry only measures groups for use by registries that utilize claims data.
G8544: I intend to report the Coronary Artery Bypass Graft (CABG) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the CABG Measures Group are patients aged 18 years and older
that have a specific procedure for isolated CABG performed:
One of the following procedure codes indicating CABG: 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

•

Measure #166 need only be reported when the patient does not have a history of a prior CVA.
Measure #167 need only be reported when the patient does not have a history renal
insufficiency or a baseline serum creatinine > 2.0. Measure #169, #170, and #171 need only
be reported when the patient is not deceased prior to discharge. Therefore, these measures
are only applicable to a patient when these additional criteria are indicated.

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SPECIFICATION FOR MEASURES GROUP REPORTING ONLY
•

Report a numerator option on all applicable measures within the CABG Measures Group for
each patient within the EP’s patient sample.

•

Instructions for qualifying numerator option reporting for each of the measures within the
CABG Measures Group are displayed on the next several pages. The following composite Gcode has been created for registry only measures groups for use by registries that utilize
claims data. This composite G-code may be reported in lieu of the individual quality-data codes
for each of the measures within the group, if all quality actions for the patient have been
performed for all the measures within the group. However, it is not necessary to submit the
following composite G-code for registry-based submissions.
Composite G-code G8497: All quality actions for the applicable measures in the Coronary
Artery Bypass Graft (CABG) Measures Group have been performed for this patient

•

To report satisfactorily the CABG Measures Group it requires all applicable measures for
each patient within the EP’s patient sample to be reported each time an isolated CABG
procedure is performed during the reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30 unique
patients seen during the reporting period. When using the 80% Patient Sample Method, report
all applicable measures on at least 80% of the patient sample for the EP for the 12-month or
six-month reporting period.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #43: Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery
(IMA) in Patients with Isolated CABG Surgery
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery using an IMA
graft
NUMERATOR:
Patients who received an IMA graft in isolated CABG

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
IMA Graft Performed
CPT II 4110F: Internal mammary artery graft performed for primary, isolated coronary
artery bypass graft procedure
IMA Graft not Performed for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4110F to report documented
circumstances that appropriately exclude patients from the denominator.
4110F with 1P: Documentation of medical reason(s) for not performing an internal
mammary artery graft for primary, isolated coronary artery bypass graft
procedure
IMA Graft not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4110F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4110F with 8P: Internal mammary artery graft not performed for primary, isolated coronary
artery bypass graft procedure, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #44: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in
Patients with Isolated CABG Surgery
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received a
beta-blocker within 24 hours prior to surgical incision
NUMERATOR:
Patients undergoing isolated CABG who received a beta-blocker within 24 hours prior to surgical
incision

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Preoperative Beta-blocker Received
CPT II 4115F: Beta blocker administered within 24 hours prior to surgical incision
Preoperative Beta-blocker not Received for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4115F to report documented
circumstances that appropriately exclude patients from the denominator.
4115F with 1P: Documentation of medical reason(s) for not administering beta blocker
within 24 hours prior to surgical incision
Preoperative Beta-blocker not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4115F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4115F with 8P: Beta blocker not administered within 24 hours prior to surgical incision,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based re porting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require
intubation > 24 hours
NUMERATOR:
Patients undergoing isolated CABG who require intubation > 24 hours
Numerator Instructions: For performance, a lower rate indicates better performance.

OR

Numerator Options:
Prolonged intubation (> 24 hrs) required (G8569)
Prolonged intubation (> 24 hrs) not required (G8570)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who developed
deep sternal wound infection (involving muscle, bone, and/or mediastinum requiring operative
intervention) within 30 days postoperatively
NUMERATOR:
Patients who developed a deep sternal wound infection within 30 days postoperatively (must have
ALL of the following conditions: wound opened with excision of tissue [incision and drainage] or reexploration of mediastinum, positive culture and treatment with antibiotics)
Numerator Instructions: For performance, a lower rate indicates better performance.

OR

Numerator Options:
Development of deep sternal wound infection within 30 days postoperatively (G8571)
No deep sternal wound infection (G8572)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #166: Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident
(CVA)
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who had a
stroke/CVA within 24 hours postoperatively
NUMERATOR:
Patients who have a stroke/CVA within 24 hours postoperatively
Numerator Instructions: For performance, a lower rate indicates better performance.

OR

Numerator Options:
Stroke/CVA following isolated CABG surgery (G8573)
No stroke/CVA following isolated CABG surgery (G8574)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who develop
postoperative renal insufficiency or require dialysis
NUMERATOR:
Patients who develop postop renal insufficiency or require dialysis (indicate whether the patient
had acute or worsening renal insufficiency resulting in one or more of the following: 1) increase of
serum creatinine to > 2.0, and 2x most recent preoperative creatinine level; 2) a new requirement
for dialysis postoperatively)
Numerator Instructions: For performance, a lower rate indicates better performance.

OR

Numerator Options:
Developed postoperative renal insufficiency or required dialysis (G8575)
No postoperative renal insufficiency/dialysis not required (G8576)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #168: Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a
return to the operating room (OR) for mediastinal bleeding/tamponade, graft occlusion (due to
acute closure, thrombosis, technical or embolic origin), or other cardiac reason
NUMERATOR:
Patients who require a return to the OR for bleeding/tamponade, graft occlusion, or other cardiac
reason
Numerator Instructions: For performance, a lower rate indicates better performance.

OR

Numerator Options:
Reoperation required due to bleeding/tamponade, graft occlusion or other cardiac reason
(G8577)
Reoperation not required due to bleeding/tamponade, graft occlusion or other cardiac
reason (G8578)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #169: Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at
Discharge
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have
antiplatelet medication at discharge
NUMERATOR:
Patients who were discharged on antiplatelet medication

OR
OR

Numerator Options:
Antiplatelet medication at discharge (G8579)
Antiplatelet medication contraindicated/not indicated (G8580)
No antiplatelet medication at discharge (G8581)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #170: Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at
Discharge
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were
discharged on beta-blockers
NUMERATOR:
Patients who were discharged on beta-blockers

OR
OR

Numerator Options:
Beta-blocker at discharge (G8582)
Beta-blocker contraindicated/not indicated (G8583)
No beta-blocker at discharge (G8584)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #171: Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have antilipid treatment at discharge
NUMERATOR:
Patients with an anti-lipid treatment at discharge

OR
OR

Numerator Options:
Anti-lipid treatment at discharge (G8585)
Anti-lipid treatment contraindicated/not indicated (G8586)
No anti-lipid treatment at discharge (G8587)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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RHEUMATOID ARTHRITIS MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN RHEUMATOID ARTHRITIS MEASURES GROUP:
#108. Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
#176. Rheumatoid Arthritis (RA): Tuberculosis Screening
#177. Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
#178. Rheumatoid Arthritis (RA): Functional Status Assessment
#179. Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
#180. Rheumatoid Arthritis (RA): Glucocorticoid Management
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Rheumatoid Arthritis Measures Group by submitting the
measures group-specific intent G-code at least once during the reporting period when billing a
patient claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not
necessary to submit the measures group-specific intent G-code on more than one claim. It is
not necessary to submit the measures group-specific intent G-code for registry-based
submissions.
G8490: I intend to report the Rheumatoid Arthritis Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Rheumatoid Arthritis Measures Group are patients aged 18
years and older with a specific diagnosis of rheumatoid arthritis accompanied by a specific
patient encounter:
One of the following diagnosis codes indicating rheumatoid arthritis: 714.0, 714.1, 714.2,
714.81
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

•

Report quality-data codes on all measures within the Rheumatoid Arthritis Measures Group for
each patient within the EP’s patient sample.

•

Instructions for quality-data code reporting for each of the measures within the Rheumatoid
Arthritis Measures Group are displayed on the next several pages. If all quality actions for the
patient have been performed for all the measures within the group, the following composite Gcode may be reported in lieu of the individual quality-data codes for each of the measures

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within the group. It is not necessary to sumit the following composite G-code for registry-based
submissions.
Composite G-code G8499: All quality actions for the applicable measures in the Rheumatoid
Arthritis Measures Group have been performed for this patient
•

To report satisfactorily the Rheumatoid Arthritis Measures Group it requires all measures for
each patient within the EP’s patient sample to be reported a minimum of once during the
reporting period.

•

When using the 30 Patient Sample Method, report all measures for the 30 unique patients
seen. When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #108: Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug
(DMARD) Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed,
dispensed, or administered at least one ambulatory prescription for a DMARD
NUMERATOR:
Patients who were prescribed, dispensed, or administered at least one disease modifying antirheumatic drug (DMARD)
Definitions:
Prescribed – May include prescription given to the patient for DMARD therapy at one or
more visits in the 12-month period OR patient already taking DMARD therapy as
documented in current medication list.
Biologic DMARD Therapy – Includes Adalimunab, Etanercept, Infliximab, Abatacept,
Anakinra and Rituximab

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
DMARD Prescribed, Dispensed, or Administered
CPT II 4187F: Disease modifying anti-rheumatic drug therapy prescribed, dispensed, or
administered
DMARD not Prescribed, Dispensed, or Administered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4187F to report documented
circumstances that appropriately exclude patients from the denominator.
4187F with 1P: Documentation of medical reason(s) for not prescribing, dispensing, or
administering disease modifying anti-rheumatic drug therapy
DMARD not Prescribed, Dispensed, or Administered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4187F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4187F with 8P: Disease modifying anti-rheumatic drug therapy was not prescribed,
dispensed, or administered, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #176: Rheumatoid Arthritis (RA): Tuberculosis Screening
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have documentation of
a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a
first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
NUMERATOR:
Patients for whom a TB screening was performed and results interpreted within six months prior to
receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
Numerator Instructions: Patients are considered to be receiving a first course of therapy
using a biologic DMARD only if they have never previously been prescribed or dispensed a
biologic DMARD.
Definition:
Biologic DMARD Therapy – Includes Adalimunab, Etanercept, Infliximab, Abatacept,
Anakinra (Rituximab is excluded)
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tuberculosis Screening Performed and Results Interpreted
(Two CPT II codes [3455F & 4195F] are required on the claim form to submit this
numerator option)
CPT II 3455F: TB screening performed and results interpreted within six months prior to
initiation of first-time biologic disease modifying anti-rheumatic drug therapy for RA
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis
TB Screening not Performed or Results not Interpreted for Medical Reasons
(Two CPT II codes [3455F-1P & 4195F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 3455F to report documented
circumstances that appropriately exclude patients from the denominator.
3455F with 1P: Documentation of medical reason for not screening for TB or interpreting
results (i.e., patient positive for TB and documentation of past treatment;
patient has recently completed a course of anti-TB therapy)
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis
OR

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OR

If patient does not meet denominator inclusion because biologic DMARD
prescription is Rituximab or this is not the first course of biologic DMARD therapy
for RA, report:
(One CPT II code [4196F] is required on the claim form to submit this numerator option)
CPT II 4196F: Patient not receiving first-time biologic disease modifying anti-rheumatic
drug therapy for rheumatoid arthritis
TB Screening not Performed or Results not Interpreted, Reason not Specified
(Two CPT II codes [3455F-8P& 4195F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3455F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3455F with 8P: TB screening not performed or results not interpreted, reason not
otherwise specified
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment
and classification of disease activity within 12 months
NUMERATOR:
Patients with disease activity assessed by a standardized descriptive or numeric scale or
composite index and classified into one of the following categories: low, moderate or high, at least
once within 12 months
Definition:
Assessment and Classification of Disease Activity – Assesses if physicians are
utilizing a standardized, systematic approach for evaluating the level of disease activity.
The scales/instruments listed are examples of how to define activity level and cut-off points
can differ by scale. Standardized descriptive or numeric scales and/or composite indexes
could include but are not limited to: DAS28, SDAI, CDAI, RADAI, RAPID.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Disease Activity Assessed and Classified
CPT II 3470F: Rheumatoid arthritis (RA) disease activity, low
OR
CPT II 3471F: Rheumatoid arthritis (RA) disease activity, moderate
OR
CPT II 3472F: Rheumatoid arthritis (RA) disease activity, high
Disease Activity not Assessed and Classified, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3470F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3470F with 8P: Disease activity not assessed and classified, reason not otherwise
specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA for whom a functional
status assessment was performed at least once within 12 months
NUMERATOR:
Patients for whom a functional status assessment was performed at least once within 12 months
Definitions:
Functional Status Assessment – This measure assesses if physicians are using a
standardized descriptive or numeric scale, standardized questionnaire, or notation of
assessment of the impact of RA on patient activities of daily living. Examples of tools used
to assess functional status include but are not limited to: Health Assessment Questionnaire
(HAQ), Modified HAQ, HAQ-2; American College of Rheumatology’s Classification of
Functional Status in Rheumatoid Arthritis.
Activities of Daily Living – Could include a description of any of the following:
dressing/grooming, rising from sitting, walking/running/ability to ambulate, stairclimbing,
reaching, gripping, shopping/running errands/house or yard work.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Functional Status Assessed
CPT II 1170F: Functional status assessed
Functional Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1170F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1170F with 8P: Functional status not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease
Prognosis
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment
and classification of disease prognosis at least once within 12 months
NUMERATOR:
Patients with at least one documented assessment and classification (good/poor) of disease
prognosis utilizing clinical markers of poor prognosis at least once within 12 months
Numerator Instructions: This measure evaluates if physicians are assessing and
classifying disease prognosis using a standardized, systematic approach. Disease
prognosis should be classified as either poor or good.
Definitions:
Poor Prognosis – RA patients with features of poor prognosis have active disease with
high tender and swollen joint counts, often have evidence of radiographic erosions,
elevated levels of rheumatoid factor (RF) and or anti-cyclic citrullinated peptide (anti-CCP)
antibodies, and an elevated erythrocyte sedimentation rate, and an elevated C-reactive
protein level.
Clinically Important Markers of Poor Prognosis – Classification should be based upon
at a minimum the following: functional limitation (e.g., HAQ Disability Index), extraarticular
disease (e.g. vasculitis, Sjorgen’s syndrome, RA lung disease, rheumatoid nodules), RF
positivity, positive anti-CCP antibodies (both characterized dichotomously, per CEP
recommendation), and/or bony erosions by radiography.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Disease Prognosis Assessed and Classified
CPT II 3475F: Disease prognosis for rheumatoid arthritis assessed, poor prognosis
documented
OR
CPT II 3476F: Disease prognosis for rheumatoid arthritis assessed, good prognosis
documented
Disease Prognosis not Assessed and Classified, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3475F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3475F with 8P: Disease prognosis for rheumatoid arthritis not assessed and classified,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have been assessed
for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or
equivalent) with improvement or no change in disease activity, documentation of glucocorticoid
management plan within 12 months
NUMERATOR:
Patients who have been assessed for glucocorticoid use and for those on prolonged doses of
prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity,
documentation of a glucocorticoid management plan within 12 months
Definitions:
Prolonged Dose – Doses > 6 months in duration
Prednisone Equivalents – Determine using the following:
1 mg of prednisone = 1 mg of prednisolone; 5 mg of cortisone; 4 mg of hydrocortisone; 0.8
mg of triamcinolone; 0.8 mg of methylprednisolone; 0.15 mg of dexamethasone; 0.15 mg
of betamethasone
Glucocorticoid Management Plan – Includes documentation of attempt to taper steroids
OR documentation of a new prescription for a non-glucocorticoid disease-modifying
antirheumatic drug (DMARD) OR increase in dose of non-glucocorticoid DMARD dose for
persistent RA disease activity at current or reduced dose
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Glucocorticoid Use Assessed
(One CPT II code [419xF] is required on the claim form to submit this numerator option)
CPT II 4192F: Patient not receiving glucocorticoid therapy
OR
CPT II 4193F: Patient receiving < 10 mg daily prednisone (or equivalent), or RA disease
activity is worsening, or glucocorticoid use is for less than 6 months
OR
Glucocorticoid Use Assessed and Management Plan Documented
(Two CPT II codes [4194F and 0540F] are required on the claim form to submit this
numerator option)
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity
AND
CPT II 0540F: Glucocorticoid Management Plan documented

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OR

OR

Glucocorticoid Plan not Documented for Medical Reasons
(Two CPT II codes [0540F-1P and 4194F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 0540F to report documented
circumstances that appropriately exclude patients from the denominator.
0540F with 1P: Documentation of medical reason(s) for not documenting glucocorticoid
dose and documenting management plan (i.e., glucocorticoid prescription
is for a medical condition other than RA)
AND
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity
Glucocorticoid Dose not Documented, Reason not Specified
(One CPT II code [4194F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 4194F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4194F with 8P: Glucocorticoid dose was not documented, reason not otherwise specified
OR
Glucocorticoid Plan not Documented, Reason not Specified
(Two CPT II codes [0540F-8P and 4194F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 0540F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0540F with 8P: Glucocorticoid plan not documented, reason not otherwise specified
AND
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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PERIOPERATIVE CARE MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN PERIOPERATIVE CARE MEASURES GROUP:
#20. Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
#21. Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation
Cephalosporin
#22. Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)
#23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL
Patients)
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Perioperative Care Measures Group by submitting the
measures group-specific intent G-code at least once during the reporting period when billing a
patient claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not
necessary to submit the measures group-specific intent G-code on more than one claim. It is
not necessary to submit the measures group-specific intent G-code for registry-based
submissions.
G8492: I intend to report the Perioperative Care Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Perioperative Care Measures Group are patients aged 18 years
and older that have a specific surgical procedure performed:
One of the following surgical procedure codes: 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364, 19366, 19367, 19368, 19369, 22558,
22600, 22612, 22630, 27125, 27130, 27132, 27134, 27137, 27138, 27235, 27236, 27244,
27245, 27269, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 39545, 39561, 43045,
43100, 43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123,
43124, 43130, 43135, 43300, 43305, 43310, 43312, 43313, 43320, 43324, 43325, 43326,
43330, 43331, 43340, 43341, 43350, 43351, 43352, 43360, 43361, 43400, 43401, 43405,
43410, 43415, 43420, 43425, 43496, 43500, 43501, 43502, 43510, 43520, 43605, 43610,
43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43653, 43800,
43810, 43820, 43825, 43830, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850,
43855, 43860, 43865, 43870, 44005, 44010, 44020, 44021, 44050, 44055, 44120, 44125,
44126, 44127, 44130, 47420, 47425, 47460, 47480, 47560, 47561, 47570, 47600, 47605,
47610, 47612, 47620, 47700, 47701, 47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900,48020, 48100, 48120, 48140, 48145,

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48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545,
48547, 48548, 48554, 48556, 49215, 50320, 50340, 50360, 50365, 50370, 50380, 60521,
60522, 61313, 61510, 61512, 61518, 61548, 61697, 61700, 62230, 63015, 63020, 63047,
63056, 63081, 63267, 63276
•

Report quality-data codes on all measures within the Perioperative Care Measures Group for
each patient within the EP’s patient sample.

•

Instructions for quality-data code reporting for each of the measures within the Perioperative
Care Measures Group are displayed on the next several pages. If all quality actions for the
patient have been performed for all the measures within the group, the following composite Gcode may be reported in lieu of the individual quality-data codes for each of the measures
within the group. It is not necessary to submit the following composite G-code for registrybased submissions.
Composite G-code G8501: All quality actions for the applicable measures in the Perioperative
Care Measures Group have been performed for this patient

•

To report satisfactorily the Perioperative Care Measures Group it requires all measures for
each patient within the EP’s patient sample to be reported each time a surgical procedure is
performed during the reporting period.

•

When using the 30 Patient Sample Method, report all measures for 30 unique patients seen.
When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #20: Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral
antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the
surgical incision (or start of procedure when no incision is required)
NUMERATOR:
Surgical patients who have an order for prophylactic parenteral antibiotic to be given within one
hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required)
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic parenteral antibiotic is to be
given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical
incision (or start of procedure when no incision is required) OR documentation that
prophylactic parenteral antibiotic has been given within one hour (if fluoroquinolone or
vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision
is required).
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Table 1A: The antimicrobial drugs listed below are considered prophylactic parenteral
antibiotics for the purposes of this measure. 4047F-8P should be reported when antibiotics
from this table were not ordered.
• Ampicillin/sulbactam
• Cefuroxime
• Gentamicin
• Aztreonam
• Ciprofloxacin
• Levofloxacin
• Cefazolin
• Clindamycin
• Metronidazole
• Cefmetazole
• Ertapenem
• Moxifloxacin
• Cefotetan
• Erythromycin base
• Neomycin
• Cefoxitin
• Gatifloxacin
• Vancomycin
Documentation of Order for Prophylactic Parenteral Antibiotic (written order, verbal
order, or standing order/protocol)
CPT II 4047F: Documentation of order for prophylactic parenteral antibiotics to be given
within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or
start of procedure when no incision is required)
OR
Documentation that Prophylactic Parenteral Antibiotic has been Given within One
Hour Prior to the Surgical Incision (or start of procedure when no incision is
required)
CPT II 4048F: Documentation that administration of prophylactic parenteral antibiotic was
initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical
incision (or start of procedure when no incision is required), as ordered
OR
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Order for Prophylactic Parenteral Antibiotic not Given for Medical Reasons
Append a modifier (1P) to CPT Category II code 4047F to report documented
circumstances that appropriately exclude patients from the denominator.
4047F with 1P: Documentation of medical reason(s) for not ordering prophylactic
parenteral antibiotics to be given within one hour (if fluoroquinolone or
vancomycin, two hours) prior to the surgical incision (or start of procedure
when no incision is required)
OR
Order for Administration of Prophylactic Parenteral Antibiotic not Given, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4047F with 8P: Prophylactic parenteral antibiotics were not ordered to be given or
given within one hour (if fluoroquinolone or vancomycin, two hours)
prior to the surgical incision (or start of procedure when no incision is
required), reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #21: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order
for cefazolin OR cefuroxime for antimicrobial prophylaxis
NUMERATOR:
Surgical patients who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for cefazolin or cefuroxime for antimicrobial prophylaxis
OR documentation that cefazolin or cefuroxime was given.
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Acceptable First and Second Generation Cephalosporin Prophylactic Antibiotics
First generation cephalosporin: cefazolin
Second generation cephalosporin: cefuroxime

OR

OR

Documentation of order for cefazolin OR cefuroxime for antimicrobial prophylaxis
(written order, verbal order, or standing order/protocol)
CPT II 4041F: Documentation of order for cefazolin OR cefuroxime for antimicrobial
prophylaxis
Note: CPT Category II code 4041F is provided for antibiotic ordered or antibiotic given.
Report CPT Category II code 4041F if cefazolin OR cefuroxime was given for antimicrobial
prophylaxis.
Order for First or Second Generation Cephalosporin not Ordered for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4041F to report documented
circumstances that appropriately exclude patients from the denominator.
4041F with 1P: Documentation of medical reason(s) for not ordering cefazolin OR
cefuroxime for antimicrobial prophylaxis
Order for First or Second Generation Cephalosporin not Ordered, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4041F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4041F with 8P: Order for cefazolin OR cefuroxime for antimicrobial prophylaxis was not
documented, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #22: Perioperative Care: Discontinuation of Prophylactic Antibiotics (NonCardiac Procedures)
DESCRIPTION:
Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with
the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral
antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24
hours of surgical end time
NUMERATOR:
Non-cardiac surgical patients who have an order for discontinuation of prophylactic parenteral
antibiotics within 24 hours of surgical end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic parenteral antibiotic is to be
discontinued within 24 hours of surgical end time OR specifying a course of antibiotic
administration limited to that 24-hour period (e.g., “to be given every 8 hours for three
doses” or for “one time” IV dose orders) OR documentation that prophylactic parenteral
was discontinued within 24 hours of surgical end time.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Documentation of Order for Discontinuation of Prophylactic Parenteral Antibiotics
(written order, verbal order, or standing order/protocol) Within 24 Hours of Surgical
End Time
(Two CPT II codes [4049F & 4046F] are required on the claim form to submit this
numerator option)
CPT II 4049F: Documentation that order was given to discontinue prophylactic antibiotics
within 24 hours of surgical end time, non-cardiac procedure
Note: CPT Category II code 4049F is provided for documentation that antibiotic
discontinuation was ordered or that antibiotic discontinuation was accomplished. Report
CPT Category II code 4049F if antibiotics were discontinued within 24 hours.
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
Prophylactic Parenteral Antibiotics not Discontinued for Medical Reasons
(Two CPT II codes [4049F-1P & 4046F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 4049F to report documented
circumstances that appropriately exclude patients from the denominator.
4049F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic
antibiotics within 24 hours of surgical end time

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AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR

OR

If patient is not eligible for this measure because patient did not receive
prophylactic parenteral antibiotics within specified timeframe, report:
(One CPT II code [4042F] is required on the claim form to submit this numerator option)
CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4
hours prior to surgical incision nor given intraoperatively
Prophylactic Parenteral Antibiotics not Discontinued, Reason not Specified
(Two CPT II codes [4049F-8P & 4046F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4049F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4049F with 8P: Order was not given to discontinue prophylactic antibiotics within 24 hours
of surgical end time, non-cardiac procedure, reason not otherwise
specified
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis
is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis
to be given within 24 hours prior to incision time or within 24 hours after surgery end time
NUMERATOR:
Surgical patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after
surgery end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for VTE prophylaxis OR documentation that VTE
prophylaxis was given.
Definition:
Mechanical Prophylaxis – Does not include TED hose.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Appropriate VTE Prophylaxis Ordered
CPT II 4044F: Documentation that an order was given for venous thromboembolism (VTE)
prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end
time
Note: A single CPT Category II code is provided for VTE prophylaxis ordered or VTE
prophylaxis given. If VTE prophylaxis is given, report 4044F.
VTE Prophylaxis not Ordered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4044F to report documented
circumstances that appropriately exclude patients from the denominator.
4044F with 1P: Documentation of medical reason(s) for patient not receiving any form of
VTE prophylaxis (LMWH, LDUH, adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis) within 24 hours prior to incision time or 24 hours
after surgery end time
VTE Prophylaxis not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4044F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4044F with 8P: Order was not given for venous thromboembolism (VTE) prophylaxis to be
given within 24 hours prior to incision time or 24 hours after surgery end
time, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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BACK PAIN MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN BACK PAIN MEASURES GROUP:
#148. Back Pain: Initial Visit
#149. Back Pain: Physical Exam
#150. Back Pain: Advice for Normal Activities
#151. Back Pain: Advice Against Bed Rest
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Back Pain Measures Group by submitting the measures
group-specific intent G-code at least once during the reporting period when billing a patient
claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not necessary to
submit the measures group-specific intent G-code on more than one claim. It is not necessary
to submit the measures group-specific intent G-code for registry-based submissions.
G8493: I intend to report the Back Pain Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Back Pain Measures Group are patients aged 18-79 years with a
specific diagnosis for back pain accompanied by a specific patient encounter OR patients aged
18-79 years that have a specific back surgical procedure performed:
One of the following diagnosis codes indicating back pain: 721.3, 721.41, 721.42, 721.90,
722.0, 722.10, 722.11, 722.2, 722.30, 722.31, 722.32, 722.39, 722.4, 722.51, 722.52, 722.6,
722.70, 722.71, 722.72, 722.73, 722.80, 722.81, 722.82, 722.83, 722.90, 722.91, 722.92,
722.93, 723.0, 724.00, 724.01, 724.02, 724.09, 724.2, 724.3, 724.4, 724.5, 724.6, 724.70,
724.71, 724.79, 738.4, 738.5, 739.3, 739.4, 756.12, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9,
847.2
Accompanied by
One of the following patient encounter codes: 97001, 97002, 99201, 99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215
OR
One of the following back surgical procedure codes: 22210, 22214, 22220, 22222, 22224,
22226, 22532, 22533, 22534, 22548, 22554, 22556, 22558, 22585, 22590, 22595, 22600,
22612, 22614, 22630, 22632, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844,

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22845, 22846, 22847, 22848, 22849, 63001, 63003, 63005, 63011, 63012, 63015, 63016,
63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048,
63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085,
63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103 , 63170, 63172, 63173, 63180,
63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200
•

Report quality-data codes on all measures within the Back Pain Measures Group for each
patient within the EP’s patient sample.

•

Instructions for quality-data code reporting for each of the measures within the Back Pain
Measures Group are displayed on the next several pages. If all quality actions for the patient
have been performed for all the measures within the group, the following composite G-code
may be reported in lieu of the individual quality-data codes for each of the measures within the
group.It is not necessary to submit the following composite G-code for registry-based
submissions.
Composite G-code G8502: All quality actions for the applicable measures in the Back Pain
Measures Group have been performed for this patient

•

To satisfactorily report the Back Pain Measures Group for the 30 Patient Sample Method it
requires all measures for each patient within the sample to be reported where the initial visit to
the clinician for each episode of back pain or each surgery for back pain that occurred during
the corresponding reporting period. If the patient’s initial visit for this episode of back pain
occurred prior to the beginning of the reporting period, report that the visit in the sample is a
subsequent visit for the episode and this will not count toward the 30 patient sample. This
measures group may be reported by more than one clinician if multiple clinicians evaluate or
treat the patient for the back pain episode.

•

To satisfactorily report the Back Pain Measures Group for the 80% Patient Sample Method it
requires all measures for each patient within the EP’s patient sample to be reported on the first
visit to the clinician for each episode of back pain or each surgery for back pain occurring
during the corresponding reporting period. If the patient’s initial visit for this episode of back
pain occurred prior to the beginning of the corresponding reporting period, report that the first
visit of the reporting period is a subsequent visit for the episode. This measures group may be
reported by more than one clinician if multiple clinicians evaluate or treat the patient for the
back pain episode.

•

When using the 30 Patient Sample Method, report all measures for 30 unique patients seen.
When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #148: Back Pain: Initial Visit
DESCRIPTION:
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing
back surgery who had back pain and function assessed during the initial visit to the clinician for the
episode of back pain
NUMERATOR:
Patients who had all five of the following components assessed at the initial visit to the clinician for
an episode of back pain: pain assessment, functional status, patient history (including notation of
presence or absence of warning signs), assessment of prior treatment and response, and
employment status
Definitions:
Pain Assessment – Must use any of the following assessment tools:
• SF-36
• Oswestry Low Back Pain Disability Questionnaire
• Roland-Morris Disability Questionnaire
• Quebec Pain Disability Scale
• Sickness Impact Profile
• Multidimensional Pain Inventory
OR
If none of the above tools are used, documentation of any of the following pain scales is
acceptable:
• McGill Pain Questionnaire
• Visual analog scale
• Brief pain inventory
• Chronic pain grade
• Neuropathic pain scale
• Numerical rating scale (e.g., pain intensity 1–10)
• Verbal descriptive scale (e.g., pt. report: “burning, shooting, stabbing”)
• Faces pain scale
Functional Status Assessment – Must use any of the following assessment tools:
• SF-36
• Oswestry Low Back Pain Disability Questionnaire
• Roland-Morris Disability Questionnaire
• Quebec Pain Disability Scale
• Sickness Impact Profile
• Multidimensional Pain Inventory
OR
If none of the above tools are used, there must be documentation that activities of daily
living (ADL) were assessed. Assessment of all of the following ADLs must be documented:
• Eating
• Bathing
• Using the toilet
• Dressing
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•

Getting up from bed or a chair

Patient History – Documentation necessary to satisfy assessment for red flags, which can
include the following:
• Indication/notation of presence or absence of red flags
• Notation of specific symptoms that may indicate the presence of red flags
(examples noted below)
o “Red Flags” include:
History of cancer or unexplained weight loss
Current infection or immunosuppression
Fracture or suspected fracture
• Motor vehicle accident or industrial injury with
suspicion of fracture
• Major fall with suspicion of fracture
Cauda equina syndrome or progressive neurologic deficit
• Saddle anesthesia
• Recent onset bladder dysfunction (urine retention,
increased frequency, overflow incontinence)
• Recent onset fecal incontinence (loss of bowel
control)
• Major motor weakness
Assessment of Prior Treatment and Response – If applicable, documentation that
patient has been queried about back pain episode(s), treatment and response. Notation
could include the following:
• No prior back pain
• Diagnosis and dates of back pain reports for the previous two years, or as far
back as the patient is able to provide information
• Report from referring physician with summary of back pain history
• Patient report of history and attempted treatments, including diagnostic tests
(e.g., imaging)
Employment Status – Use of either of the following assessment tools will satisfy this
requirement:
• Sickness Impact Profile
• Multidimensional Pain Inventory
OR
Variables of an employment assessment can count. These variables must include
documentation of the following:
• Type of work, including job tasks that may affect back pain management
• Work status (e.g., out of work, part-time work, work with or without limitations)
• If patient is not working or limited in work capacity, length of time for work
limitations
• Workers’ compensation or litigation involvement
Episode – Patient with back pain who has not been seen or treated for back pain by any
practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back
pain. If a patient has a four-month period without treatment, and then sees both a primary
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care physician and a specialist, both visits are considered the initial visit with that clinician.
A new episode can either be a recurrence for a patient with prior back pain or a patient
with a new onset of back pain. The first clinical encounter after the four months without
being seen or treated for back pain is considered the beginning of the new episode.
Initial Visit – First visit to the clinician during an episode of back pain. There can only be
one initial visit with each clinician, but there can be more than one initial visit for a patient,
if multiple clinicians evaluate or treat the patient for the back pain episode. Report the
appropriate Quality Data Codes on the claim for each initial visit. For each subsequent
encounter after the initial visit with that clinician, or if the initial visit with that clinician
occurred prior to the start of the reporting period, then report 0526F as described below.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Back Pain and Function Assessed
CPT II 1130F: Back pain and function assessed, including all of the following: Pain
assessment AND functional status AND patient history, including notation of presence or
absence of “red flags” (warning signs) AND assessment of prior treatment and response,
AND employment status
If patient is not eligible for this measure because back pain episode began prior to
the reporting period, report:
CPT II 0526F: Subsequent visit for episode
Back Pain and Function not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1130F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1130F with 8P: Back pain and function was not assessed during the initial visit, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #149: Back Pain: Physical Exam
DESCRIPTION:
Percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back
surgery who received a physical examination at the initial visit to the clinician for the episode of
back pain
NUMERATOR:
Patients who had a physical examination at the initial visit to the clinician for a new episode of back
pain
Definitions:
Physical Examination – For patients with radicular symptoms, documentation of physical
exam must include the following, at a minimum:
• Indication of straight leg raise test
AND
• Notation of completion of neurovascular exam (a neurovascular exam must include
ankle and knee reflexes; quadriceps; ankle and great toe dorsiflexion strength; plantar
flexion; muscle strength; motor testing; pulses in lower extremities; and sensory exam)
For patients without radicular symptoms, documentation of physical exam must include
the following:
• Documentation of straight leg raise, neurovascular exam or clear notation of absence
or presence of neurologic deficits
Episode – Patient with back pain who has not been seen or treated for back pain by any
practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back
pain. If a patient has a four-month period without treatment, and then sees both a primary
care physician and a specialist, both visits are considered the initial visit with that clinician.
A new episode can either be a recurrence for a patient with prior back pain or a patient
with a new onset of back pain. The first clinical encounter after the four months without
being seen or treated for back pain is considered the beginning of the new episode.
Initial Visit – First visit to the clinician during an episode of back pain. There can only be
one initial visit with each clinician, but there can be more than one initial visit for a patient,
if multiple clinicians evaluate or treat the patient for the back pain episode. Report the
appropriate Quality Data Codes on the claim for each initial visit. For each subsequent
encounter after the initial visit with that clinician, or if the initial visit with that clinician
occurred prior to the start of the reporting period, then report 0526F as described below.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Physical Exam Performed
CPT II 2040F: Physical examination on the date of the initial visit for low back pain
performed, in accordance with specifications
If patient is not eligible for this measure because back pain episode began prior to
the reporting period, report:
CPT II 0526F: Subsequent visit for episode

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OR

Physical Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2040F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2040F with 8P: Physical exam was not performed during the initial visit, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #150: Back Pain: Advice for Normal Activities
DESCRIPTION:
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing
back surgery who received advice for normal activities at the initial visit to the clinician for the
episode of back pain
NUMERATOR:
Patients with documentation of advice to maintain or resume normal activities at the initial visit to
the clinician for a new episode of back pain
Definitions:
Episode – Patient with back pain who has not been seen or treated for back pain by any
practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back
pain. If a patient has a four-month period without treatment, and then sees both a primary
care physician and a specialist, both visits are considered the initial visit with that clinician.
A new episode can either be a recurrence for a patient with prior back pain or a patient
with a new onset of back pain. The first clinical encounter after the four months without
being seen or treated for back pain is considered the beginning of the new episode.
Initial Visit – First visit to the clinician during an episode of back pain. There can only be
one initial visit with each clinician, but there can be more than one initial visit for a patient,
if multiple clinicians evaluate or treat the patient for the back pain episode. Report the
appropriate Quality Data Codes on the claim for each initial visit. For each subsequent
encounter after the initial visit with that clinician, or if the initial visit with that clinician
occurred prior to the start of the reporting period, then report 0526F as described below.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advice for Normal Activities Performed
CPT II 4245F: Patient counseled during the initial visit to maintain or resume normal
activities
If patient is not eligible for this measure because back pain episode began prior to
the reporting period, report:
CPT II 0526F: Subsequent visit for the episode
Advice for Normal Activities not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4245F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4245F with 8P: Advice for normal activities was not performed during the initial visit,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #151: Back Pain: Advice Against Bed Rest
DESCRIPTION:
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing
back surgery who received advice against bed rest lasting four days or longer at the initial visit to
the clinician for the episode of back pain
NUMERATOR:
Patients with documentation of advice against bed rest lasting four days or longer at the initial visit
to the clinician for an episode of back pain
Definitions:
Episode – Patient with back pain who has not been seen or treated for back pain by any
practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back
pain. If a patient has a four-month period without treatment, and then sees both a primary
care physician and a specialist, both visits are considered the initial visit with that clinician.
A new episode can either be a recurrence for a patient with prior back pain or a patient
with a new onset of back pain. The first clinical encounter after the four months without
being seen or treated for back pain is considered the beginning of the new episode.
Initial Visit – First visit to the clinician during an episode of back pain. There can only be
one initial visit with each clinician, but there can be more than one initial visit for a patient,
if multiple clinicians evaluate or treat the patient for the back pain episode. Report the
appropriate Quality Data Codes on the claim for each initial visit. For each subsequent
encounter after the initial visit with that clinician, or if the initial visit with that clinician
occurred prior to the start of the reporting period, then report 0526F as described below.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advice Against Bed Rest Performed
CPT II 4248F: Patient counseled during the initial visit for an episode of back pain against
bed rest lasting 4 days or longer
If patient is not eligible for this measure because back pain episode began prior to
the reporting period, report:
CPT II 0526F: Subsequent visit for episode
Advice Against Bed Rest not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4248F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4248F with 8P: Advice against bed rest was not performed during the initial visit, reason
not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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HEPATITIS C MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN HEPATITIS C MEASURES GROUP:
# 84. Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
# 85. Hepatitis C: HCV Genotype Testing Prior to Treatment
# 86. Hepatitis C: Antiviral Treatment Prescribed
# 87. Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment
# 89. Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
# 90. Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy
#183. Hepatitis C: Hepatitis A Vaccination in Patients with HCV
#184. Hepatitis C: Hepatitis B Vaccination in Patients with HCV
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Hepatitis C Measures Group by submitting the measures
group-specific intent G-code at least once during the reporting period when billing a patient
claim for both the 30 Patient Sample and 80% Patient Sample Methods. It is not necessary to
submit the measures group-specific intent G-code on more than one claim. It is not necessary
to submit the measures group-specific intent G-code for registry-based submissions.
G8545: I intend to report the Hepatitis C Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Hepatitis C Measures Group are patients aged 18 years and
older with a specific diagnosis of chronic hepatitis C accompanied by a specific patient
encounter:
One of the following diagnosis code indicating chronic hepatitis C: 070.54
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215

•

Report quality-data codes on all applicable measures within the Hepatitis C Measures Group
for each patient within the EP’s patient sample.

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Applicable measures contain patient demographic criteria specific to the measure. For
example, Counseling Regarding Use of Contraception Prior to Antiviral Therapy is applicable
to female patients aged 18 through 44 years and all men aged 18 years and older within the
sample population, while the Antiviral Treatment Prescribed measure within this group is
applicable to all patients aged 18 years and older. EPs may find it more efficient to report all
measures in the group for each patient within their sample. Reporting measure(s) from the
group that are inapplicable to an individual patient will not affect the eligible provider’s reporting
or performance rate.
•

Instructions for quality-data code reporting for each of the measures within the Hepatitis C
Measures Group are displayed on the next several pages. If all quality actions for the patient
have been performed for all measures within the group, the following composite G-code may
be reported in lieu of the individual quality-data codes for each of the measures within the
group. It is not necessary to submit the following composite G-code for registry-based
submissions.
Composite G-code G8549: All quality actions for the applicable measures in the Hepatitis C
Measures Group have been performed for this patient

•

To report satisfactorily the Hepatitis C Measures Group it requires all applicable measures for
each patient within the EP’s patient sample to be reported a minimum of once during the
reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30 unique
patients seen. When using the 80% Patient Sample Method, report all applicable measures on
at least 80% of the patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting of Individual Measures” available for download from the CMS PQRI
website.

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Measure #84: Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6
months prior to initiation of antiviral treatment
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed within 6 months prior to initiation
of antiviral treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
RNA Testing Performed within Six Months
(Two CPT II codes [3218F & 4150F] are required on the claim form to submit this
numerator option)
CPT II 3218F: RNA testing for Hepatitis C documented as performed within six months
prior to initiation of antiviral treatment for Hepatitis C
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
RNA Testing not Performed within Six Months for Medical Reason
(Two CPT II codes [3218F-1P & 4150F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 3218F to report documented
circumstances that appropriately exclude patients from the denominator.
3218F with 1P: Documentation of medical reason(s) for not performing RNA testing within
six months prior to initiation of antiviral treatment for Hepatitis C (eg, if
patient is first seen by physician after initiation of treatment)
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
OR

OR

If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One CPT II code [4151F] is required on the claim form to submit this numerator option)
CPT II 4151F: Patient not receiving antiviral treatment for Hepatitis C
RNA Testing not Performed within Six Months, Reason not Specified
(Two CPT II codes [3218F-8P & 4150F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3218F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.

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3218F with 8P: RNA testing for Hepatitis C was not documented as performed within six
months prior to initiation of antiviral treatment for Hepatitis C, reason not
otherwise specified
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #85: Hepatitis C: HCV Genotype Testing Prior to Treatment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of
antiviral treatment
NUMERATOR:
Patients for whom HCV genotype testing was performed prior to initiation of antiviral treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis C Genotype Testing Performed
(One CPT II code & one G-code [3266F & G8459] are required on the claim form to submit
this numerator option)
CPT II 3266F: Hepatitis C genotype testing documented as performed prior to initiation of
antiviral treatment for Hepatitis C
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8458] is required on the claim form to submit this numerator option)
G8458: Clinician documented that patient is not an eligible candidate for genotype testing;
patient not receiving antiviral treatment for Hepatitis C
Genotype Testing not Performed, Reason not Specified
(One CPT II code & one G-code [3266F-8P & G8459] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 3266F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3266F with 8P: Hepatitis C genotype testing was not documented as performed prior to
initiation of antiviral treatment for Hepatitis C, reason not otherwise
specified
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #86: Hepatitis C: Antiviral Treatment Prescribed
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were
prescribed peginterferon and ribavirin therapy within the 12-month reporting period
NUMERATOR:
Patients who were prescribed peginterferon and ribavirin therapy within the 12 month reporting
period
Definition:
Prescribed – May include prescription given to the patient for peginterferon and ribavirin
theray at one or more visits in the 12-month period OR patient already taking peginterferon
and ribavirin therapy as documented in current medication list.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Peginterferon and Ribavirin Therapy Prescribed
CPT II 4153F: Combination peginterferon and ribavirin therapy prescribed
Peginterferon and Ribavirin Therapy not Prescribed for Medical, Patient or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4153F to report documented
circumstances that appropriately exclude patients from the denominator.
4153F with 1P: Documentation of medical reason(s) for not prescribing peginterferon and
ribavarin therapy within 12 month reporting period (eg, patient was not a
candidate for therapy, could not tolerate).
4153F with 2P: Documentation of patient reason(s) for not prescribing peginterferon and
ribavirin therapy within 12 month reporting period (eg, patient declined).
4153F with 3P: Documentation of system reason(s) for not prescribing peginterferon and
ribavirin therapy within 12 month reporting period (eg, patient has no
insurance coverage, therapy not covered).
Peginterferon and Ribavirin Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4153F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4153F with 8P: Combination peginterferon and ribavirin therapy was not prescribed,
reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #87: Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks
from the initiation of antiviral treatment
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed at 12 weeks from the initiation of
antiviral treatment
Definition:
12 Weeks from Initiation – Patients for whom testing was performed between 11-13
weeks from the initiation of antiviral treatment will meet the numerator for this measure.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis C Quantitative RNA Testing at 12 weeks
(One CPT II code & one G-code [3220F & G8461] are required on the claim form to submit
this numerator option)
CPT II 3220F: Hepatitis C quantitative RNA testing documented as performed at 12 weeks
from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks for Medical or
Patient Reasons
(One CPT II code & one G-code [3220F-xP & G8461] are required on the claim form to
submit this numerator option)
Append a modifier (1P or 2P) to CPT Category II code 3220F to report documented
circumstances that appropriately exclude patients from the denominator.
3220F with 1P: Documentation of medical reason(s) for not performing quantitative
HCV RNA at 12 weeks from initiation of antiviral treatment
3220F with 2P: Documentation of patient reason(s) for not performing quantitative HCV
RNA at 12 weeks from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8460] is required on the claim form to submit this numerator option)
G8460: Clinician documented that patient is not an eligible candidate for quantitative RNA
testing at week 12; patient not receiving antiviral treatment for Hepatitis C

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OR

Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks, Reason not
Specified
(One CPT II code & one G-code [3220F-8P & G8461] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 3220F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3220F with 8P: Hepatitis C quantitative RNA testing was not documented as performed at
12 weeks from initiation of antiviral treatment, reason not otherwise
specified
AND
G8461: Patient receiving antiviral treatment for Hepatitis C

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #89: Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
counseled about the risks of alcohol use at least once within 12-months.
NUMERATOR:
Patients who were counseled about the risks of alcohol use at least once within the 12 month
reporting period
Definition:
Counseling – May include documentation of a discussion regarding the risks of
alcohol, or notation to decrease or abstain from alcohol intake.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Counseling Regarding Risk of Alcohol Consumption
CPT II 4158F: Patient counseled about risks of alcohol use
Counseling Regarding Risk of Alcohol Consumption not Performed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4158F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4158F with 8P: Patient counseled about risks of alcohol use not performed, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #90 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral
Therapy
DESCRIPTION:
Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with
a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled
regarding contraception prior to the initiation of treatment
NUMERATOR:
Patients who were counseled regarding contraception prior to the initiation of treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Counseling Regarding Contraception Received
(One CPT II code & one G-code [4159F & G8463] are required on the claim form to submit
this numerator option)
CPT II 4159F: Counseling regarding contraception received prior to initiation of antiviral
treatment
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
Counseling Regarding Contraception not Received for Medical Reason
(One CPT II code & one G-code [4159F-1P & G8463] are required on the claim form to
submit this numerator option)
Append a modifier (1P) to CPT Category II code 4159F to report documented
circumstances that appropriately exclude patients from the denominator.
4159F with 1P: Documentation of medical reason(s) for not counseling patient regarding
contraception
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
OR

OR

If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8462] is required on the claim form to submit this numerator option)
G8462: Clinician documented that patient is not an eligible candidate for counseling
regarding contraception prior to antiviral treatment; patient not receiving antiviral treatment
for Hepatitis C
Counseling Regarding Contraception not Received, Reason not Specified
(One CPT II code & one G-code [4159F-8P & G8463] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 4159F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.

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4159F with 8P: Counseling regarding contraception not received prior to initiation of
antiviral treatment, reason not otherwise specified
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #183: Hepatitis C: Hepatitis A Vaccination in Patients with HCV
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at
least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A
NUMERATOR:
Patients who have received at least one injection of hepatitis A vaccine, or who have documented
immunity to hepatitis A

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis A Vaccine Injection Received or Patient Has Documented Immunity to
Hepatitis A
CPT II 4148F: Hepatitis A vaccine injection administered or previously received
OR
CPT II 3215F: Patient has documented immunity to Hepatitis A
Hepatitis A Vaccine Injection not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4148F to report documented
circumstances that appropriately exclude patients from the denominator.
4148F with 1P: Documentation of medical reason(s) for not administering at least one
injection of hepatitis A vaccine
4148F with 2P: Documentation of patient reason(s) for not administering at least one
injection of hepatitis A vaccine
Hepatitis A Vaccine Injection not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4148F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4148F with 8P: Hepatitis A Vaccine not received, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #184: Hepatitis C: Hepatitis B Vaccination in Patients with HCV
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at
least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B
NUMERATOR:
Patients who have received at least one injection of hepatitis B vaccine or who have documented
immunity to hepatitis B

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis B Vaccine Injection Received or Patient Has Documented Immunity to
Hepatitis B
CPT II 4149F: Hepatitis B vaccine injection administered or previously received
OR
CPT II 3216F: Patient has documented immunity to Hepatitis B
Hepatitis B Vaccine Injection not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4149F to report documented
circumstances that appropriately exclude patients from the denominator.
4149F with 1P: Documentation of medical reason(s) for not administering at least one
injection of hepatitis B vaccine
4149F with 2P: Documentation of patient reason(s) for not administering at least one
injection of Hepatitis B vaccine
Hepatitis B Vaccine not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4149F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4149F with 8P: Hepatitis B Vaccine not received, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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HEART FAILURE (HF) MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: REGISTRY ONLY
2010 PQRI MEASURES IN HEART FAILURE (HF) MEASURES GROUP:
# 5. Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
# 8. Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
# 114. Inquiry Regarding Tobacco Use (Preventive Care and Screening)
# 115. Advising Smokers and Tobacco Users to Quit (Preventive Care and Screening)
# 198. Heart Failure: Left Ventricular Function (LVF) Assessment
# 199. Heart Failure: Patient Education
INSTRUCTIONS FOR REPORTING: (These instructions apply to registry reporting. Do not
report this measures group via claims.)
•

It is not necessary to submit the measures group-specific intent G-code for registry-based
submissions. However, the measures group-specific intent G-code has been created for
registry only measures groups for use by registries that utilize claims data.
G8548: I intend to report the Heart Failure (HF) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Heart Failure (HF) Measures Group are patients aged 18 years
and older with a specific diagnosis of heart failure accompanied by a specific patient
encounter:
One of the following diagnosis codes indicating heart failure: 398.91, 402.01, 402.11,
402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4,
425.5, 425.7, 425.8, 425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31,
428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325,
99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350

•

Report a numerator option on all applicable measures within the Heart Failure (HF) Measures
Group for each patient within the EP’s patient sample.

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•

Instructions for qualifying numerator option reporting for each of the measures within the Heart
Failure (HF) Measures Group are displayed on the next several pages. The following
composite G-code has been created for registry only measures groups for use by registries
that utilize claims data. This composite G-code may be reported in lieu of the individual qualitydata codes for each of the measures within the group, if all quality actions for the patient have
been performed for all the measures within the group. However, it is not necessary to submit
the following composite G-code for registry-based submissions.
Composite G-code G8551: All quality actions for the applicable measures in the Heart Failure
(HF) Measures Group have been performed for this patient

•

To report satisfactorily the Heart Failure (HF) Measures Group it requires all applicable
measures for each patient within the EP’s patient sample to be reported a minimum of once
during the reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30 unique
patients seen. When using the 80% Patient Sample Method, report all applicable measures on
at least 80% of the patient sample for the EP for the 12-month or six-month reporting period.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF
< 40%) who were prescribed ACE inhibitor or ARB therapy
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Definition:
Prescribed – May include prescription given to the patient for ACE inhibitor or ARB
therapy at one or more visits in the 12-month period OR patient already taking ACE
inhibitor or ARB therapy as documented in current medication list.

OR

Numerator Options:
ACE Inhibitor or ARB Therapy Prescribed
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed (4009F)
AND
Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)
Documentation of medical reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 1P)
Documentation of patient reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 2P)
Documentation of system reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 3P)
AND
Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)
OR
Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly
depressed left ventricular systolic function (3022F)
OR
Left ventricular ejection fraction (LVEF) not performed or documented (3021F with 8P)

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OR

Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy was not prescribed, reason not otherwise specified (4009F with 8P)
AND
Left ventricular ejection fraction < 40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #8: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have
LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy
NUMERATOR:
Patients who were prescribed beta-blocker therapy
Definition:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one
or more visits in the 12-month period OR patient already taking beta-blocker therapy as
documented in current medication list.

OR

Numerator Options:
Beta-blocker therapy prescribed for patients with left ventricular ejection fraction (LVEF)
<40% or documentation as moderately or severely depressed left ventricular systolic
function (G8450)
Clinician documented patient with left ventricular ejection fraction (LVEF) <40% or
documentation as moderately or severely depressed left ventricular systolic function was
not eligible candidate for beta-blocker therapy (G8451)
OR
Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly
depressed left ventricular systolic function (G8395)
OR
Left ventricular ejection fraction (LVEF) not performed or documented (G8396)

OR

Beta-blocker therapy not prescribed for patients with left ventricular ejection fraction
(LVEF) <40% or documentation as moderately or severely depressed left ventricular
systolic function (G8452)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #114: Inquiry Regarding Tobacco Use (Preventive Care and Screening)
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tobacco Use Assessed
(Two CPT II codes [1000F & 103xF] are required on the claim form to submit this
numerator option)
CPT II 1000F: Tobacco use assessed
AND
CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user (eg, chew, snuff)
OR
CPT II 1036F: Current tobacco non-user
Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1000F with 8P: Tobacco use not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #115: Advising Smokers and Tobaco Users to Quit (Preventive Care and
Screening)
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers or tobacco users who received
advice to quit smoking
NUMERATOR:
Patients who received advice to quit smoking or smokeless tobacco use
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advising Smoker or Smokeless Tobacco User to Quit
(One G-code and one CPT II code [G845x & 400xF) are required on the claim form to
submit this numerator option)
G8455: Current tobacco smoker
OR
G8456: Current smokeless tobacco user (eg, chew, snuff)
AND
CPT II 4000F: Tobacco use cessation intervention, counseling
OR
CPT II 4001F: Tobacco use cessation intervention, pharmacologic therapy
If patient is not eligible for this measure because patient is a non tobacco user,
report:
(One G-code [G8457) is required on the claim form to submit this numerator option)
Tobacco Non-User
G8457: Current tobacco non-user
Tobacco Smoker or Smokeless Tobacco User not Advised to Quit or Tobacco Use
not Assessed, Reason not Specified
(One CPT II code {4000F-8P} is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 4000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4000F with 8P: Tobacco use cessation intervention not counseled or tobacco use not
assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #198: Heart Failure: Left Ventricular Function (LVF) Assessment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of Heart Failure who have
quantitative or qualitative results of LVF assessment recorded
NUMERATOR:
Patients with quantitative or qualitative results of LVF assessment recorded

OR

Numerator Options:
Left ventricular function (LVF) assessment (eg, echocardiography, nuclear test, or
ventriculography) documented in the medical record (Includes: Quantitative or qualitative
assessment results) (3020F)
Quantitative or qualitative results of LVF assessment not Performed or Assessed, Reason
Not Specified (3020F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #199: Heart Failure: Patient Education
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who were provided
with patient education on disease management and health behavior changes during one or more
visit(s) within 12 months
NUMERATOR:
Patients who were provided with patient education on disease management and health behavior
changes* during one or more visits within 12 months
Definition: *Patient education should include one or more of the following: Weight
monitoring; Diet (sodium restriction); Symptom management; Physical activity; Smoking
cessation; Medication instruction; Minimizing or avoiding use of NSAIDs; Referral for
visiting nurse, or specific educational or management programs; Prognosis/end-of-life
issues

OR

Numerator Options:
Patient education, written/oral, appropriate for patients with heart failure performed
(4003F)
Patient education, written/oral, appropriate for patients with heart failure not performed,
Reason Not Specified (4003F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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CORONARY ARTERY DISEASE (CAD) MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: REGISTRY ONLY
2010 PQRI MEASURES IN CORONARY ARTERY DISEASE (CAD) MEASURES GROUP:
# 6. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with
CAD
# 114. Inquiry Regarding Tobacco Use (Preventive Care and Screening)
# 115. Advising Smokers and Tobacco Users to Quit (Preventive Care and Screening)
# 196. Coronary Artery Disease (CAD): Symptom and Activity Assessment
# 197. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
INSTRUCTIONS FOR REPORTING: (These instructions apply to registry reporting. Do not
report this measures group via claims.)
•

It is not necessary to submit the measures group-specific intent G-code for registry-based
submissions. However, the measures group specific intent G-code has been created for
registry only measure groups for use by registries that utilize claims data.
G8489: I intend to report the Coronary Artery Disease (CAD) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Coronary Artery Disease (CAD) Measures Group are patients
aged 18 years and older with a specific diagnosis of CAD accompanied by a specific patient
encounter:
One of the following diagnosis codes indicating CAD: 410.00, 410.01, 410.02, 410.10,
410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42,
410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81,
410.82, 410.90, 410.91, 410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9,
414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81,
V45.82
Accompanied by

One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
•

Report a numerator option on all applicable measures within the Coronary Artery Disease
(CAD) Measures Group for each patient within the EP’s patient sample.

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•

Instructions for qualifying numerator option reporting for each of the measures within the
Coronary Artery Disease (CAD) Measures Group are displayed on the next several pages. The
following composite G-code has been created for registry only measures groups for use by
registries that utilize claims data. This composite G-code may be reported in lieu of the
individual quality-data codes for each of the measures within the group, if all quality actions for
the patient have been performed for all the measures within the group. However, it is not
necessary to submit the following composite G-code for registry-based submissions.
Composite G-code G8498: All quality actions for the applicable measures in the Coronary
Artery Disease (CAD) Measures Group have been performed for this patient

•

To report satisfactorily for the Coronary Artery Disease (CAD) Measures Group it requires all
applicable measures for each patient within the EP’s patient sample to be reported a
minimum of once during the reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30 unique
patients seen. When using the 80% Patient Sample Method, report all applicable measures on
at least 80% of the patient sample for the EP for the 12-month or six-month reporting period.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #6: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for
Patients with CAD
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral
antiplatelet therapy
NUMERATOR:
Patients who were prescribed oral antiplatelet therapy
Numerator Instructions: Oral antiplatelet therapy consists of aspirin, clopidogrel or
combination of aspirin and extended release dipyridamole.
Definition:
Prescribed – May include prescription given to the patient for aspirin or clopidogrel at one
or more visits in the 12-month period OR patient already taking aspirin or clopidogrel as
documented in current medication list.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Oral Antiplatelet Therapy Prescribed
CPT II 4011F: Oral antiplatelet therapy prescribed
Oral Antiplatelet Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to Category II code 4011F to report documented
circumstances that appropriately exclude patients from the denominator.
4011F with 1P: Documentation of medical reason(s) for not prescribing oral antiplatelet
therapy
4011F with 2P: Documentation of patient reason(s) for not prescribing oral antiplatelet
therapy
4011F with 3P: Documentation of system reason(s) for not prescribing oral antiplatelet
therapy
Oral Antiplatelet Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4011F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4011F with 8P: Oral antiplatelet therapy was not prescribed, reason not otherwise
specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #114: Inquiry Regarding Tobacco Use (Preventive Care and Screening)
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tobacco Use Assessed
(Two CPT II codes [1000F & 103xF] are required on the claim form to submit this
numerator option)
CPT II 1000F: Tobacco use assessed
AND

OR

CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user (eg, chew, snuff)
OR
CPT II 1036F: Current tobacco non-user
Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1000F with 8P: Tobacco use not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #115: Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers or tobacco users who received
advice to quit smoking
NUMERATOR:
Patients who received advice to quit smoking or smokeless tobacco use
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advising Smoker or Smokeless Tobacco User to Quit
(One G-code and one CPT II code [G845x & 400xF) are required on the claim form to
submit this numerator option)
G8455: Current tobacco smoker
OR
G8456: Current smokeless tobacco user (eg, chew, snuff)
AND

OR

CPT II 4000F: Tobacco use cessation intervention, counseling
OR
CPT II 4001F: Tobacco use cessation intervention, pharmacologic therapy
If patient is not eligible for this measure because patient is a non tobacco user,
report:
(One G-code [G8457) is required on the claim form to submit this numerator option)
Tobacco Non-User
G8457: Current tobacco non-user

OR

Tobacco Smoker or Smokeless Tobacco User not Advised to Quit or Tobacco Use
not Assessed, Reason not Specified
(One CPT II code {4000F-8P} is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 4000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4000F with 8P: Tobacco use cessation intervention not counseled or tobacco use not
assessed, reason not otherwise specified
NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #196: Coronary Artery Disease (CAD): Symptom and Activity Assessment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were evaluated for
both level of activity and anginal symptoms during one or more visits.
NUMERATOR:
Patients evaluated for both level of activity and anginal symptoms during one or more office visits

OR

Numerator Options:
Anginal symptoms and level of activity assessed (1002F)
Anginal symptoms and level of activity assessed not assessed, reason not specified
(1002F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #197: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDLCholesterol
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a
lipid-lowering therapy (based on current ACC/AHA guidelines).
NUMERATOR:
Patients who were prescribed lipid-lowering therapy
NUMERATOR NOTE: For those registries that utilize claims data, the quality-data code
4002F may be used for this measure.

OR

OR

Numerator Options:
Lipid-lowering therapy prescribed
Lipid-lowering therapy not prescribed for medical reason
OR
Lipid-lowering therapy not prescribed for patient reason
OR
Lipid-lowering therapy not prescribed for system reason
Lipid-lowering therapy not prescribed, reason not specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP:
#114. Inquiry Regarding Tobacco Use (Preventive Care and Screening)
#115. Advising Smokers and Tobacco Users to Quit (Preventive Care and Screening)
#201. Ischemic Vascular Disease (IVD): Blood Pressure Management Control
#202. Ischemic Vascular Disease (IVD): Complete Lipid Profile
#203. Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C) Control
#204. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Ischemic Vascular Disease (IVD) Measures Group by
submitting the measures group-specific intent G-code at least once during the reporting period
when billing a patient claim for both the 30 Patient Sample and 80% Patient Sample Methods.
It is not necessary to submit the measures group-specific intent G-code on more than one
claim. It is not necessary to submit the measures group-specific intent G-code for registrybased submissions.
G8547: I intend to report the Ischemic Vascular Disease (IVD) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Ischemic Vascular Disease (IVD) Measures Group are patients
aged 18 years and older with a specific diagnosis of IVD accompanied by a specific patient
encounter OR patients aged 18 years and older with a coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA) surgical procedure:
One of the following diagnosis codes indicating IVD: 410.11, 410.21, 410.31, 410.41,
410.51, 410.61, 410.71, 410.81, 410.91, 411.0, 411.1, 411.81, 411.89, 413.0, 413.1,
413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9,
429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80, 433.81,
433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91, 440.1, 440.20, 440.21,
440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22, 444.81, 444.89,
444.9, 445.01, 445.02, 445.81, 445.89
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215

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OR

One of the following coronary artery bypass graft (CABG) or percutaneous
transluminal coronary angioplasty (PTCA) surgical procedure codes: 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534,
33535, 33536, 33140, 92980, 92982, 92995
•

Report quality-data codes on all applicable measures within the Ischemic Vascular Disease
(IVD) Measures Group for each patient within the EP’s patient sample.

•

Instructions for quality-data code reporting for each of the measures within the Ischemic
Vascular Disease (IVD) Measures Group are displayed on the next several pages. If all quality
actions for the patient have been performed for all the measures within the group, the following
composite G-code may be reported in lieu of the individual quality-data codes for each of the
measures within the group. It is not necessary to submit the following composite G-code for
registry-based submissions.
Composite G code G8552: All quality actions for the applicable measures in the Ischemic
Vascular Disease (IVD) Measures Group have been performed for this patient

•

To report satisfactorily the Ischemic Vascular Disease (IVD) Measures Group requires all
applicable measures for each patient within the EP’s patient sample to be reported a
minimum of once during the reporting period.

•

When using the 30 Patient Sample Method, report all applicable measures for the 30
unique patients seen. When using the 80% Patient Sample Method, report all applicable
measures on at least 80% of the patient sample for the EP for the 12-month or six-month
reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365) for the line item on the claim containing G8547 (and
G8552 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #114: Inquiry Regarding Tobacco Use (Preventive Care and Screening)
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tobacco Use Assessed
(Two CPT II codes [1000F & 103xF] are required on the claim form to submit this
numerator option)
CPT II 1000F: Tobacco use assessed
AND

OR

CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user (eg, chew, snuff)
OR
CPT II 1036F: Current tobacco non-user
Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1000F with 8P: Tobacco use not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #115: Advising Smokers and Tobacco Users to Quit (Preventive Care and
Screening)
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers or tobacco users who received
advice to quit smoking
NUMERATOR:
Patients who received advice to quit smoking or smokeless tobacco use
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advising Smoker or Smokeless Tobacco User to Quit
(One G-code and one CPT II code [G845x & 400xF) are required on the claim form to
submit this numerator option)
G8455: Current tobacco smoker
OR
G8456: Current smokeless tobacco user (eg, chew, snuff)
AND

OR

OR

CPT II 4000F: Tobacco use cessation intervention, counseling
OR
CPT II 4001F: Tobacco use cessation intervention, pharmacologic therapy
If patient is not eligible for this measure because patient is a non tobacco user,
report:
(One G-code [G8457) is required on the claim form to submit this numerator option)
Tobacco Non-User
G8457: Current tobacco non-user
Tobacco Smoker or Smokeless Tobacco User not Advised to Quit or Tobacco Use
not Assessed, Reason not Specified
(One CPT II code [4000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 4000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4000F with 8P: Tobacco use cessation intervention not counseled or tobacco use not
assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #201: Ischemic Vascular Disease (IVD): Blood Pressure Management Control
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who had
most recent blood pressure in control (less than 140/90 mmHg)
NUMERATOR:
Patients whose most recent blood pressure < 140/90 mmHg
Numerator Instructions: To describe both systolic and diastolic blood pressure values,
each must be reported separately. If there are multiple blood pressures on the same date
of service, use the lowest systolic and lowest diastolic blood pressure on that date as the
representative blood pressure.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Blood Pressure Measurement Performed
Systolic Pressure (Select one (1) code from this section):
G8588: Most recent systolic blood pressure < 140 mmHg
OR
G8589: Most recent systolic blood pressure ≥ 140 mmHg
AND
Diastolic Pressure (Select one (1) code from this section):
G8590: Most recent diastolic blood pressure < 90 mmHg
OR
G8591: Most recent diastolic blood pressure ≥ 90 mmHg
Blood Pressure Measurement not Documented, Reason not Specified
G8592: No documentation of blood pressure measurement

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #202: Ischemic Vascular Disease (IVD): Complete Lipid Profile
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who
received at least one lipid profile within 12 months
NUMERATOR:
Patients who received at least one lipid profile (or ALL component tests)

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Lipid Profile Performed
G8593: Lipid panel results documented and reviewed (must include total cholesterol, HDLC, triglycerides and calculated LDL-C)
Note: If LDL-C could not be calculated due to high triglycerides, count as complete
lipid profile.
Lipid Profile not Performed, Reason not Specified
G8594: Lipid profile not performed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #203: Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C)
Control
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who
had most recent LDL-C level in control (less than 100 mg/dl)
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent LDL-C <100 mg/dL
G8595: Most recent LDL-C < 100 mg/dL
LDL-C was not Performed
G8596: LDL-C was not performed
OR
Most Recent LDL-C ≥100 mg/dL
G8597: Most recent LDL-C ≥ 100 mg/dL

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #204: Ischemic Vascular Disease (IVD): Use Aspirin or Another Antithrombotic
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) with
documented use of aspirin or other antithrombotic.
NUMERATOR:
Patients who are using aspirin or another antithrombotic therapy
Numerator Instructions: Oral antithrombotic therapy consists of aspirin, clopidogrel or
combination of aspirin and extended release dipyridamole.

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Aspirin or Another Antithrombotic Therapy Used
G8598: Aspirin or another antithrombotic therapy used
Aspirin or Another Antithrombotic Therapy not Used, Reason not Specified
G8599: Aspirin or another antithrombotic therapy not used, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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HIV/AIDS MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: REGISTRY ONLY
2010 PQRI MEASURES IN HIV/AIDS MEASURES GROUP:
# 159. HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
# 160. HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
# 161. HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent
Antiretroviral Therapy
# 162. HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
# 205. HIV/AIDS: Sexually Transmitted Diseases – Chlamydia and Gonorrhea Screenings
# 206. HIV/AIDS: Screening for High Risk Sexual Behaviors
# 207. HIV/AIDS: Screening for Injection Drug Use
# 208. HIV/AIDS: Sexually Transmitted Diseases – Syphilis Screening
INSTRUCTIONS FOR REPORTING: (These instructions apply to registry reporting. Do not
report this measures group via claims.)
•

It is not necessary to submit the measures group-specific intent G-code for registry-based
submissions. However, the measures group-specific intent G-code has been created for
registry only measures groups for use by registries that utilize claims data.
G8491: I intend to report the HIV/AIDS Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the HIV/AIDS Measures Group are patients aged 13 years and older
with a specific diagnosis of HIV/AIDS accompanied by a specific patient encounter:
One of the following diagnosis codes indicating HIV/AIDS: 042, 079.53, V08
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215

•

Report a numerator option on all measures within the HIV/AIDS Measures Group for each
patient within the EP’s patient sample.

•

Instructions for qualifying numerator option reporting for each of the measures within the
HIV/AIDS Measures Group are displayed on the next several pages. The following composite
G-code has been created for registry only measures groups for use by registries that utilize
claims data. This composite G-code may be reported in lieu of the individual quality-data codes
for each of the measures within the group, if all quality actions for the patient have been

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performed for all the measures within the group. However, it is not necessary to submit the
following composite G-code for registry-based submissions.
Composite G code G8500: All quality actions for the applicable measures in the HIV/AIDS
Measures Group have been performed for this patient
•

To report satisfactorily for the HIV/AIDS Measures Group it requires all measures for each patient
within the EP’s patient sample to be reported a minimum of once during the reporting period.
Measure #159 will be reported once during the reporting period for measures group purposes.

•

When using the 30 Patient Sample Method, report all measures for the 30 unique patients seen.
When using the 80% Patient Sample Method, report all measures on at least 80% of the patient
sample for the EP for the 12-month or six-month reporting period.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #159: HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
DESCRIPTION:
Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+
cell count or CD4+ cell percentage was performed at least once every 6 months
NUMERATOR:
Patients with CD4+ cell count or CD4+ cell percentage performed at least once every 6 months
NUMERATOR NOTE: Report this measure once during the reporting period for measures
group purposes.

OR

Numerator Options:
CD4+ cell count or CD4+ cell percentage documented as performed (3500F)
CD4+ cell count or percentage not documented as performed, reason not specified (3500F
with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #160: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
DESCRIPTION:
Percentage of patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell count
<200 cells/mm3 who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count
NUMERATOR:
Patients who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count
Definition:
Prescribed – May include prescription given to the patient for PCP prophylaxis therapy at
one or more visits in the 12-month period OR patient already taking PCP prophylaxis
therapy as documented in current medication list.

OR

Numerator Options:
Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low CD4+ cell
count or percentage (4280F)
AND
CD4+ cell count <200 cells/mm3 (3494F)
Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low CD4+
cell count or percentage for medical reason (4280F with 1P)
(i.e., patient’s CD4+ cell count above threshold within 3 months after CD4+ cell count
below threshold, indicating that the patient’s CD4+ levels are within an acceptable range
and the patient does not require PCP prophylaxis)
AND
CD4+ cell count <200 cells/mm3 (3494F)
OR

OR

CD4+ cell count 200 – 499 cells/mm3 (3495F)
OR
CD4+ cell count ≥500 cells/mm3 (3496F)
CD4+ cell count not performed, reason not specified (3494F with 8P)
OR
PCP prophylaxis was not prescribed within 3 months of low CD4+ cell count, reason not
specified (4280F with 8P)
AND
CD4+ cell count <200 cells/mm3 (3494F)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #161: HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are
Prescribed Potent Antiretroviral Therapy
DESCRIPTION:
Percentage of patients with a diagnosis of HIV/AIDS aged 13 years and older: who have a history
of a nadir CD4+ cell count below 350/mm3 or who have a history of an AIDS-defining condition,
regardless of CD4+ cell count; who were prescribed potent antiretroviral therapy
NUMERATOR:
Patients who were prescribed potent antiretroviral therapy
Numerator Instructions: Nadir (lowest ever) CD4+ cell count may be the present count
Definitions:
Potent Antiretroviral Therapy – Potent antiretroviral therapy is described as any
antiretroviral therapy that has demonstrated optimal efficacy and results in durable
suppression of HIV as shown by prior clinical trials. For potent antiretroviral therapy
recommendations, refer to current DHHS guidelines available for download at the following
address as of 11/3/08 - http://www.aids.gov.
AIDS-defining Condition – Conditions included in the 1993 AIDS surveillance case
definition:
• Candidiasis of bronchi, trachea, or lungs;
• Candidiasis, esophageal;
• Cervical cancer, invasive;
• Coccidiodomycosis, disseminated or extrapulmonary;
• Cryptococcosis, extrapulmonary;
• Crytosporidiosis, chronic intestinal (greater than 1 month’s duration);
• Cytomegalovirus disease (other than liver, spleen, or nodes);
• Cytomegalovirus retinitis (with loss of vision);
• Encephalopathy, HIV-related;
• Herpes simplex: chronic ulcer(s) (greater than 1 month’s duration);
• Bronchitis, pneumonitis, or esophagitis;
• Histoplasmosis, disseminated or extrapulmonary;
• Isosporiasis, chronic intestinal (greater than 1 month’s duration);
• Kaposi’s sarcoma;
• Lymphoma, Burkitt’s (or equivalent term);
• Lymphoma, immunoblastic (or equivalent term);
• Lymphoma, primary, of brain;
• Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary;
• Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary);
• Mycobacterium, other species or unidentified species, disseminated or
extrapulmonary;
• Pneumocystis carinii pneumonia;
• Pneumonia, recurrent;
• Progressive multifocal leukoencephalopathy;
• Salmonella septicemia, recurrent;
• Toxoplasmosis of brain;
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• Wasting syndrome due to HIV. (NYSDOH, 2007)
Prescribed – May include prescription given to the patient for potent antiretroviral therapy
at one or more visits in the 12-month period OR patient already taking potent antiretroviral
therapy as documented in current medication list.
Numerator Options:
Potent antiretroviral therapy prescribed (4276F)
AND

OR
OR

History of nadir CD4+ cell count <350 cells/mm3 (3492F)
OR
History of AIDS-defining condition (3490F)
No history of nadir CD4+ cell count <350 cells/mm3 AND no history of AIDS-defining
condition (3493F)
Potent antiretroviral therapy not prescribed, reason not specified (4276F with 8P)
AND
History of nadir CD4+ cell count < 350 cells/mm3 (3492F)
OR
History of AIDS-defining condition (3490F)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #162: HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral
Therapy
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are receiving
potent antiretroviral therapy, who have a viral load below limits of quantification after at least 6
months of potent antiretroviral therapy or patients whose viral load is not below limits of
quantification after at least 6 months of potent antiretroviral therapy and have documentation of a
plan of care
NUMERATOR:
Patients with viral load below limits of quantification or patients with viral load not below limits of
quantification who have a documented plan of care
Numerator Instructions: Viral load below limits of quantification is determined using
laboratory cutoff levels for reference laboratory used by clinic or provider
Definitions:
Potent Antiretroviral Therapy – Potent antiretroviral therapy is described as any
antiretroviral therapy that has demonstrated optimal efficacy and results in durable
suppression of HIV as shown by prior clinical trials. For potent antiretroviral therapy
recommendations, refer to current DHHS guidelines available for download at the following
address as of 11/3/08 - http://www.aids.gov.
Plan of Care – May include altering the therapy regimen, reaffirming to the patient the
importance of high adherence to the regimen, or reassessment of viral load at a specified
future date
Numerator Options:
HIV RNA viral load below limits of quantification (3502F)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
OR

OR
OR

HIV RNA viral load not below limits of quantification (3503F)
AND
HIV RNA control plan of care, documented (0575F)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
Patient receiving potent antiretroviral therapy for less than 6 months or not receiving potent
antiretroviral therapy (4271F)
Viral load not performed or documented, reason not specified (3502F with 8P)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
OR

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Plan of care for viral load not below limits of quantification was not documented, reason
not specified (0575F with 8P)
AND
HIV RNA viral load not below limits of quantification (3503F)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #205: HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and
Gonorrhea
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia
and gonorrhea screenings were performed at least once since the diagnosis of HIV infection
NUMERATOR:
Patients with chlamydia and gonorrhea screenings performed at least once since the diagnosis of
HIV infection.

OR
OR

Numerator Options:
Chlamydia and gonorrhea screenings documented as performed (3511F)
Chlamydia and gonorrhea screenings not documented as performed, due to patient reason
(3511F with 2P)
Chlamydia and gonorrhea screenings not documented as performed, reason not specified
(3511F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #206: HIV/AIDS: Screening for High Risk Sexual Behaviors
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for high risk sexual behaviors at least once within 12 months.
NUMERATOR:
Patients who were screened for high risk sexual behaviors at least once within 12 months.

OR

Numerator Options:
Patient screened for high risk sexual behavior (4293F)
Patient not screened for high risk sexual behaviors, reason not specified (4293F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #207: HIV/AIDS: Screening for Injection Drug Use
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for injection drug use at least once within 12 months.
NUMERATOR:
Patients who were screened for injection drug use at least once within 12 months.

OR

Numerator Options:
Patient screened for injection drug use (4290F)
Patient not screened for injection drug use, reason not specified (4290F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #208: HIV/AIDS: Screening for Syphilis
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for syphilis at least once within 12 months.
NUMERATOR:
Patients who were screened for syphilis at least once within 12 months.

OR
OR

Numerator Options:
Syphilis screening documented as performed (3512F)
Syphilis screening not documented as performed, due to patient reason (3512F with 2P)
Syphilis screening not documented as performed, reason not specified (3512F with 8P)

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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COMMUNITY–ACQUIRED PNEUMONIA (CAP) MEASURES GROUP OVERVIEW
2010 PQRI REPORTING OPTIONS FOR MEASURES GROUPS: CLAIMS, REGISTRY
2010 PQRI MEASURES IN COMMUNITY–ACQUIRED PNEUMONIA (CAP) MEASURES
GROUP:
#56. Community-Acquired Pneumonia (CAP): Vital Signs
#57. Community-Acquired Pneumonia (CAP): Assessment of Oxygen
#58. Community-Acquired Pneumonia (CAP): Assessment of Mental Status
#59. Community-Acquired Pneumonia (CAP): Empiric Antibiotic
INSTRUCTIONS FOR REPORTING: (These instructions apply to both Claims and Registry
reporting, unless otherwise specified.)
•

Indicate your intention to report the Community-Acquired Pneumonia (CAP) Measures Group
by submitting the measures group-specific intent G-code at least once during the reporting
period when billing a patient claim for both the 30 Patient Sample and 80% Patient Sample
Methods. It is not necessary to submit the measures group-specific intent G-code on more
than one claim. It is not necessary to submit the measures group-specific intent G-code for
registry-based submissions.
G8546: I intend to report the Community-Acquired Pneumonia (CAP) Measures Group

•

Select patient sample method:
30 Patient Sample Method: 30 unique patients meeting patient sample criteria for the
measures group.
OR
80% Patient Sample Method: All patients meeting patient sample criteria for the measure
group during the entire reporting period (January 1 through December 31, 2010 OR July 1
through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients
must meet the measures group patient sample criteria to report satisfactory. For the six-month
reporting period, a minimum of 8 patients must meet the measures group patient sample
criteria to report satisfactory.

•

Patient sample criteria for the Community-Acquired Pneumonia (CAP) Measures Group are
patients aged 18 years and older with a specific diagnosis of Community-Acquired Pneumonia
(CAP) accompanied by a specific patient encounter:
The following diagnosis codes indicating CAP: 481, 482.0, 482.1, 482.2, 482.30, 482.31,
482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89,
482.9, 483.0, 483.1, 483.8, 485, 486, 487.0
Accompanied by
One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291*, 99324, 99325,
99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350

*Clinicians utilizing the critical care code (99291) must indicate the emergency department
place of service (23) on the Part B claim form in order to report this measure.
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•

Report quality-data codes on all measures within the Community-Acquired Pneumonia (CAP)
Measures Group for each patient within the EP’s patient sample.

•

Instructions for quality-data code reporting for each of the measures within the CommunityAcquired Pneumonia (CAP) Measures Group are displayed on the next several pages. If all
quality actions for the patient have been performed for all measures within the group, the
following composite G-code may be reported in lieu of the individual quality-data codes for
each of the measures within the group. It is not necessary to submit the following composite Gcode for registry-based submissions.

Composite G code G8550: All quality actions for the applicable measures in the
Community-Acquired Pneumonia (CAP) Measures Group have been performed for this
patient
•

To report satisfactorily for the Community-Acquired Pneumonia (CAP) Measures Group it
requires all measures for each patient within the EP’s patient sample to be reported once
during each occurrence of CAP. Each unique occurrence is defined as a 45-day period
from onset of community-acquired bacterial pneumonia.

•

When using the 30 Patient Sample Method, report all measures for the 30 patients seen.
When using the 80% Patient Sample Method, report all measures on at least 80% of the
patient sample for the EP for the 12-month or six-month reporting period.

•

For claims-based submissions, the carrier/MAC remittance advice notice sent to the practice
will show a denial remark code (N365)for the line item on the claim containing G8487 (and
G8495 if reported) as well as all other line items containing QDCs. (N365) indicates that the
code is not payable and is used for reporting/informational purposes only. Other
services/codes on the claim will not be affected by the addition of a measures group-specific
intent G-code or other QDCs. The N365 remark code does NOT indicate whether the QDC is
accurate for that claim or for the measure the EP is attempting to report, but does indicate that
the QDC was processed and transmitted to the NCH.

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #56: Community-Acquired Pneumonia (CAP): Vital Signs
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with vital signs documented and reviewed
NUMERATOR:
Patients with vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and
reviewed
Definition:
Medical Record – May include one of the following: Clinician documentation that vital
signs were reviewed, dictation by the clinician including vital signs, clinician initials in the
chart that vital signs were reviewed, or other indication that vital signs had been
acknowledged by the clinician

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Vital Signs Documented and Reviewed
CPT II 2010F: Vital signs (temperature, pulse, respiratory rate, and blood pressure)
documented and reviewed
Vital Signs not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2010F with 8P: Vital signs (temperature, pulse, respiratory rate, and blood pressure)
not documented and reviewed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #57: Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with oxygen saturation documented and reviewed
NUMERATOR:
Patients with oxygen saturation documented and reviewed
Definition:
Medical Record – May include one of the following: Clinician documentation that oxygen
saturation was reviewed, dictation by the clinician including oxygen saturation, clinician
initials in the chart that oxygen saturation was reviewed, or other indication that oxygen
saturation had been acknowledged by the clinician

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Oxygen Saturation Documented and Reviewed
CPT II 3028F: Oxygen saturation results documented and reviewed (includes assessment
through pulse oximetry or arterial blood gas measurement)
Oxygen Saturation not Documented and Reviewed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 3028F to report documented
circumstances that appropriately exclude patients from the denominator.
3028F with 1P: Documentation of medical reason(s) for not documenting and reviewing
oxygen saturation
3028F with 2P: Documentation of patient reason(s) for not documenting and reviewing
oxygen saturation
3028F with 3P: Documentation of system reason(s) for not documenting and reviewing
oxygen saturation
Oxygen Saturation not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3028F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3028F with 8P: Oxygen saturation results not documented and reviewed, reason not
otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #58: Community-Acquired Pneumonia (CAP): Assessment of Mental Status
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with mental status assessed
NUMERATOR:
Patients for whom mental status was assessed
Definition:
Medical Record – May include: Documentation by clinician that patient’s mental status
was noted (e.g., patient is oriented or disoriented).

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Mental Status Assessed
CPT II 2014F: Mental status assessed
Mental Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2014F with 8P: Mental status not assessed, reason not otherwise specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Measure #59: Community-Acquired Pneumonia (CAP): Empiric Antibiotic
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with an appropriate empiric antibiotic prescribed
NUMERATOR:
Patients with appropriate empiric antibiotic prescribed
Definitions:
Appropriate Empiric Antibiotic – For treatment of community-acquired bacterial
pneumonia (CAP) should include any medication from one of the following four drug
classes: Fluoroquinolones, Macrolides, Doxycycline, Beta Lactam with Macrolide or
Doxycycline (as defined by current ATS/IDSA guidelines).
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.

OR

OR

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Appropriate Empiric Antibiotic Prescribed
CPT II 4045F: Appropriate empiric antibiotic prescribed
Appropriate Empiric Antibiotic not Prescribed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4045F to report documented
circumstances that appropriately exclude patients from the denominator.
4045F with 1P: Documentation of medical reason(s) for not prescribing appropriate
empiric antibiotic
4045F with 2P: Documentation of patient reason(s) for not prescribing appropriate empiric
antibiotic
4045F with 3P: Documentation of system reason(s) for not prescribing appropriate empiric
antibiotic
Appropriate Empiric Antibiotic not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4045F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4045F with 8P: Appropriate empiric antibiotic not prescribed, reason not otherwise
specified

NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures
groups option. For all other claims-based or registry-based reporting options, please see the measures’ full specifications in the document “2010
PQRI Measure Specifications Manual for Claims and Registry Reporting for Individual Measures” available for download from the CMS PQRI
website.

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Symbol and Copyright Information
The following notice applies to each of the measures that contain an asterisk (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the American Medical
Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium)
and the National Committee for Quality Assurance (NCQA) pursuant to government sponsorship under subcontract
6205-05-054 with Mathematica Policy Research, Inc. under contract 500-00-0033 with Centers for Medicare &
Medicaid Services.
These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not
been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the AMA, (on behalf of the Consortium) or NCQA. Neither the AMA, NCQA, Consortium nor its
members shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
KIND.
© 2004-6 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
CPT® contained in the Measures specifications is copyright 2008 American Medical Association; G codes and
associated descriptions included in these Measure specifications are in the public domain.

The following notice applies to each of the measures that contain a triangle (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while
copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health
care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association. All Rights Reserved
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

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CPT® contained in the Measures specifications is copyright 2008 American Medical Association.

The following notice applies to each of the measures that contain a diamond (

) before the title:

NCQA Notice of Use. Broad public use and dissemination of these measures is encouraged and the measure developers
have agreed with NQF that noncommercial uses do not require the consent of the measure developer. Use by health
care providers in connection with their own practices is not commercial use. Commercial use of a measure does require
the prior written consent of the measure developer. As used herein, a "commercial use" refers to any sale, license, or
distribution of a measure for commercial gain, or incorporation of a measure into any product or service that is sold,
licensed, or distributed for commercial gain, (even if there is no actual charge for inclusion of the measure.)
These performance measures were developed and are owned by the National Committee for Quality Assurance
("NCQA"). These performance measures are not clinical guidelines and do not establish a standard of medical care.
NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that
uses or reports performance measures and NCQA has no liability to anyone who relies on such measures. NCQA holds
a copyright in this measure and can rescind or alter this measure at any time. Users of the measure shall not have the
right to alter, enhance, or otherwise modify the measure and shall not disassemble, recompile, or reverse engineer the
source code or object code relating to the measure. Anyone desiring to use or reproduce the measure without
modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial
uses must be approved by NCQA and are subject to a license at the discretion of NCQA. ©2004 National Committee
for Quality Assurance, all rights reserved.
Performance measures developed by NCQA for CMS may look different from the measures solely created and owned
by NCQA.

The following notice applies to each of the measures that contain a spade ( ) before the title:
These measures were developed by Quality Insights of Pennsylvania as a special project under the Quality Insights'
Medicare Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with the Centers for Medicare
& Medicaid Services. These measures are in the public domain.

The following notice applies to each of the measures that contain an Omega (
These measures are owned by The Society of Thoracic Surgeons (STS).

) before the title:

Physician Performance Measures (Measures) and related data specifications developed by the American Medical
Association (AMA) in collaboration with the Physician Consortium for Performance Improvement® (PCPI) and the
National Committee for Quality Assurance (NCQA), pursuant to government sponsorship under Subcontract No. 641407-089 with Mathematica Policy Research under Contract HHSM-500-2005-000251(0004) with Centers for Medicare
and Medicaid Services. These performance Measures are not clinical guidelines and do not establish a standard of
medical care, and have not been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the AMA, (on behalf of the PCPI) or NCQA. Neither the AMA, NCQA, PCPI nor its members
shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
KIND.
© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the PCPI and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.

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CPT® contained in the Measures specifications is copyright 2007 American Medical Association. LOINC® copyright
2004 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004 College of American
Pathologists (CAP). All Rights Reserved. Use of SNOMED CT® is only authorized within the United States.

The following notice applies to each of the measures that contain a square ( ) before the title:
Physician Performance Measures (Measures) and related data specifications have been developed by the American
Medical Association (AMA) in collaboration with the Physician Consortium for Performance ImprovementTM (the
Consortium) and the National Committee for Quality Assurance (NCQA).
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not
been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposed, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and American Medical Association, (on behalf of the Consortium) or NCQA. Neither the AMA,
NCQA, Consortium nor its members shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY
KIND.
© 2007 American Medical Association and National Committee for Quality Assurance. All Rights Reserved
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

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File Type	application/pdf
File Title	2010 PQRI Measures Groups Specifications
Subject	2010, PQRI, Measure, Groups, Handbook, Pay-for-Reporting, Physician, Quality, Reporting, Initiative
Author	CMS
File Modified	2009-11-13
File Created	2009-11-13