Registry-based and Qualified Clinical Data Registry-based Reporting Mechanisms (Eligible Professionals Participating Individually or as Part of a Group Practice)

Physician Quality Reporting System (PQRS) (CMS-10276)

2015_PQRS_ImplementationGuide

Registry-based and Qualified Clinical Data Registry-based Reporting Mechanisms (Eligible Professionals Participating Individually or as Part of a Group Practice)

OMB: 0938-1059

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2016-03-23 - Revision of a currently approved collection

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2015 Physician Quality
Reporting System (PQRS):
Implementation Guide
1/15/2015

Table of Contents

Introduction ................................................................................................................................................. 3
PQRS Measure Selection Considerations .................................................................................................. 6
Satisfactorily Report Measures ................................................................................................................. 11
Reporting Electronically Using an EHR ..................................................................................................... 12
Reporting via Qualified Registry................................................................................................................ 15
Participation via Qualified Clinical Data Registry (QCDR)......................................................................... 17
PQRS Group Practice Reporting Option (GPRO) via Web Interface ........................................................ 18
CAHPS for PQRS - CMS-Certified Survey Vendor ................................................................................... 19
Reporting PQRS Data via Claims ............................................................................................................. 21
Appendix A: Glossary of Terms ................................................................................................................ 30
Appendix B: Decision Trees - 2015 PQRS Reporting/Participation for Avoiding the 2017 Negative
Payment Adjustment ............................................................................................................ 36
Appendix C: Satisfactory Reporting via Claims Scenario.......................................................................... 44
Appendix D: CMS-1500 Claim PQRS Example ....................................................................................... 45
Appendix E: PQRS EHR Process ............................................................................................................. 47
Appendix F: PQRS Registry Process........................................................................................................ 48
Appendix G: PQRS GPRO Web Interface Process .................................................................................. 49
Appendix H: QCDR Process ..................................................................................................................... 50
Appendix I: PQRS Claims-Based Process ................................................................................................ 51

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Introduction
Purpose
The 2015 PQRS Implementation Guide helps eligible professionals (EPs) and group practices
participating in PQRS via the group practice reporting option (GPRO) understand and report for 2015
PQRS. It addresses common PQRS implementation concerns, such as:
•

Program questions: What is PQRS? Why should I participate?

•

Measures and Analysis questions: How do I select which measures to report? How does my
data get analyzed?

•

Reporting questions: What are the different ways I can report? When do I need to report and
how do I report?

To supplement this guide, EPs may get the latest information about PQRS on the PQRS website, via the
PQRS listserv and also on Twitter. Help Desk support is also available Monday – Friday from 7:00 AM7:00 PM CST at 1-866-288-8912 (TTY: 1-877-715-6222) or at [email protected].
What is PQRS?
PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of
quality information by individual EPs and group practices. Those who do not satisfactorily report data on
quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare
Part B beneficiaries (including Railroad Retirement Board, Medicare Secondary Payer, and Critical
Access Hospitals [CAH] method II) will be subject to a negative payment adjustment under PQRS.
Medicare Part C–Medicare Advantage beneficiaries are not included. Reporters may choose from the
following reporting options to submit their quality data:
•

Reporting electronically using an electronic health record (EHR)

•

Qualified Registry

•

Qualified Clinical Data Registry (QCDR)

•

PQRS Group Practice Reporting Option (GPRO) via Web Interface

•

CMS-Certified Survey Vendor

•

Claims

Beginning in 2015, CAHs using billing method II may participate in PQRS by all reporting mechanisms
including claims-based reporting.
All EPs who do not meet the criteria for satisfactory reporting or participating for 2015 PQRS will
be subject to the 2017 negative payment adjustment with no exceptions.

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Who is eligible to participate in PQRS?
Medicare physicians, practitioners, and therapists providing covered professional services paid under or
based on the MPFS are eligible professionals under PQRS. To the extent that EPs are providing services
which get paid under or based on the MPFS, those services are eligible for PQRS negative payment
adjustments. Individual EPs, EPs in group practices participating in PQRS via GPRO (PQRS group
practices), Accountable Care Organizations (ACOs) reporting PQRS via the Web Interface, and
Comprehensive Primary Care (CPC) practice sites are eligible to participate in PQRS. View the complete
list of EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification
Number [TIN]).
EPs or group practices participating via GPRO, using their individual rendering National Provider Identifier
(NPI) or Tax Identification Number (TIN), may report the quality clinical action for measures within PQRS.
Most services payable under fee schedules or methodologies other than the PFS are not included in 2015
PQRS (for example, services provided in federally qualified health centers, portable X-ray suppliers,
independent laboratories including place-of-service code “81,” independent diagnostic testing facilities,
hospitals, rural health clinics, skilled nursing facilities, ambulance providers, and ambulatory surgery
center facilities). Suppliers of durable medical equipment (DME) are not eligible to report measures via
PQRS since DME is not paid under the MPFS.
Why should I participate in PQRS?
•

Help improve health care quality. Driving quality improvement is a core function of CMS. The
vision for the CMS Quality Strategy is to optimize health outcomes by leading clinical quality
improvement and health system transformation. PQRS plays a crucial role to facilitate physician
participation in this process committed to quality improvement.

•

Be a satisfactory reporter and avoid the 2017 PQRS negative payment adjustment.
Additional information on how to avoid the PQRS negative payment adjustment can be found in
this Guide and supporting documentation on the CMS PQRS website.

Note: “Satisfactory reporting” refers to participating in PQRS in 2015 to avoid the 2017 negative
payment adjustment while “satisfactory participation” refers to EPs participating in the “qualified clinical
data registry (QCDR)” reporting option.

What are quality measures?
Quality measures are indicators of the quality of care provided by physicians. They are tools that help us
measure or quantify health care processes, outcomes, patient perceptions, and organizational structure
and/or systems that are associated with the ability to provide high-quality health care and/or that relate to
one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered,
equitable, and timely care. Refer to page 7 for more information on quality measures.
It is important to review and understand each measure specification especially as it pertains to a specific
reporting option. The measure specification specific to the reporting option will provide definitions and
specific instructions for satisfactorily reporting the measure. This guide provides a web address under
each reporting option for easy location of the measures specifications. Refer to the next section, “PQRS
Measure Selection Considerations” for more information about denominators and numerators. Also
refer to Appendix A, “Glossary of Terms,” which further defines the terms denominator and numerator as
well as other terms commonly used in PQRS.

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Disclaimer: If reporting for PQRS through another CMS program (such as the Medicare
Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care
Organizations), please check the program’s requirements for information on how to report
quality data to avoid the PQRS negative payment adjustment. Please note, although CMS has
attempted to align or adopt similar reporting requirements across programs, EPs should look
to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program,
Value-Based Payment Modifier (VM), etc. requirements of each of these programs.

CPT only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or
related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does
not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein.

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PQRS Measure Selection Considerations
The 2015 PQRS measures address various aspects of care, such as prevention, chronic- and acute-care
management, procedure-related care, resource utilization, and care coordination. EPs and PQRS group
practices are not required to report on all of the measures and must select which measures they would
like to report.
How should I determine which measures to report?

Step 1:
Review the
Measures
List

Review the 2015 Physician Quality Reporting System (PQRS) Measures
List, available on the Measures Codes section of the CMS PQRS website, to
determine which measures, associated domains, and reporting option(s) may be
of interest and applicable to the EP or group practice participating in PQRS via
GPRO.
• Not all measures are available under each PQRS reporting option. EPs
or PQRS group practices should avoid individual measures that do not
or may infrequently apply to the services they provide to Medicare
patients.
•

•

With alignment of quality measures across CMS quality reporting
programs, some measures from the EHR Incentive Program may have
been updated or modified during their National Quality Forum
endorsement process. This may result in different measurement titles,
number versions, or National Quality Strategy (NQS) domains from the
corresponding PQRS specification. Please refer to program specific
documentation for accurate interpretation of measures and reporting
criteria.
The GPRO Web Interface reporting option has set measures, all of
which must be reported.

Consider the following factors when selecting measures for reporting:
Step 2:
Consider
important
factors

Step 3:
Review
specifications

•

Clinical conditions usually treated.

•

Types of care typically provided – e.g., preventive, chronic, acute.

•

Settings where care is usually delivered – e.g., office, emergency
department (ED), surgical suite.

•
•

Quality improvement goals for 2015.
Other quality reporting programs in use or being considered by the
National Quality Strategy (see further explanation below).

After making a selection of potential measures, review the specifications for
the selected reporting option for each measure under consideration. Select
those measures that apply to services most frequently provided to Medicare
patients by the EP or PQRS group practice.
• EPs or PQRS group practices should review each measure’s
denominator coding to determine which patients may be eligible for the
selected PQRS measure(s). EPs can report individual measures or
Measures Groups, while PQRS group practices can only report
individual measures.
• Group practices must report using an EHR or via registry in order to
select their measures.

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The National Quality Strategy (NQS)
In 2015, measures are classified according to the 6 NQS domains based on the NQS’s priorities. PQRS
reporting options typically require an EP or PQRS group practice to report 9 or more measures covering
at least 3 NQS domains, plus additional cross-cutting measures for EPs with billable face-to-face
encounters for satisfactory reporting or participation to avoid the 2017 negative payment adjustment.
The Six NQS Domains

Patient Safety

Person and CaregiverCentered Experience and
Outcomes

Communication and
Care Coordination

Effective
Clinical Care

Community/
Population Health

Efficiency and
Cost Reduction

What is a measure?
Measures consist of two major components: denominators and numerators.
PQRS Denominators and Numerators

Each component is defined by specific codes described in the respective measure's specification along
with the reporting instructions and use of modifiers.
See below for an example of a measurement specification construct:

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Measure component #1: Denominator
The first measure component is the denominator, which describes the eligible cases for a measure or the
eligible patient population. Physician Quality Reporting measure denominators are identified by ICD-9-CM
(future ICD-10-CM), CPT Category I, and HCPCS codes, as well as patient demographics (age, gender,
etc.), and place of service (if applicable). For registry and electronic reporting using an EHR, other clinical
coding sets may be included such as SNOMED, LOINC, or RxNorm.
Measure component #2: Numerator
The second component is the numerator describing the specific clinical action required by the measure
for performance. EPs may use the codes present in the numerator to report the outcome of the action as
indicated by the measure. PQRS measure numerators are quality-data codes (QDCs) consisting of
specified non-payable CPT Category II codes and/or temporary G-codes. For registry and electronic
reporting using an EHR, other clinical coding sets may be included such as SNOMED, LOINC, or RxNorm
in order to capture a specific quality action, test, or value.
How is a measure calculated?
Calculating the PQRS reporting rate (dividing the number or reported numerator outcomes by
denominator-eligible encounters) identifies the percentage of a defined patient population that was
reported for the measure. For performance rate calculations, some patients may be subtracted from the
denominator based on medical, patient, or system performance exclusions allowed by the measure.
The final performance rate calculation represents the eligible population that received a particular process
of care or achieved a particular outcome (measure defined performance met outcome). It is important to
review and understand each measure's specification, as it contains definitions and specific instructions for
reporting the measure.
How do I report PQRS measures?
PQRS offers several reporting mechanisms for reporting measures. There may be different options
available within the specific reporting mechanism to satisfactorily report to avoid the 2017 negative
payment adjustment. Refer to Appendix B: Decision Tree - Avoiding the 2017 PQRS Negative
Payment Adjustment for the Decision Trees designed to help participants select among the multiple
reporting mechanisms available in PQRS. EPs and PQRS group practices should consider which
reporting mechanism best fits their practice and should choose measures within the same option of
reporting. Following are reporting mechanisms available to individual EPs and PQRS group practices.

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•

Please note that PQRS defines a group practice as a single Tax Identification Number (TIN) with
2 or more individual EPs (as identified by Individual National Provider Identifier [NPI]) that have
reassigned their billing rights to the TIN.
Individual EPs
•
•
•
•
•

EHR direct product that is Certified
Electronic Health Record Technology
(CEHRT)
EHR data submission vendor (DSV) that
is CEHRT
Qualified PQRS registry
Qualified Clinical Data Registry (QCDR)
Medicare Part B claims submitted to CMS

PQRS Group Practices
•
•
•
•
•

•

GPRO Web Interface (25+ providers)
Qualified PQRS registry (2+ providers)
EHR direct product that is CEHRT (2+
providers)
EHR data submission vendor that is
CERT (2+ providers)
CAHPS for PQRS using CMS-certified
survey vendor (2+ providers) (CAHPS is
supplemental to other reporting
mechanisms)
PQRS group practices must register for
their selected reporting mechanism by
June 30, 2015. For more information
about reporting PQRS measures as a
group, visit the Group Practice Reporting
Option webpage.

Note: As outlined in the 2015 MPFS final rule, CMS will publicly report the individual EP and PQRS group
practice quality measure data collected via all reporting mechanisms. This information is targeted for
publication on Physician Compare in 2016, if technically feasible. For more information on public
reporting, view the CMS Physician Compare Initiative website.
Analysis of PQRS Data: Reporting Frequency (previously known as Measure Tags) and
Performance Timeframes
Reporting frequency and performance timeframes are considerations for satisfactorily reporting through
the various PQRS reporting mechanisms.
What is “reporting frequency”?
Each measure specification includes a reporting frequency for each denominator-eligible patient (see
section on Measure Selection Considerations) seen during the reporting period. The reporting
frequency described in the measure specification’s instructions applies to each individual EP and PQRS
group practice submitting individual PQRS measures. The reporting frequency is used in analyzing each
measure to help determine satisfactory reporting, according to the reporting frequency in the
“Instructions” section of the measure:

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What is a performance timeframe?
A measure’s performance timeframe is defined in the measure’s description and is distinct from the
reporting frequency requirement defined in the measure’s instructions. The performance timeframe,
unique to each measure, outlines the timeframe in which the clinical action described in the numerator
may be completed. See Appendix A’s Glossary of Terms.

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Satisfactorily Report Measures
PQRS eligible professionals and group practices can refer to the following educational resources:
•

2015 Physician Quality Reporting System (PQRS) Electronic Health Record (EHR) Reporting
Made Simple

•

2015 Physician Quality Reporting System (PQRS) Measures – Registry Reporting Made Simple

•

2015 Physician Quality Reporting System (PQRS) Qualified Clinical Data Registry (QCDR)
Participation Made Simple

•

2015 Physician Quality Reporting System (PQRS) Measures – Claims Reporting Made Simple

•

2015 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Web
Interface Reporting Made Simple

•

2015 CAHPS for PQRS (Certified Survey Vendor) Made Simple

What’s the difference between “satisfactory reporting” vs. “satisfactory participation?”
“Satisfactory reporting” refers to participating in 2015 PQRS to avoid the 2017 negative payment
adjustment while “satisfactory participation” refers to EPs participating in the “qualified clinical data
registry (QCDR)” reporting option.
What are the components of a measure?
Please refer to page 7 for more information on measure components.
How should I select which reporting mechanism to use?
Refer to Appendix B: Decision Tree - Avoiding the 2017 PQRS Negative Payment Adjustment for
the Decision Trees designed to help participants select among the multiple reporting mechanisms
available in PQRS

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Reporting Electronically Using an EHR
EPs and PQRS group practices may report electronically using an Electronic Health Record (EHR) to
satisfactorily report PQRS measures and avoid the 2017 PQRS negative payment adjustment.
Requirements for Reporting Electronically Using an EHR
To reduce the burden on providers participating in multiple quality reporting programs, CMS has aligned
several reporting requirements for those reporting electronically using an EHR:
•

eCQM specifications:
The electronic clinical quality
measures (eCQM)
specifications are used for
multiple programs, including
the electronic reporting option
for PQRS as well as the
Medicare EHR Incentive
Program.

eCQM
specifications

Elements

•

Criteria for satisfactory
aligned across
reporting: The criteria for
PQRS & EHR
satisfactory reporting under
Incentive
PQRS using an EHR are
Program
aligned with the Medicare
Criteria for
CEHRT
satisfactory
EHR Incentive Program.
technology
reporting
Satisfactory reporting of
PQRS EHR quality measures
will allow EPs and PQRS
group practices to qualify for
the clinical quality measures (CQM) component of Meaningful Use. Group practices electing to
report electronically using an EHR can refer to the Medicare EHR Incentive Programs Clinical
Quality Measures for Eligible Professionals document posted on the eCQM Library webpage for
reporting guidance.

•

Using Certified EHR Technology: The criteria for satisfactory electronic reporting using an EHR
for PQRS are aligned with the clinical quality measure (CQM) component of the Medicare EHR
Incentive Program, which requires EPs and group practices to submit CQMs using a direct EHR
product that is Certified EHR Technology (CEHRT). The Office of the National Coordinator for
Health Information Technology (ONC) certification process has established standards and other
criteria for structured data that EHRs must use.

2015 eCQMs for EPs
The electronic clinical quality measures (eCQM) specifications are used for multiple programs, including
the electronic reporting option for PQRS as well as the Medicare EHR Incentive Program, to reduce the
burden on providers participating in multiple quality programs. Please follow the link provided below to the
Medicare EHR Incentive Program’s eCQM Library webpage to obtain the 2014 eCQM Specifications for
Eligible Professionals Table July 2014 and supporting documentation. EPs and group practices
electronically reporting PQRS using an EHR are required to use the July 2014 updated version of
the 2014 eCQMs for the 2015 program year.
By satisfactorily reporting eCQMs using direct EHR or EHR data submission vendor products, an EP or
group practice will avoid the 2017 PQRS negative payment adjustment.

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For 2014 and beyond, CMS discontinued the PQRS qualification requirement for data submission
vendors and direct EHR vendors. The EHR products have to be certified (CEHRT) under the program
established by ONC. Although CMS discontinued qualifying EHR products, vendors will be able to
continue to submit test files. Allowing submission of test files is an important tool for providers and
provides an opportunity to determine whether the vendor products are able to successfully submit data to
CMS. Beginning in 2014, EPs and group practices must provide CMS their EHR Certification Number of
the product being used by their direct EHR or EHR Data Submission Vendor (DSV).
Direct Submission from an EHR System
If EPs and group practices are submitting quality measure data directly from an EHR system, they must
register for an IACS account. For more information about how eligible professionals register for an IACS
account, visit the “Physician and Other Health Care Professionals Quality Reporting Portal” (Portal).

Direct EHR Vendor
Direct EHR vendors are those vendors that are certifying an EHR product and version for EPs or group
practices to use to directly submit their PQRS measures data to CMS in the CMS-specified format(s) on
their own behalf.
Data format options for submitting data via Direct EHR vendor product that is CEHRT
The Quality Data Model (QDM)-based Quality Reporting
Documentation Architecture (QRDA) Category I format

The QDM-based QRDA Category III format

Direct EHR vendor products must be able to transmit data using the QDM-based QRDA Category I and III
formats. However, for reporting PQRS quality measures data to CMS, EPs and PQRS group practices
need to submit data choosing one of these formats (either the QDM-based QRDA Category I or III).
Version 1.0
CPT only copyright 2014 American Medical Association. All rights reserved.

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EHR Data Submission Vendor (DSV)
An EHR DSV is an entity that collects an EP’s or PQRS group practice’s clinical quality data directly from
the EP’s or PQRS group practice’s EHR. DSVs will be responsible for submitting PQRS measures data
from an EP’s or group practice’s CEHRT to CMS in a CMS-specified format(s) on behalf of the EP or the
PQRS group practice for the program year.
Data submitted to CMS by an EHR DSV must be transmitted using the QDM-based QRDA Category I or
III formats. Products must be able to transmit data using the QDM-based QRDA Category I and III
formats. However, for purposes of reporting PQRS quality measures data to CMS, EPs and PQRS group
practices need to submit data via their EHR choosing one of these formats (either QDM-based QRDA
Category I or III).
Submission of Clinical Quality Measures (CQMs)
EPs and group practices must submit final electronic reporting files with quality measure data, or ensure
that their EHR DSV submits files by the data submission deadline of February 28, 2016, to be analyzed
and used for 2015 PQRS EHR measure calculations.

Resources
•

2015 Physician Quality Reporting System (PQRS) Electronic Health Record (EHR) Reporting
Made Simple

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Reporting via Qualified Registry
EPs and PQRS group practices can avoid the 2017 PQRS negative payment adjustment by satisfactorily
reporting quality measures data using a qualified registry. The qualified registry must submit this data to
CMS via defined .xml specifications, which will be posted by fall 2015 on the Registry Reporting webpage
of the CMS website.
Qualified Registry Vendors
A qualified registry is an entity that collects clinical data from an EP or group practice participating in
PQRS via GPRO and submits it to CMS on behalf of the participants. EPs and group practices
participating in PQRS via GPRO should work directly with their chosen registry in order to submit data
satisfactorily on the selected measures or measures groups.
To select a qualified registry vendor, refer to the 2015
Participating Registry Vendors list, which will be posted in spring
2015, on the Registry Reporting page of the CMS PQRS website.

Beginning in 2015, all qualified
registries must be able to submit
ALL needed data elements and
transmit the data to CMS for at
least 9 measures covering 3
NQS domains as well as ALL
data elements for all of the crosscutting measures.

Registries can
submit 2015
PQRS data
through the first
quarter of 2016
(3/31/2016).

For 2015, and the 2016 and 2017 reporting
year’s negative payment adjustments, CMS will
determine whether an EP had a face-to-face
encounter with a patient by determining whether
or not the EP billed general office visit codes,
outpatient visits, and surgical procedures. The
list of codes are posted under Measures Codes
on the CMS PQRS website.

Reporting Criteria for Individual EPs
EPs wanting to satisfactorily report 2015 PQRS data to avoid the 2017 negative payment adjustment can
do so by meeting one of the following criteria:
1. Report on at least 9 individual measures covering 3 NQS domains for at least 50% of
the EP’s Medicare Part B FFS patients.
EPs who submit quality data for only 1 to 8 PQRS measures covering 3 NQS domains for
at least 50% of the EP’s Medicare Part B FFS patients OR who submit data for 9 or more
PQRS measures covering less than 3 domains for at least 50% of the EP’s Medicare Part
B FFS patients eligible for each measure will be subject to Measure-Applicability Validation
(MAV). (See http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/AnalysisAndPayment.html)

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Measures with a 0% performance rate will not be counted.
An EP who sees at least 1 Medicare patient (face-to-face encounter) must report on 1
cross-cutting measure.
For this reporting option, EPs should use the 2015 Physician Quality Reporting System
(PQRS) Measure Specifications Manual for Claims and Registry Reporting of
Individual Measures on the Measures Codes page of the CMS PQRS website at
http://cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html to find applicable measures.

2. Report at least 1 measures group on a 20-patient sample, a majority of which (at
least 11 out of 20) must be Medicare Part B FFS patients.
For this reporting option, EPs should use the 2015 Physician Quality Reporting System
(PQRS) Measures Groups Specifications Manual on the Measures Codes page of the
CMS PQRS website at http://cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html to find applicable measures groups.
For more information, see 2015 Physician Quality Reporting System (PQRS) Getting
Started with Measures Groups.
Beginning in 2015, the only reporting period available is 12 months.

Reporting Criteria for PQRS Group Practices
A group practice must have registered to report via qualified registry under the GPRO for 2015 PQRS.
Group practices participating in PQRS via GPRO can avoid the 2017 negative payment adjustment by
meeting the following criteria for satisfactory reporting:
1. Report on at least 9 measures covering 3 NQS domains for at least 50% of the group’s
Medicare Part B FFS patients.
Group practices that submit quality data for only 1 to 8 PQRS measures for at least 50% of
their patients or encounters eligible for each measure, OR that submit data for 9 or more
PQRS measures covering less than 3 domains for at least 50% of their patients or
encounters eligible for each measure will be subject to MAV.
Those group practices electing to report via registry will use the 2014 Physician Quality
Reporting System (PQRS) Measure Specifications Manual for Claims and Registry
Reporting of Individual Measures to find applicable measures. These specifications are
located at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html.

Resources
•

2015 Physician Quality Reporting System (PQRS) Measures – Registry Reporting Made Simple

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Participation via Qualified Clinical Data Registry (QCDR)
A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and
disease tracking to foster improvement in the quality of care provided to patients. A QCDR will complete
the collection and submission of PQRS quality measures data on behalf of EPs so that they may meet
criteria for satisfactorily participating in 2015 PQRS. The data submitted to CMS via a QCDR covers
quality measures across multiple payers and is not limited to Medicare. Reporting via QCDR is one of
three reporting mechanisms (Qualified Registry, EHR, and QCDR) that provides calculated reporting and
performance rates to CMS. See Appendix H for the QCDR process.
To select a QCDR, refer to the 2015 Participating Qualified Clinical Data Registry list on the Qualified
Clinical Data Registry Reporting page of the CMS PQRS website. This list will be posted spring 2015.
Note: The measures that may be submitted to a QCDR are not limited to the PQRS measure set,
however, no more than 30 non-PQRS measures may be submitted.
Reporting Criteria for Individual EPs
EPs can avoid the 2017 PQRS negative payment adjustment by satisfactorily participating, according the
following criteria:
1. Report at least 9 measures covering at least 3 NQS domains AND report
each measure for at least 50% of the eligible professional’s applicable
patients seen during the reporting period to which the measure applies.
2. Report on at least 2 outcome measures. If the QCDR does not possess 2
outcome measures, then the QCDR must possess at least 1 outcome
measure and 1 of the following other type of measure: 1 resource use, OR
patient experience of care, OR efficiency appropriate use, OR patient safety
measure.*
*EPs participating via QCDR should work with their selected QCDR to determine how to participate.
Participants should also refer to the 2015 Qualified Clinical Data Registry (QCDR) Participation Made
Simple document. This document serves as an educational resource to assist EPs and their staff with
accurately reporting measures, and provides helpful information on how to get started with PQRS. It will
be available as a downloadable document on the Qualified Clinical Data Registry Reporting webpage in
December 2014.
Resources
•

2015 Physician Quality Reporting System (PQRS) Qualified Clinical Data Registry (QCDR)
Participation Made Simple

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PQRS Group Practice Reporting Option (GPRO) via Web Interface
The GPRO Web Interface is a secure internet-based application available in the PQRS Portal to preregistered users. PQRS group practices wanting to report measures under the GPRO Web Interface in
the 2015 PQRS program year need to register, and must elect their reporting mechanism by June 30,
2015. This mechanism will then be the only PQRS submission method available to the group and all
individual NPIs that bill Medicare under the group’s TIN.
Avoiding the negative PQRS payment adjustment in 2017 based on satisfactory reporting of quality data,
or satisfactory completion of the GPRO Web Interface in 2015. Refer to Appendix B: Decision Trees 2015 PQRS Participation for Avoiding the 2017 Negative Payment Adjustment. Also see Appendix
G for the GPRO Web Interface Process.
Those group practices electing to report via the GPRO Web Interface should refer to the 2015 GPRO
Web Interface Narrative Measure Specifications and other supporting documentation to ensure
accurate reporting of the measures. Reporting via the Web Interface includes completion of a pre-filled
beneficiary sample. These documents are located on the GPRO Web Interface webpage.
Reporting Requirements for All Group Practices
A portion of the patients served by a group practice must be Medicare
beneficiaries. Then each group practice must report on at least 1 measure for
which there is Medicare patient data.
Report on all measures included in the Web Interface; AND populate data fields for
the first 248 consecutively ranked and assigned beneficiaries in the order in which
they appear in the group’s sample for each module or preventive care measure. If
the pool of eligible assigned beneficiaries is less than 248, then report on 100% of
assigned beneficiaries.
The group practice must report all CAHPS for PQRS summary survey modules via
CMS-certified survey vendor (CMS WILL NOT bear the cost of administering this
required survey).

Individual EPs within a group practice that satisfactorily completes the GPRO Web Interface will also
receive credit for the CQM component of the EHR Incentive Program. EPs will still be required to report
the other meaningful use objectives through the Medicare and Medicaid EHR Incentive Programs
Registration and Attestation System.
Resources
•

2015 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Web
Interface Reporting Made Simple

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CAHPS for PQRS - CMS-Certified Survey Vendor
A CMS-certified survey vendor is a newer reporting mechanism, beginning in 2014, available to group
practices. This reporting mechanism is available to group practices of 2 or more EPs wishing to
supplement their PQRS reporting with the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) for PQRS survey. Although required for group practices of 100 or more EPs, this is an extra and
companion reporting option for groups with 2-99 EPs and for EHR and registry reporting. The data
collected on these measures will be submitted on behalf of the group practice by the CMS-certified survey
vendor.
The CAHPS for PQRS survey is equal to 3 individual measures and 1 NQS domain.
Group practices of 2-99 EPs that
choose to register for CAHPS for
PQRS will need to report on at
least 6 additional measures
covering at least 2 additional NQS
domains via qualified registry,
direct EHR product, or EHR data
submission vendor.

Group practices of 25-99 EPs
that choose to register for
CAHPS for PQRS while
reporting PQRS via GPRO Web
Interface, must report all
required Web Interface
measures.

Group practices of 100 or more
EPs reporting CAHPS for PQRS
survey is a requirement of
satisfactory reporting.

Please refer to the Decision Tree in Appendix B for additional details on the reporting requirements of
this mechanism, or visit the Consumer Assessment of Healthcare Providers & Systems (CAHPS)
webpage.
Beginning in 2015, the CAHPS for PQRS survey will have 3 options for group practices to satisfactorily
report:
1: PQRS group practices of 2
or more EPs reporting via
qualified registry with CAHPS
for PQRS
•

•

Must participate via CMS-certified
survey vendor to have 12 CAHPS
for PQRS measures for the 12month reporting period
Must report at least 6 additional
measures, outside of CAHPS for
PQRS, covering at least 2 NQS
domains
•
If less than 6 measures apply,
5 measures must be reported
•
If an EP in the group sees at
least 1 Medicare patient faceto-face, the group must report 1
cross-cutting measure
•
Groups reporting on less than 6
measures will be subject to
Measure-Applicability
Validation (MAV)

2: PQRS group practices of 2
or more EPs reporting via
EHR with CAHPs for PQRS

•
•

Must report all 12 CAHPS for PQRS
measures for the 12-month reporting
period
Must report at least 6 additional
measures, outside of CAHPS for
PQRS, covering at least 2 NQS
domains
•
At least 1 of these measures
must contain Medicare patient
data

3: PQRS group practices of
25-99 EPs reporting via GPRO
Web Interface
•
•

Must report all 12 CAHPS for PQRS
measures for the 12-month reporting
period
Must report all 21 measures within
the GPRO Web Interface and
populate date fields for the first 248
consecutively ranked and assigned
beneficiaries
•
If less than 248 beneficiaries
are available, groups must
report on 100 percent of
assigned beneficiaries
•
At least 1 measure containing
Medicare patient date must be
reported

CMS will NOT bear the cost of administering CAHPS for PQRS for the 2015 program year.
Please refer to the Decision Trees in Appendix B for additional details on the reporting requirements of
this mechanism. Note: CMS-certified survey vendor or CAHPS for PQRS is required for group practices
of 100 or more EPs participating in PQRS via GPRO, but is optional for group practices with 2-99 EPs
Version 1.0
CPT only copyright 2014 American Medical Association. All rights reserved.

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participating in PQRS via GPRO. The group practice must cover the cost of administering the 2015
survey.
Summary Survey Modules
The 12 CAHPS for PQRS summary survey modules will include the following:

Resources
•

2015 CAHPS for PQRS (Certified Survey Vendor) Made Simple

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Reporting PQRS Data via Claims
The following is a list of sub-sections covered in the “Reporting PQRS Data via Claims” section:
1. Claims-based Reporting Overview
2. Getting Started
3. Claims-based Reporting Coding
4. Claims-based Reporting Principles
5. Submitting Claims

1. Claims-based Reporting Overview
Claims-based reporting is readily accessible to EPs as it is a part of routine billing processes. However, it
is not an option for PQRS group practices. There is no need to contact a registry or qualified EHR vendor
to submit data, and it’s simple to select measures and begin reporting (by adding the respective QualityData Code [QDC] to the claim). Medicare providers submit claims via the CMS-1500 form or CMS-1450
(or electronic equivalent) for reimbursement on billable services rendered to Part B beneficiaries. Eligible
professionals use their individual/rendering National Provider Identifier (NPI) to submit for services on
Medicare Part B beneficiaries.
Quality data reported to CMS through Medicare Part B claims (containing valid QDC line items for each
EP’s NPI) are processed to final action by the Medicare Administrative Contractor (MAC) and
subsequently transferred to the National Claims History (NCH) where it is available for PQRS analysis.
See Appendix E. Quality measures data reported on claims denied for payment are not included in
PQRS analysis. QDC line items from claims are analyzed according to the measure specifications,
including coding instructions, reporting frequency, and performance timeframes. See Appendix I for a
flow diagram of the PQRS claims-based process.
For additional information, see the 2015 Physician Quality Reporting System (PQRS) Measure
Specifications Manual for Claims and Registry Reporting of Individual Measures.
Example
An example of a claim in CMS-1500 format that illustrates how to report several PQRS measures is
provided. See Appendix D for the current CMS-1500 claim form (version 02/12).
2. Getting Started
Ensure that the practice identifies and reports on
all denominator eligible cases for the measures
selected by the practice. Consider implementing
an edit on the billing software that will flag each
claim every time a combination of codes listed in a
measure’s denominator is billed so the entry QDCs
is required prior to final claim submission.
Additional PQRS educational resources are
available as downloads on the CMS PQRS
webpage.
Version 1.0
CPT only copyright 2014 American Medical Association. All rights reserved.

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EPs may satisfactorily report in 2015 PQRS by
meeting the following criteria:
•

•

Report on at least 9 measures covering 3
NQS domains for at least 50% of the EP’s
Medicare Part B FFS patients. EPs that
see 1 Medicare patient in a face-to-face
encounter must also report on 1 crosscutting measure.
EPs that submit quality data for only 1 to 8
PQRS measures for at least 50% of their
patients or encounters eligible for each
measure, OR that submit data for 9 or more
PQRS measures covering less than 3
domains for at least 50% of their patients or
encounters eligible for each measure will be
subject to MAV.

•

EPs that see 1 Medicare patient (face-toface encounter), but do not report on 1
cross-cutting measure will be subject to
MAV. (See the Analysis and Payment
webpage)

•

Measures with a 0% performance rate will
not be counted.

3. Claims-based Reporting Coding
Claims follow a process so the information reaches the CMS National Claims History File (NCH). Current
Procedure Terminology (CPT) codes are used to describe medical procedures and physicians’ services,
and are maintained and distributed by the American Medical Association. Use the CPT codes in the
below tables when reporting data.
Use of Current Procedural Terminology (CPT) Category I Modifiers
•

PQRS measure specifications include specific instructions on including the CPT Category I modifiers.
Unless otherwise specified, CPT Category I codes may be reported with or without CPT modifiers.
Refer to each individual measure specification for detailed instructions regarding CPT Category I
modifiers that qualify or do not qualify a claim for denominator inclusion.

•

Note that surgical procedures billed by an assistant surgeon(s) will be excluded from the denominator
population so his/her performance rates will not be negatively impacted for PQRS. Analysis will
exclude otherwise PQRS-eligible CPT Category I codes, when submitted with assistant surgeon
modifiers 80, 81, 82, or AS. The primary surgeon, not the assistant surgeon, is responsible for
performing and reporting the quality action(s) in applicable PQRS measures.

•

Eligible CPT Category I procedure codes, billed by surgeons performing surgery on the same patient,
submitted with modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the
denominator population for applicable PQRS measure(s). Both surgeons taking part in PQRS will be
fully accountable for the clinical action(s) described in the PQRS measure(s).

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CPT Category II Codes
•

CPT Category II or CPT II codes, developed through the CPT Editorial Panel for use in performance
measurement, encode the clinical action(s) described in a measure’s numerator. CPT II codes consist
of five alphanumeric characters in a string ending with the letter “F.” CPT II codes are not modified or
updated during the reporting period and remain valid for the entire program year as published in the
measure specifications manuals and related documents for PQRS.

Quality-Data Codes
•

QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes composed
of specified CPT Category II codes and/or G-codes that describe the clinical action required by a
measure’s numerator. Clinical actions can apply to more than one condition and, therefore, can also
apply to more than one measure. Where necessary, to avoid shared CPT Category II codes, G-codes
are used to distinguish clinical actions across measures. Some measures require more than one
clinical action and may have more than one CPT Category II code, G-code, or a combination
associated with them. EPs should review numerator reporting instructions for each measure carefully.

Use of CPT II Modifiers
•

CPT II modifiers are unique to CPT II codes and may be used to report measures by appending the
appropriate modifier to a CPT II code as specified for a given measure. The modifiers for a code
cannot be combined and their use is guided by the measure’s coding instructions, which are included
in the numerator coding section of the measure specifications. Use of the modifiers is unique to CPT
II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be
appended to CPT II codes. Descriptions of each modifier are provided below to help identify
circumstances when the use of a modifier may be appropriate. Note that reporting an exclusion or
reporting modifier will alter an EP’s performance rate. Accurate reporting on all selected measures
will count toward the reporting requirements, whether the clinical action is reported as complete or not
complete (or performance met or not met).

•

CPT II code modifiers fall into two categories; exclusion modifiers and the 8P reporting modifier.

•

Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the
measure was not provided due to medical, patient, or system reason(s) documented in the medical
record. These modifiers serve as denominator exclusions for the purpose of measuring performance.
Not all exclusions will apply to every measure, and some measures do not allow any performance
exclusions. Appending a performance measure exclusion modifier falls into one of three categories;
see the graphic below for more detail.

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Performance measure exclusion modifier categories

•

There may be instances in which a G-code is indicated to represent performance exclusion. The Gcode may encompass the concepts of a medical, patient, and/or system exclusion.

•

Generally, the 8P reporting modifier is available for use only with CPT II codes to facilitate reporting
an eligible case when an action described in a measure is not performed and the reason is not
specified. Instructions for appending this reporting modifier to CPT Category II codes are included in
applicable measures. Use of the 8P reporting modifier indicates that the patient is eligible for the
measure; however, there is no indication in the record that the action described in the measure was
performed, nor was there any documented reason attributable to the exclusion modifiers. 8P
Performance measure reporting modifier - action not performed, reason not otherwise
specified

•

The 8P reporting modifier facilitates reporting an eligible case on a given measure when the clinical
action does not apply to a specific encounter. Eligible professionals can use the 8P modifier to
receive credit for satisfactory reporting but will not receive credit for performance. Eligible
professionals should use the 8P reporting modifier sensibly for applicable measures they have
selected to report. The 8P modifier may not be used freely in an attempt to meet satisfactory reporting
criteria without regard toward meeting the practice’s quality improvement goals.

•

Note: Measures with a 0% performance rate will not be counted. For example, an EP has selected
and submitted QDCs during the reporting period for 2015 PQRS Measure #6, Coronary Artery
Disease (CAD): Antiplatelet Therapy. The EP sees a patient for whom he does not choose to
prescribe oral antiplatelet therapy and the reason is not specified. However, the claim(s) for services
for that encounter contains International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM), and CPT codes that will draw the patient into the measures’ denominator
during analysis. The 8P modifier serves to include the patient in the numerator when reporting rates
are calculated for PQRS.

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4. Claims-Based Reporting Principles
Below are some helpful tips when reporting via claims.

Only 1 diagnosis can be linked to each line item, although for PQRS all diagnosis
codes will be taken into consideration for analysis.
PQRS analyzes claims data using ALL diagnoses from the base claim (Item 21 of the
CMS-1500 or electronic equivalent) and service codes for each individual eligible
professional (identified by individual NPI).
EPs should review ALL diagnosis and encounter codes listed on the claim to make
sure they are capturing ALL chosen measures applicable to that patient’s care.

For line items containing a QDC, only 1 diagnosis from the base claim should be
referenced in the diagnosis pointer field.
To report a QDC for a measure that requires reporting of multiple diagnoses, enter the
reference number in the diagnosis pointer field that corresponds to one of the
measure’s diagnoses listed on the base claim. Regardless of the reference number in
the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS
analysis.

PQRS analysis will subsequently join claims based on the same beneficiary for the
same date-of-service, for the same TIN/NPI and analyze as one claim.

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Providers should work with their billing software vendor/clearinghouse regarding line
limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are
not dropped.
A sample CMS-1500 form can also be found in Appendix D of this document.
Principles for Reporting QDCs via Claims
The following principles apply for claims-based reporting of PQRS measures:
1. QDCs must be reported:
On the claim(s) with the denominator billing code(s) that represents the eligible
Medicare Part B PFS encounter.
For the same beneficiary.
For the same date of service (DOS).
By the same eligible professional (individual rendering NPI) that performed the
covered service, applying the appropriate encounter codes (ICD-9-CM, ICD-10-CM,
CPT Category I or HCPCS codes). These codes are used to identify the measure's
denominator.

2. QDCs must be submitted with a line-item charge of one penny ($0.01) at the
time the associated covered service is performed.
The submitted charge field cannot be blank.
The line item charge should be $0.01 – the beneficiary is not liable for this nominal
amount.
Entire claims with a $0.01 charge will be rejected.
When the $0.01 nominal amount is submitted to the MAC, the PQRS code line will
be denied but will be tracked in the National Claims History (NCH) for analysis.
Important: In an effort to streamline reporting of QDCs across multiple CMS quality
reporting programs, CMS strongly encourages all EPs and practices to bill 2015
QDCs with a $0.01 charge. EPs should pursue updating their billing software
to accept the $0.01 charge prior to implementing 2015 PQRS. EPs and practices
will need to work with their billing software or EHR vendor to ensure this capability is
activated. Entering the nominal charge of $0.01 on claims will help ensure the QDCs
are processed into the CMS claims database.

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3. When a group bills, the group NPI is submitted at the claim level; therefore,
the individual rendering/performing physician’s NPI must be placed on
each line item, including all allowed charges and quality-data line items.
Solo practitioners should follow their normal billing practice of placing
their individual NPI in the billing provider field (#33a on the CMS-1500 form
or the electronic equivalent).
Note: Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs. If a denied
claim is subsequently corrected through the appeals process to the MAC, with accurate codes that also
correspond to the measure’s denominator, then QDCs that correspond to the numerator should also be
included on the resubmitted claim as instructed in the measure specifications.
Remittance Advice (RA) / Explanation of Benefits (EOB)
The RA/EOB denial code N620 is your indication that the PQRS codes are valid for the 2015 PQRS
reporting year.
•

The N620 denial code is just an indicator that the QDC codes are valid for 2015 PQRS. It does
not guarantee the QDC was correct or that reporting thresholds were met. However, when a QDC
is reported satisfactorily (by the individual EP), the N620 can indicate that the claim will be used
in calculating incentive eligibility.
EPs who bill on a $0.00 QDC line item will receive the N620 code. EPs who bill on a
$0.01 QDC line item will receive the CO 246 N620 code.
All submitted QDCs on fully processed claims are forwarded to the CMS warehouse
for analysis by the CMS quality reporting program, so providers will first want to be
sure they do see the QDC’s line item on the RA/EOB, regardless of whether the RA
N620 code appears.

•

Keep track of all cases reported so that you can verify QDCs reported against the remittance
advice notice sent by the MAC. Each QDC line-item will be listed with the N620 denial remark
code.

Claim Adjustment Reason Code (CARC) for QDCs with $0.01
The CARC 246 with Group Code CO or PR and with RARC N620 indicates that this procedure is not
payable unless non-payable reporting codes and appropriate modifiers are submitted.
•

In addition to N620, the remittance advice will show Claim Adjustment Reason Code (CARC) CO
or PR 246 (This non-payable code is for required reporting only).

•

CARC 246 reads: This non-payable code is for required reporting only.

•

EPs who bill with a charge of $0.01 on a QDC item will receive CO 246 N620 on the EOB.

Remittance Advice Remark Code (RARC) for QDCs with $0.00
The new RARC code N620 is your indication that the PQRS codes were received into the CMS National
Claims History (NCH) database.
•

EPs who bill with $0.00 charge on a QDC line item will receive an N620 code on the EOB.

1/15/2015
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•

N620 reads: This procedure code is for quality reporting/informational purposes only.

5. Submitting Claims
Submission through MACs
QDCs shall be submitted to MACs through one of the following options:

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Electronic-based Submission
PQRS QDCs are submitted on the claim just like
any other code; however, QDCs will have a
nominal $0.01 (or $0.00) charge. Electronic
submission, which is accomplished using the ASC X
12N Health Care Claim Transaction (Version 5010),
should follow the current HIPAA standard version of
the ASC x12 technical report 3.

Paper-based Submission
Use the CMS-1500 or CMS-1450 claim form
as described in the sample claims provided in
Appendix D. The CMS-1450 claim form may
also be used as applicable.

Group NPI Submission
When a group bills, the group’s NPI is submitted at the claim level, therefore, the individual rendering
EP’s NPI must be placed on each line item, including all allowed charges and quality-data line items.
Solo NPI Submission
The individual NPI of the solo practitioner must be included on the claim as is the normal billing process
for submitting Medicare claims. For PQRS, the QDC must be included on the claim(s) representing the
eligible encounter that is submitted for payment at the time the claim is initially submitted in order to be
included in PQRS analysis.
Timeliness of Quality Data Submission
Claims processed by the MAC must reach the national Medicare claims system data warehouse (NCH
file) by February 26, 2016 to be included in the analysis. Claims for services furnished toward the end of
the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not be
included in the analysis.
Resources
•

2015 Physician Quality Reporting System (PQRS) Measures – Claims Reporting Made Simple

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Appendix A: Glossary of Terms
Terms

Definitions

Base Claim
Diagnosis

PQRS refers to all diagnoses listed (Item 21 of the CMS-1500 claim form, field 66 of
the CMS-1450 form) associated with physician office, outpatient, and inpatient visits
for reporting.

CMS-1450 Form

The CMS-1450 form (UB-04 at present) can be used by an institutional provider to bill
a Medicare fiscal intermediary when a provider qualifies for a waiver from the
Administrative Simplification Compliance Act requirement for electronic submission of
claims. It is also used for billing of institutional charges to most Medicaid State
Agencies. Please contact your Medicaid State Agency for more details on their
requirements for this paper form.
New for the 2015 PQRS program year, EPs in Critical Access Hospital Method II
(CAH II) may participate in the PQRS using all reporting mechanisms, including the
claims-based reporting mechanism via the CMS-1450 form. Regardless of the
reporting mechanism, CAH II providers will need to continue to add their NPI to the
MCS-1450 claim form for analysis of PQRS reporting at the NPI-level.

CMS-1500 Form

Health Insurance Claim Form CMS-1500 is the standard paper claim form to bill
Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. Form
CMS-1500 may be suitable for billing various government and some private insurers.
Refer to Appendix D for more information.

CMS-Certified
Survey Vendor

A CMS-certified survey vendor is a new reporting mechanism for purposes of
reporting CAHPS for PQRS survey for group practices reporting via GPRO. The
CMS-certified survey vendor is required to be certified for a particular program year
by CMS in order to submit the CAHPS for PQRS survey data.

Claim

For PQRS purposes, one or more claims will be reconnected based on TIN, NPI,
beneficiary and date of service.

Claim
Adjustment
Reason Code
(CARC)

Claim adjustment reason codes (CARC) communicate an adjustment, meaning that
they must communicate why a claim or service line was paid differently than it was
billed. If there is no adjustment to a claim/line, then there is no adjustment reason
code.

CPT Category II
Codes

A set of supplemental CPT codes intended to be used for performance measurement.
These codes may be used to facilitate data collection about the quality of care
rendered by coding certain services, test results or clinical actions that support
nationally established performance measures and that the evidence has
demonstrated to contribute to quality patient care.2
For PQRS, CPT Category II codes are used to report quality measures on a claim for
measurement calculation.

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Denominator
(Eligible Cases)

The lower portion of a fraction used to calculate a rate, proportion, or ratio.
The denominator must describe the population eligible (or episodes of care) to be
evaluated by the measure. This should indicate age, condition, setting, and timeframe
(when applicable). For example, “Patients aged 18 through 75 years with a diagnosis
of diabetes.” PQRS measure denominators are identified by ICD-9-CM
(01/01/2015-10/01/2015), ICD-10-CM (10/01/2015-12/31/2015), CPT Category I, and
HCPCS codes, as well as patient demographics (age, gender, etc.), and place of
service (if applicable).
UPDATE: With enactment of the Protecting Access to Medicare Act of 2014, CMS is
examining the implications of the ICD-10 provision and will provide guidance to
providers and stakeholders soon. For more information on ICD-10 implementation,
visit the CMS ICD-10 Website:
http://www.cms.gov/Medicare/Coding/ICD10/index.html.

Denominator
Exclusion

Patients with conditions who should be removed from the measure population and
denominator before determining if numerator criteria are met.

Denominator
Statement

A statement that describes the population eligible for the performance measure. For
example, “Patients aged 18 through 75 years with a diagnosis of diabetes.”

Diagnosis
Pointer

Item 24E of the CMS-1500 claim form or electronic equivalent. For PQRS, the line
item containing the quality-data code (QDC) for the measure should point to one
diagnosis (from Item 21) per measure-specific denominator coding.
To report a QDC for a measure that requires reporting of multiple diagnoses, enter
the reference number in the diagnosis pointer field that corresponds to one of the
measure’s diagnoses listed on the base claim. Regardless of the reference number in
the diagnosis pointer field, both primary and all secondary diagnoses are considered
in PQRS analysis.

Electronic
Health Record
(EHR)

The Electronic Health Record (EHR) is a longitudinal electronic record of patient
health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems,
medications, vital signs, past medical history, immunizations, laboratory data and
radiology reports. The EHR automates and streamlines the clinician's workflow. The
EHR has the ability to generate a complete record of a clinical patient encounter - as
well as supporting other care-related activities directly or indirectly via interface including evidence-based decision support, quality management, and outcomes
reporting.

Eligible
Professional
(EP)

Refer to http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS for a list of professionals eligible to report in 2015 PQRS.
Providers not defined as eligible professionals in the Tax Relief and Health Care Act
of 2006 or the Medicare Improvements for Patients and Providers Act of 2008 are not
eligible to report in PQRS and do not qualify to avoid the 2017 PQRS negative
payment adjustment. Services payable under fee schedules or methodologies other
than the Medicare Physician Fee Schedule (PFS) are not included in PQRS (for
example, services provided in federally qualified health centers, portable x-ray
suppliers, independent laboratories, independent diagnostic testing facilities,
hospitals, rural health clinics, ambulance providers, and ambulatory surgery center
facilities). In addition, suppliers of durable medical equipment (DME) are not eligible
for PQRS since DME is not paid under the PFS.

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Encounter

Encounters with patients during the reporting period which include: CPT Category I
E/M service codes, CPT Category I procedure codes, or HCPCS codes found in a
PQRS measure’s denominator. These codes count as eligible to meet a measure’s
inclusion requirements when occurring during the reporting period.

G-codes for
PQRS

A set of CMS-defined temporary HCPCS codes used to report quality measures on a
claim. G-codes are maintained by CMS.

Group Practice
Reporting
Option (GPRO)

The Group Practice Reporting Option (GPRO) was introduced in 2010 as a reporting
mechanism for group practices to qualify to earn a PQRS incentive. PQRS defines a
group practice as a single Tax Identification Number (TIN) with 2 or more individual
eligible professionals (as identified by Individual National Provider Identifier [NPI]) that
have reassigned their billing rights to the TIN.

ICD-10-CM
Diagnosis
Codes

ICD-10-CM is a clinical modification of the World Health Organization’s ICD-10, which
consists of a diagnostics classification system. ICD-10-CM includes the level of detail
needed for morbidity classification and diagnostics specificity in the United States.9
For more information on ICD-10 implementation visit the CMS ICD-10 Website:
http://www.cms.gov/Medicare/Coding/ICD10/index.html.

Line-Item
Diagnosis

Six service lines in Section 24 of the CMS-1500 claim form to accommodate
submission of the rendering NPI and supplemental information to support the billed
service, including the pointed diagnosis from Item 21.
QDCs are submitted on the line item in section 24 for PQRS.

Measure

•

Performance Measure
•

A quantitative tool (e.g., rate, ratio, index, percentage) that provides an
indication of performance in relation to a specified process or outcome.

•

See also process measure and outcome measure.1,6

Measure Types
•

Outcome measure: A measure that assesses the results of healthcare that
are experienced by patients: clinical events, recovery and health status,
6
experiences in the health system, and efficiency/cost.

•

Process measure: A measure that focuses on steps that should be followed
to provide good care. There should be a scientific basis for believing that the
process, when executed well, will increase the probability of achieving a
desired outcome.6

•

Structural measure: A measure that assesses features of a healthcare
organization or clinician relevant to its capacity to provide healthcare.6

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Measure
Reporting
Frequency (also
referred to as
Measure Tag)

•

Patient-Process: Report a minimum of once per reporting period per individual
eligible professional (NPI).

If the measure is reported more than once during the reporting period,
performance rates are calculated using the most advantageous QDC
submitted.

Reflect quality actions performed throughout the reporting period or other
timeframe.

Patient-Intermediate: Report a minimum of once per reporting period per
individual eligible professional (NPI).

If the measure is reported more than once during the reporting period,
performance rates are calculated using the most recent QDC submitted.

Often reflects lab or other test value, so the most recent measurement is
desired.

Patient-Periodic: Report once per timeframe specified in the measure for each
individual eligible professional (NPI) during the reporting period.

o
•

Examples include once per month and three times per year.

Episode: Report once for each occurrence of a particular illness/condition by
each individual eligible professional (NPI) during the reporting period.

Usually reflects a clinical episode, difficult to determine from a single Part B
claim.

Requires specialized analytics to determine the episode.

•

Procedure: Report each time a procedure is performed by the individual eligible
professional (NPI) during the reporting period.

•

Visit: Report each time the patient is seen by the individual eligible professional
(NPI) during the reporting period.

NPI

National Provider Identifier of the individual eligible professional billing under the Tax
ID (“NPI within the Tax ID”).

Numerator

The upper portion of a fraction used to calculate a rate, proportion, or ratio.
The numerator must detail the quality clinical action expected that satisfies the
condition(s) and is the focus of the measurement for each patient, procedure, or other
unit of measurement established by the denominator (that is, patients who received a
particular service or providers that completed a specific outcome/process). PQRS
measure numerators are CPT Category II codes and G-codes.

Numerator
Statement

A statement that describes the clinical action that satisfies the conditions of the
performance measure.
For example, “Patients that were assessed for the presence or absence of urinary
incontinence.”

Performance
Timeframe

A designated timeframe within which the action described in a performance measure
should be completed. This timeframe is generally included in the measure description
and may or may not coincide with the measure’s data reporting frequency
requirement.

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Performance
Measure
Exclusion
Modifiers

Modifiers developed exclusively for use with CPT Category II codes to indicate
documented medical (1P), patient (2P), or system (3P) reasons for excluding patients
from a measure’s denominator.2

Performance
Measure
Reporting
Modifier 8P

The 8P reporting modifier is intended to be used as a “reporting modifier” to allow the
reporting of circumstances when an action described in a measure’s numerator is not
performed and the reason is not otherwise specified.
8P performance measure reporting modifier - action not performed, reason not
otherwise specified 2

Place of Service

References Place of Service Codes (POS) from the list provided in section 10.5 of the
Medicare Claims Processing Manual.

Qualified
Clinical Data
Registry (QCDR)

A CMS-approved entity (such as a registry, certification board, collaborative, etc.) that
collects medical and/or clinical data for the purpose of patient and disease tracking to
foster improvement in the quality of care furnished to patients.

Quality-Data
Code (QDC)

Specified CPT Category II codes with or without modifiers and G-codes used for
submission of PQRS data via claims-based or registry reporting mechanisms. The
2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for
Claims and Registry contains all codes associated with each PQRS measure and
instructions for data submission.

Qualified
Registry

An entity that collects clinical data from an eligible professional or group practice and
submits it to CMS on behalf of the eligible professional or group practice.

Rationale

A brief statement describing the evidence base and/or intent for the measure that
serves to guide interpretation of results.4

Remittance
Advice (RA)

Means utilized by Medicare contractors to communicate to providers, submitting
measures through the claims-based reporting mechanism, of processing decisions
such as payments, adjustments, and denials.7

Remittance
Advice Remark
Codes (RARC)

Remittance Advice Remark Codes (RARCs) are used to provide additional
explanation for an adjustment already described by a Claim Adjustment Reason Code
(CARC) or to convey information about remittance processing. Each RARC identifies
a specific message as shown in the Remittance Advice Remark Code List. There are
two types of RARCs, supplemental and informational. The majority of the RARCs are
supplemental; these are generally referred to as RARCs without further distinction.
Supplemental RARCs provide additional explanation for an adjustment already
described by a CARC. The second type of RARC is informational; these RARCs are
all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey
information about remittance processing and are never related to a specific
adjustment or CARC.

Reporting
Frequency

The number of times quality-data codes (QDCs) specified for a quality measure must
be submitted on claims during the reporting period. The reporting frequency for each
measure is described in the 2015 Physician Quality Reporting System (PQRS)
Measure Specifications Manual for Claims and Registry posted on the CMS Web site
at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html.

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Reporting
Options

2015 reporting mechanisms available for incentive payment: claims-based; registrybased; electronic health record (EHR); participation via qualified clinical data registry;
CAHPS for PQRS, or group practice reporting option (GPRO). Refer to Appendix B:
“Decision Tree – 2015 PQRS Reporting/Participation for Avoiding the 2017 Negative
Payment Adjustment.

Reporting
Period

The period during which PQRS measures are to be reported for covered professional
services provided.
12-month (January 1, 2015 through December 31, 2015) time periods are available
depending upon the 2015 reporting option the eligible professional selects for
submitting PQRS quality data.

Sources

1. Agency for Health Care Research & Quality (AHRQ) National Quality Measures Clearinghouse
Glossary

2. IBID, PSNet, Patient Safety Network Glossary
3. American Medical Association (AMA), CPT® Category II Index of Alphabetic Clinical Topics
4. Institute of Medicine (IOM), Performance Measurement Accelerating Improvement, Appendix A
Glossary, National Academies Press

5. Joint Commission on Accreditation of Health Care Organizations (JCAHO)
6. CMS Blueprint for the CMS Measures Management System, Version 11, July 2014
7. QualityNet, QMIS Specification Manual for National Hospital Quality Measures, Appendix D-3,
Glossary of Terms version 2.3b, 9-28-2007

8. CMS Medicare Learning Network, Understanding the Remittance Advice: A Guide for Medicare
Providers, Physicians, Suppliers, and Billers

9. Medicare Claims Processing Manual: Chapter 26 – Completing and Processing Form CMS – 1500
Data Set

10. American Health Information Management Association (AHIMA), Understanding ICD-10, retrieved
from official AHIMA website

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Appendix B: Decision Trees - 2015 PQRS Reporting/Participation for
Avoiding the 2017 Negative Payment Adjustment

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2015 Program Reporting Options
Number assigned coordinates with appropriate box on the Appendix B: 2015 PQRS Participation for
Avoiding the 2017 Negative Payment Adjustment Decision Tree.
1. Claims-based reporting of less than 9 individual measures covering 3 or more NQS domains for 50%
or more of an EP’s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if
see at least 1 Medicare patient in a face-to-face encounter (12 months)
Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV)
2. Claims-based reporting of at least 9 individual measures covering 1-2 NQS domains for 50% or more
of an EP’s applicable Medicare Part B FFS patients and at least 1 cross-cutting measures if see at
least 1 Medicare patient in a face-to-face encounter (12 months)
Note: This reporting option is subject to Claims Measure-Applicability Validation (MAV)
3. Claims-based reporting of at least 9 individual measures covering at least 3 NQS domains for 50% or
more of an EP’s applicable Medicare Part B FFS patients (12 months)
4. Qualified registry-based reporting of less than 9 individual measures covering 3 or more NQS
domains for 50% or more of an EP’s applicable Medicare Part B FFS patients and at least 1 crosscutting measures if see at least 1 Medicare patient in a face-to-face encounter (12 months)
Note: This reporting option is subject to Registry Measure-Applicability Validation (MAV)
5. Qualified registry-based reporting of at least 9 individual measures covering at 1-2 NQS domains for
50% or more of an EP’s applicable Medicare Part B FFS patients and at least 1 cross-cutting
measures if see at least 1 Medicare patient in a face-to-face encounter (12 months)
Note: This reporting option is subject to Registry Measure-Applicability Validation (MAV)
6. Qualified registry-based reporting of at least 9 individual measures covering at least 3 NQS domains
for 50% or more of an EP’s applicable Medicare Part B FFS patients and at least 1 cross-cutting
measures if see at least 1 Medicare patient in a face-to-face encounter (12 months)
7. Qualified registry-based reporting of at least one measures group for 20 or more patients, the majority
(11) of which must be Medicare Part B FFS patients and at least1 cross-cutting measures if see at
least 1 Medicare patient in a face-to-face encounter (12 months)
8. Direct CEHRT electronic reporting using an EHR of at least 9 individual measures covering at least 3
NQS domains (12 months)
9. CEHRT EHR Data Submission Vendor reporting of at least 9 individual measures covering at least 3
NQS domains (12 months)
10. GPRO-based reporting (2+ eligible professionals) of 1-8 individual measures covering 3 NQS
domains via registry for 50% or more of a group’s applicable Medicare Part B FFS patients and at
least 1 cross-cutting measures if see at least 1 Medicare patient in a face-to-face encounter OR
Have all CAHPS for PQRS summary survey modules (12) reported on the group’s behalf via a CMScertified survey vendor AND Report at least 6 additional measures covering 2 NQS domains using a
qualified registry; Of these 6 measures, if any EP in the group practice sees at least 1 Medicare
patient in a face-to-face encounter, the group practice is required to report on at least 1 measure in
the cross-cutting measure set. (12 months)
Note: This reporting option is subject to Registry Measure-Applicability Validation (MAV)
Version 1.0
CPT only copyright 2014 American Medical Association. All rights reserved.

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11. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures covering 1-2 NQS
domains via registry for 50% or more of the group’s applicable Medicare Part B FFS patients and at
least 1 cross-cutting measures if see at least 1 Medicare patient in a face-to-face encounter OR
Have all CAHPS for PQRS summary survey modules (12) reported on the group’s behalf via a CMScertified survey vendor AND Report at least 6 additional measures covering 2 NQS domains using a
qualified registry; Of these 6 measures, if any EP in the group practice sees at least 1 Medicare
patient in a face-to-face encounter, the group practice is required to report on at least 1 measure in
the cross-cutting measure set. (12 months)
Note: This reporting option is subject to Registry Measure-Applicability Validation (MAV)
12. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures covering at least 3
NQS domains via registry for 50% or more of the group’s applicable Medicare Part B FFS patients
and at least 2 cross-cutting measures if see at least 1 Medicare patient in a face-to-face encounter
OR Have all CAHPS for PQRS summary survey modules (12) reported on the group’s behalf via a
CMS-certified survey vendor AND Report at least 6 additional measures covering 2 NQS domains
using a qualified registry; Of these 6 measures, if any EP in the group practice sees at least 1
Medicare patient in a face-to-face encounter, the group practice is required to report on at least 1
measure in the cross-cutting measure set. (12 months)
13. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures covering at least 3
NQS domains via Direct EHR Product that is CEHRT OR Have all CAHPS for PQRS summary
survey modules (12) reported on the group’s behalf via a CMS-certified survey vendor AND Report at
least 6 additional measures covering 2 NQS domains using a qualified registry; Of these 6 measures,
if any EP in the group practice sees at least 1 Medicare patient in a face-to-face encounter, the group
practice is required to report on at least 1 measure in the cross-cutting measure set. (12 months)
14. GPRO-based reporting (2+ eligible professionals) of at least 9 individual measures covering at least 3
NQS domains via EHR Data Submission Vendor that is CEHRT OR Have all CAHPS for PQRS
summary survey modules (12) reported on the group’s behalf via a CMS-certified survey vendor AND
Report at least 6 additional measures covering 2 NQS domains using a qualified registry; Of these 6
measures, if any EP in the group practice sees at least 1 Medicare patient in a face-to-face
encounter, the group practice is required to report on at least 1 measure in the cross-cutting measure
set. (12 months)
15. GPRO-based reporting (25-99 eligible professionals) of all applicable measures included in the
submission Web Interface provided by CMS for consecutive, confirmed, and completed patients for
each disease module and preventive care measures (12 months)
16. GPRO-based reporting (100+ eligible professionals) of all applicable measures included in the
submission Web Interface provided by CMS for consecutive, confirmed, and completed patients for
each disease module and preventive care measures AND report all CAHPS for PQRS summary
survey modules via CMS-certified survey vendor (12 months)
17. Qualified clinical data registry-based reporting of at least 9 measures covering at least 3 NQS
domains for 50% or more of the EP’s applicable Medicare Part B FFS patients AND report at least 2
outcome measures and at least 1 additional outcome measure or resource use, patient experience of
care, or efficient/appropriate use measure (all payers) (12 months)

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Appendix C: Satisfactory Reporting via Claims Scenario

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Appendix D: CMS-1500 Claim PQRS Example
Examples of an individual NPI reporting on a single CMS-1500 claim.
See http://www.cms.gov/manuals/downloads/clm104c26.pdf for more information and complete billing requirements.

•

The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease
(CAD), and urinary incontinence:

•

Measure #2 (LDL-C) with QDC 3048F + diabetes line-item diagnosis (24E points to DX 250.00 in Item 21);

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•

Measure #3 (BP in Diabetes) with QDCs 3074F + 3078F + diabetes line-item diagnosis (24E points to Dx 250.00 in Item 21);

•

Measure #6 (CAD) with QDC 4011F + CAD line-item diagnosis (24E points to Dx 414.00 in Item 21); and

•

Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRS, there is no specific diagnosis associated with this
measure. Point to the appropriate diagnosis for the encounter.

•

Note: All diagnoses listed in Item 21 will be used for PQRS analysis. Measures that require the reporting of two or more diagnoses on
claim will be analyzed as submitted in Item 21.

•

NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing.

•

If billing software limits the line items on a claim, you may add a nominal line-item charge of a penny to one of the QDC line items on that
second claim. PQRS analysis will subsequently join both claims based on the same beneficiary, for the same date-of-service, for the same
TIN/NPI and analyze as one claim.

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Appendix E: PQRS EHR Process

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Appendix F: PQRS Registry Process

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Appendix G: PQRS GPRO Web Interface Process

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Appendix H: QCDR Process

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Appendix I: PQRS Claims-Based Process

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File Type	application/pdf
File Title	2015 Physician Quality Reporting System (PQRS) Implementation Guide - Reporting for Incentive
Subject	2015 PQRS Implementation Guide
Author	CMS
File Modified	2015-01-20
File Created	2015-01-15