Practice Scenario: Test

Pick Your Pace

Practice Scenario: Test

Pick Your Pace Practice Scenario #1: Test

Dr. Jones is a family physician in a small practice and has never reported to the Physician Quality Reporting System (PQRS) or the Medicare and Medicaid Electronic Health Records (EHR Incentive Program (also called Meaningful Use). He does not have an EHR, but he wants to start participating in Medicare's Quality Payment Program (QPP) because he realizes he can’t afford the automatic negative adjustments if he does not report. He’s heard it should be easy to avoid the 2019 QPP negative payment adjustments by doing minimal reporting under one of the Pick Your Pace options in 2017. How should he begin participating in QPP?


Dr. Jones can avoid a 2019 negative adjustment by reporting as little as one measure for one patient in the quality category of the Merit-based Incentive Payment System (MIPS). Since he does not have an EHR, the most inexpensive way to report a quality measure will be through claims-based reporting. When reporting through claims, only Medicare Part B professional fee-for-service patients are reported (excludes Medicare Advantage and private payers). Dr. Jones follows these steps:

1. Dr. Jones goes to the QPP website’s list of 2017 quality measures( He filters the list by “Data Submission Method” and selects “Claims” from the drop down list. (See the screenshot below.)

He selects the quality measure “Controlling High Blood Pressure”(8 page PDF) from the list and clicks on the title to find the quality identification number (Quality ID: 236). (See the screenshot below.)

Dr. Jones downloads the measure specifications for measure #236, found in the “Quality Measures Specifications” file on the QPP Educational Resources( ­webpage. (See the screenshot below.)

2. Dr. Jones reads the measure specifications to thoroughly understand the instructions for reporting. He can use the measure flowchart as a decision tool.

a. This measure is to be reported a minimum of once per performance period for patients with hypertension seen during the performance period.

b. The “DENOMINATOR” instructs that the measure is to be reported for patients who are 18-85 years of age with hypertension that was present within the first six months of the measurement period or any time prior to the measurement period.

c. The “NUMERATOR” for this measure includes patients whose blood pressure at the most recent visit is adequately controlled (i.e., systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period. There are different quality data codes (QDC) that should be used, depending on the specific circumstances of each patient and exclusions. QDCs are CPT II or Level II G codes designed specifically for quality reporting.

3. Dr. Jones proceeds with seeing patients. During the day, a patient named Julie comes in for a visit. Julie has had hypertension for several years. She is 67 years old and enrolled in Medicare Part B. Therefore, Julie is eligible for the quality measure. The nurse flags Julie’s chart so Dr. Jones realizes this patient should be reported for QPP.

4. The nurse takes Julie’s blood pressure, which is 130/80. After the visit, the claim is prepared as usual. Hypertension, along with any other diagnoses, are recorded, and the evaluation and management (E&M) codes are added to the claim. In addition, the QDCs must be added prior to submitting the claim. Claims cannot be resubmitted to add QDC codes if they were omitted on the original claim.

a. Dr. Jones uses the measure flowchart to help him determine which QDCs should be reported. He follows the logic and adds QDC G8752 since Julie’s systolic blood pressure is less than 140 and QDC G8754 since her diastolic blood pressure is less than 90.

b. The claim is submitted as usual.


Reporting at least one measure will protect Dr. Jones from the 2019 negative payment adjustment. Reporting additional measures will help increase his practice’s score in the quality performance category. Dr. Jones can report more than six measures. However, the six with the highest performance are the ones that count towards his quality category score. The more quality measures he reports that meet the data completeness criteria, the higher his score will be, and the higher his potential for a positive payment adjustment.

Each quality measure submitted will receive a baseline of three points. Measures reported for a continuous 90 days, with at least 20 patients, that include 50% of the denominator-eligible patients will be scored on performance. Performance will be compared to a benchmark and awarded 3 to 10 points. Download the 2017 quality measure benchmarks »(

Earning Additional Points

Dr. Jones could improve his MIPS final score by reporting measures and earning points in the improvement activities (IA) or advancing care information (ACI) performance categories. Each of these categories has specific requirements.

  • To earn points in the IA category, Dr. Smith must attest to having performed at least one activity for a minimum of 90 days in 2017. Please see the QPP Improvement Activities( webpage for a list of improvement activities.
  • If Dr. Jones chooses to invest in an EHR, he must attest to at least the four required ACI measures in 2017 to earn points in the ACI category. Additional points can be earned for a high performance on ACI required and optional measures. Please see the QPP Advancing Care Information( webpage for a list of ACI measures.

Since Dr. Smith doesn’t have an EHR, he isn’t eligible to earn points under ACI, but could attest to performing one or more IAs for a minimum of 90 days. Please refer to the QPP Improvement Activities( webpage for a list of IAs.

Other Reporting Options

Instead of submitting using claims, Dr. Jones could choose to use a qualified registry. However, there will likely be a charge associated with the use of a registry. CMS will publish a list of qualified registries later in 2017. Following the close of calendar year 2017, data will be submitted only once for the entire year when using a registry. With claims-based reporting, Dr. Jones needs to submit data for at least one measure, for at least one patient, to avoid the 2019 negative payment adjustment.

Preparing for the Future

Claims-based reporting can be tedious and prone to error when used to report six measures. Some billing software offers assistance with quality reporting under claims, so Dr. Jones should check with his practice’s vendor to see if such assistance is available.

Without an EHR, he is limited in the options available for reporting. Other possibilities include using a qualified registry or a qualified clinical data registry (QCDR). Although, most QCDRs do require an EHR. Using a registry may better prepare Dr. Jones for full participation in QPP and success in the future.