Form CMS-10519 Attachment D - Survey

Physician Quality Reporting System (PQRS) and Electronic Prescribing Incentive (eRx) Program Data Assessment, Accuracy and Incorrect Payments Identification Support Contract

Sponsored by:

U.S. Department of Health and Human Services,

Centers for Medicare & Medicaid Services

Public Burden Statement: According to the Paperwork Reduction Act of 1995, a federal agency may not conduct, and a person is not required to respond to, an information collection request unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is [0938-1255]. The time required to complete this information collection is estimated to average 15 minutes per respondent, including the time to review instructions and complete and review the information collection. If you have comments concerning the accuracy of this burden estimate or any suggestions for reducing this burden, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.

OMB No.: [0938-1255]

Expires: [11/30/2017]

Participation in this Survey

You have been selected to participate in an important survey as an entity that submits data to the Centers for Medicare & Medicaid Services (CMS) as part of the Physician Quality Reporting System (PQRS)/Electronic Prescribing (eRx) Incentive programs.

This survey was developed under CMS’ guidance as they continue to work toward improving data quality for the PQRS and eRx programs. The survey is a data collection tool to facilitate the identification, creation, and deployment of process improvements, as well as the development of data quality recommendations for CMS, as the Agency moves toward value-based purchasing and as they expand public reporting of performance information on Physician Compare.

The survey consists of approximately 30 questions regarding how you collect, validate, and submit data that are reported through the PQRS/eRx programs. It is a simple, web-based application that will be completed online. The User Guide is provided electronically within the survey, under the “Help” tab, to facilitate successful completion of the survey.

The link to access the survey is provided in an invitation email. We estimate that it will take approximately one hour or less to complete and submit the survey. Please note that after your survey is submitted, you may be contacted to answer a few follow-up questions. We estimate that the time required to complete the follow-up survey will be less than 30 minutes. Please do not include any Personally Identifiable Information (PII) in your survey responses.

Please note that your participation in this important effort is required as an entity that submits data to CMS.

The Questions in the Survey

The survey uses a series of questions, arranged by category, to gather information about data handling practices, training, and quality assurance, as well as the challenges that stakeholders faced in participating in the PQRS and eRx Incentive Programs.

Table 1: Question Categories, below, provides a description of each question category.

Category	Description
Corporate Information	Displays demographic information currently on file for the Registry, such as Company Name, Address, and Telephone Number.
Training	Type of training provided to EPs and Registry staff.
Data Handling	Processes for data collection and submission.
Quality Assurance	Validation and verification steps completed prior to data submission.
eRx	Processes for collecting and submitting eRx data.
Feedback	User feedback about specific components of the Program. Free-form text and file uploads are permitted.

Table 1: Question Categories

The following section(s) provide samples of questions, by category, that are currently used in the survey. Where necessary, questions may be customized for a particular reporting option (e.g., Registry, Claims, EHR Direct, etc.)

Category: Training

Question #	Question
T1	What type of education do you provide to Eligible Professionals (EPs) on the clinical measure specifications?
T2	What support do you provide to your EPs to select the appropriate measures for data submission to CMS? Check all that apply.
T3	What type of training do you provide to Registry staff on the clinical measure specifications?
T4	If your staff encounters issues with interpreting the clinical measures specification, please describe how you remedy the issue.
T5	If you completed research and you are still not able to resolve a question about a particular clinical measure specification, what do you do?
T6	Do you provide training or other communication(s) to EPs regarding the requirement that the Reporting Rate must be >= 80%?
T7	If you provide training or other communication(s) to EPs regarding the requirement that the Reporting Rate must be >= 80%, then please describe the training/communication method.
T8	Do you provide training or other communication(s) to EPs that explains the requirement that they must have Medicare Part B PFS Charges to participate in the PQRS program?
T9	Do you provide training or other communication(s) to EPs that explains that they must have 25 unique denominator eligible cases to report eRx?

Category: Data Handling

Question #	Question
DH2	What external source does your Registry use to validate the TIN/NPI combination?
DH3	Does your Registry have a process to validate that there are Medicare Part B PFS charges for the TIN/NPI combination you are submitting?
DH9	Please describe the method your Registry used to calculate the Reporting Rate.
DH10	Please describe the method your Registry used to calculate the Performance Rate.
DH11	Please describe how the error occurred where the Numerator > Denominator for some EPs.
DH12	Prior to collecting measures from EP's do you validate that the measures are still active (e.g. not retired)?
DH13	Please describe the method your Registry used to calculate the Measure Group Reporting Rate?
DH14	Please describe any data validation checks your registry does to ensure that EPs do not have any measures with Performance Rate that are zero?
DH15	Did you review the 2012 Registry Data Issues Report for your organization?
DH16	If yes, please describe how you used the information in that report and/or any limitations to the information provided in the report?

Category: Quality Assurance

Question #	Question
QA7	Does your Registry do any benchmark comparisons with EP submissions on their performance rate?
QA8	Does your Registry do any benchmark comparisons with EP submissions on the number of exclusions reported when applicable?
QA9	Please describe the method your Registry used to validate the Performance Rate.
QA10	Are EPs able to view his/her Performance Rate in your data collection tool?
QA11	Does your data collection tool have automated warnings that pop up during the data collection process if the Numerator > Denominator?
QA12	Does your data collection tool have automated warnings that pop up during the data collection process if the Measure Group Denominators are not equal to the Individual Measures Denominators?
QA13	Does your data collection tool have automated warnings that pop up during the data collection process if there are Measures missing from the Measure Groups?
QA14	Does your data collection tool have automated warnings that pop up during the data collection process if the Measure Group Reporting Rate is not calculated correctly?
QA15	Does your data collection tool have automated warnings that pop up during the data collection process if there are not 25 unique denominator eligible cases when reporting eRx?
QA16	Does your data collection tool have automated warnings that pop up during the data collection process if the Performance Rate is not greater than zero percent?
QA17	Is there a check that is built into your data collection tool that validates that the Reporting Rate is >= 80%?

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