DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Parts 403, 405, 410, 414, 425, and 498 

[CMS-1612-P] 

RIN 0938-AS12 

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, 

Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare 

and Medicaid Innovation Models & Other Revisions to Part B for CY 2015. 

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed Rule. 

SUMMARY: This major proposed rule addresses changes to the physician fee schedule, and 

other Medicare Part B payment policies to ensure that our payment systems are updated to reflect 

changes in medical practice and the relative value of services, as well as changes in the statute. 

See the Table of Contents for a listing of the specific issues addressed in this proposed rule. 

DATES: Comment date: To be assured consideration, comments must be received at one of the 

addresses provided below, no later than 5 p.m. on September 2, 2014. 

ADDRESSES: In commenting, please refer to file code CMS-1612-P. Because of staff and 

resource limitations, we cannot accept comments by facsimile (FAX) transmission. 

 You may submit comments in one of four ways (please choose only one of the ways 

listed): 

1. Electronically. You may submit electronic comments on this regulation to 

www.regulations.gov. Follow the instructions for "submitting a comment." 

 2. By regular mail. You may mail written comments to the following address ONLY: 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 
 2 

Attention: CMS-1612-P, 

P.O. Box 8013, 

Baltimore, MD 21244-8013. 

Please allow sufficient time for mailed comments to be received before the close of the 

comment period. 

3. By express or overnight mail. You may send written comments to the following 

address ONLY: 

 Centers for Medicare & Medicaid Services, 

 Department of Health and Human Services, 

 Attention: CMS-1612-P, 

 Mail Stop C4-26-05, 

 7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your 

written comments before the close of the comment period to either of the following addresses: 

a. For delivery in Washington, DC-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Room 445-G, Hubert H. Humphrey Building, 

 200 Independence Avenue, SW., 

 Washington, DC 20201 

(Because access to the interior of the Hubert H. Humphrey Building is not readily 

available to persons without federal government identification, commenters are encouraged to 

leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-
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in clock is available for persons wishing to retain a proof of filing by stamping in and retaining 

an extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

If you intend to deliver your comments to the Baltimore address, please call telephone 

number (410) 786-7195 in advance to schedule your arrival with one of our staff members. 

 Comments mailed to the addresses indicated as appropriate for hand or courier delivery 

may be delayed and received after the comment period.

FOR FURTHER INFORMATION CONTACT: 

Gail Addis, (410) 786-4552, for issues related to the refinement panel or for any 

physician payment issues not identified below. 

Chava Sheffield, (410) 786–2298, for issues related to practice expense methodology, 

impacts, the sustainable growth rate, conscious sedation, or conversion factors. 

Kathy Kersell, (410) 786–2033, for issues related to direct practice expense inputs. 

Jessica Bruton, (410) 786-5991, for issues related to potentially misvalued services or 

work RVUs. 

Craig Dobyski, (410) 786–4584, for issues related to geographic practice cost indices or 

malpractice RVUs. 

Ken Marsalek, (410) 786–4502, for issues related to telehealth services. 

Pam West, (410) 786-2302, for issues related to conditions for therapists in private 

practice. 

Marianne Myers, (410) 786-5962, for issues related to ambulance extender provisions. 
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Amy Gruber, (410) 786-1542, for issues related to changes in geographic area 

designations for ambulance payment. 

Anne Tayloe-Hauswald, (410) 786–4546, for issues related to clinical lab fee schedule. 

Corinne Axelrod, (410) 786–5620, for issues related to Rural Health Clinics or Federally 

Qualified Health Centers. 

Renee Mentnech, (410) 786-6692, for issues related to access to identifiable data for the 

Centers for Medicare & Medicaid models. 

Marie Casey, (410) 786–7861, for issues related to local determination process for 

clinical diagnostic laboratory tests. 

Frederick Grabau, (410) 786-0206, for issues related to private contracting/opt -out. 

David Walczak, (410) 786-4475, for issues related to payment policy for substitute 

physician billing arrangements (locum tenens). 

Melissa Heesters, (410) 786-0618, for issues related to reports of payments or other 

transfers of value to covered recipients. 

Rashaan Byers, (410) 786–2305, for issues related to physician compare. 

Christine Estella, (410) 786–0485, for issues related to the physician quality reporting 

system. 

Alexandra Mugge (410) 786-4457, for issues related to EHR incentive program. 

Patrice Holtz, (410)786–5663, for issues related to comprehensive primary care initiative. 

Terri Postma, (410) 786-4169, for issues related to Medicare Shared Savings Program. 

Kimberly Spalding Bush, (410) 786–3232, for issues related to value-based modifier and 

improvements to physician feedback. 

SUPPLEMENTARY INFORMATION: 

 Inspection of Public Comments: All comments received before the close of the comment 

period are available for viewing by the public, including any personally identifiable or 
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confidential business information that is included in a comment. We post all comments received 

before the close of the comment period on the following website as soon as possible after they 

have been received: http://www.regulations.gov. Follow the search instructions on that website 

to view public comments. 

 Comments received timely will also be available for public inspection as they are 

received, generally beginning approximately 3 weeks after publication of a document, at the 

headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To 

schedule an appointment to view public comments, phone 1-800-743-3951. 

Table of Contents 

I. Executive Summary and Background 

A. Executive Summary 

B. Background 

C. Health Information Technology 

II. Provisions of the Proposed Rule for PFS 

A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs) 

B. Potentially Misvalued Services Under the Physician Fee Schedule 

C. Malpractice Relative Value Units (RVUs) 

D. Geographic Practice Cost Indices (GPCIs) 

E. Medicare Telehealth Services 

F. Valuing New, Revised and Potentially Misvalued Codes 

G. Chronic Care Management (CCM) 

H. Definition of Colorectal Cancer Screening Tests 

I. Payment of Secondary Interpretation of Images 

J. Conditions Regarding Permissible Practice Types for Therapists in Private Practice 
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K. Payments for Physicians and Practitioners Managing Patients on Home Dialysis 

III. Other Provisions of the Proposed Regulations 

A. Ambulance Extender Provisions 

B. Changes in Geographic Area Delineations for Ambulance Payment 

C. Clinical Laboratory Fee Schedule 

D. Removal of Employment Requirements for Services Furnished “Incident to” Rural 

Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Visits

E. Access to Identifiable Data for the Center for Medicare and Medicaid Models 

F. Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests 

G. Private Contracting/Opt-out 

H. Solicitation of Comments on the Payment Policy for Substitute Physician Billing 

Arrangements 

I. Reports of Payments or Other Transfers of Value to Covered Recipients 

J. Physician Compare Website 

K. Physician Payment, Efficiency, and Quality Improvements – Physician Quality 

Reporting System 

L. Electronic Health Record (EHR) Incentive Program 

M. Medicare Shared Savings Program 

N. Value-Based Payment Modifier and Physician Feedback Program 

IV. Collection of Information Requirements 

V. Response to Comments 

VI. Regulatory Impact Analysis 

Regulations Text 

Acronyms 
 7 

 In addition, because of the many organizations and terms to which we refer by acronym 

in this proposed rule, we are listing these acronyms and their corresponding terms in alphabetical 

order below: 

AAA Abdominal aortic aneurysms 

ACO Accountable care organization 

AMA American Medical Association 

ASC Ambulatory surgical center 

ATA American Telehealth Association 

ATRA American Taxpayer Relief Act (Pub. L. 112-240) 

BBA Balanced Budget Act of 1997 (Pub. L. 105-33) 

BBRA [Medicare, Medicaid and State Child Health Insurance Program] Balanced Budget 

Refinement Act of 1999 (Pub. L. 106-113) 

CAD Coronary artery disease 

CAH Critical access hospital 

CBSA Core-Based Statistical Area 

CCM Chronic care management 

CEHRT Certified EHR technology 

CF Conversion factor 

CG-CAHPS Clinician and Group Consumer Assessment of Healthcare Providers and Systems 

CLFS Clinical Laboratory Fee Schedule 

CNM Certified nurse-midwife 

CP Clinical psychologist 

CPC Comprehensive Primary Care 

CPEP Clinical Practice Expert Panel 
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CPT [Physicians] Current Procedural Terminology (CPT codes, descriptions and other 

data only are copyright 2013 American Medical Association. All rights reserved.) 

CQM Clinical quality measure 

CSW Clinical social worker 

CT Computed tomography 

CY Calendar year 

DFAR Defense Federal Acquisition Regulations 

DHS Designated health services 

DM Diabetes mellitus 

DSMT Diabetes self-management training 

eCQM Electronic clinical quality measures 

EHR Electronic health record 

E/M Evaluation and management 

EP Eligible professional 

eRx Electronic prescribing 

ESRD End-stage renal disease 

FAR Federal Acquisition Regulations 

FFS Fee-for-service 

FQHC Federally qualified health center 

FR Federal Register 

GAF Geographic adjustment factor 

GAO Government Accountability Office

GPCI Geographic practice cost index 

GPO Group purchasing organization 

GPRO Group practice reporting option 
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GTR Genetic Testing Registry 

HCPCS Healthcare Common Procedure Coding System 

HHS [Department of] Health and Human Services 

HOPD Hospital outpatient department 

HPSA Health professional shortage area 

IDTF Independent diagnostic testing facility 

IPPS Inpatient Prospective Payment System 

IQR Inpatient Quality Reporting 

ISO Insurance service office 

IWPUT Intensity of work per unit of time 

LCD Local coverage determination 

MA Medicare Advantage 

MAC Medicare Administrative Contractor 

MAP Measure Applications Partnership 

MAPCP Multi-payer Advanced Primary Care Practice 

MAV Measure application validity [process] 

MCP Monthly capitation payment 

MedPAC Medicare Payment Advisory Commission 

MEI Medicare Economic Index 

MFP Multi-Factor Productivity 

MIPPA Medicare Improvements for Patients and Providers Act (Pub. L. 110-275) 

MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003 

(Pub. L. 108-173, enacted on December 8, 2003) 

MP Malpractice 

MPPR Multiple procedure payment reduction 
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MRA Magnetic resonance angiography 

MRI Magnetic resonance imaging 

MSA Metropolitan Statistical Areas 

MSPB Medicare Spending per Beneficiary 

MSSP Medicare Shared Savings Program 

MU Meaningful use 

NCD National coverage determination 

NCQDIS National Coalition of Quality Diagnostic Imaging Services 

NP Nurse practitioner 

NPI National Provider Identifier 

NPP Nonphysician practitioner 

NQS National Quality Strategy 

OACT CMS’s Office of the Actuary 

OBRA ‘89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) 

OBRA ’90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101- 508) 

OES Occupational Employment Statistics 

OMB Office of Management and Budget 

OPPS Outpatient prospective payment system 

OT Occupational therapy 

PA Physician assistant 

PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113-93) 

PC Professional component 

PCIP Primary Care Incentive Payment 

PE Practice expense 

PE/HR Practice expense per hour 
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PEAC Practice Expense Advisory Committee 

PECOS Provider Enrollment, Chain, and Ownership System 

PFS Physician Fee Schedule 

PLI Professional Liability Insurance 

PMA Premarket approval 

PQRS Physician Quality Reporting System 

PPIS Physician Practice Expense Information Survey 

PT Physical therapy 

PY Performance year 

QCDR Qualified clinical data registry 

QRUR Quality and Resources Use Report 

RBRVS Resource-based relative value scale 

RFA Regulatory Flexibility Act 

RHC Rural health clinic 

RIA Regulatory impact analysis 

RUC American Medical Association/Specialty Society Relative (Value) Update 

Committee 

RUCA Rural Urban Commuting Area 

RVU Relative value unit 

SBA Small Business Administration 

SGR Sustainable growth rate 

SIM State Innovation Model 

SLP Speech-language pathology 

SMS Socioeconomic Monitoring System 

SNF Skilled nursing facility 
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TAP Technical Advisory Panel 

TC Technical component 

TIN Tax identification number 

UAF Update adjustment factor 

UPIN Unique Physician Identification Number 

USPSTF United States Preventive Services Task Force 

VBP Value-based purchasing 

VM Value-Based Payment Modifier 

Addenda Available Only Through the Internet on the CMS Website 

The PFS Addenda along with other supporting documents and tables referenced in this 

proposed rule are available through the Internet on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. Click on the link on the left side of the screen titled, ‘‘PFS 

Federal Regulations Notices’’ for a chronological list of PFS Federal Register and other related 

documents. For the CY 2015 PFS proposed rule, refer to item CMS–1612–P. Readers who 

experience any problems accessing any of the Addenda or other documents referenced in this 

proposed rule and posted on the CMS website identified above should contact 

Larry.Chan@cms.hhs.gov. 

CPT (Current Procedural Terminology) Copyright Notice 

 Throughout this proposed rule, we use CPT codes and descriptions to refer to a variety of 

services. We note that CPT codes and descriptions are copyright 2013 American Medical 

Association. All Rights Reserved. CPT is a registered trademark of the American Medical 

Association (AMA). Applicable Federal Acquisition Regulations (FAR) and Defense Federal 

Acquisition Regulations (DFAR) apply. 

I. Executive Summary and Background 
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A. Executive Summary 

1. Purpose 

 This major proposed rule would revise payment polices under the Medicare Physician 

Fee Schedule (PFS) and make other policy changes related to Medicare Part B payment. These 

changes would be applicable to services furnished in CY 2015. 

2. Summary of the Major Provisions 

The Social Security Act (the Act) requires us to establish payments under the PFS based 

on national uniform relative value units (RVUs) that account for the relative resources used in 

furnishing a service. The Act requires that RVUs be established for three categories of 

resources: work, practice expense (PE); and malpractice (MP) expense; and, that we establish by 

regulation each year’s payment amounts for all physicians’ services, incorporating geographic 

adjustments to reflect the variations in the costs of furnishing services in different geographic 

areas. In this major proposed rule, we propose RVUs for CY 2015 for the PFS, and other 

Medicare Part B payment policies, to ensure that our payment systems are updated to reflect 

changes in medical practice and the relative value of services, as well as changes in the 

statute. In addition, this proposed rule includes discussions and proposals regarding: 

● Misvalued PFS Codes. 

● Telehealth Services. 

● Chronic Care Management Services. 

● Establishing Values for New, Revised, and Misvalued Codes. 

● Updating the Ambulance Fee Schedule regulations. 

● Changes to Core-Based Statistical Areas for Ambulance Payment. 

● Updating the- 

++ Physician Compare Website. 

++ Physician Quality Reporting System. 
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++ Medicare Shared Savings Program. 

++ Electronic Health Record (EHR) Incentive Program. 

● Value-Based Payment Modifier and the Physician Feedback Program. 

3. Summary of Costs and Benefits 

 The Act requires that annual adjustments to PFS RVUs not cause annual estimated 

expenditures to differ by more than $20 million from what they would have been had the 

adjustments not been made. If adjustments to RVUs would cause expenditures to change by 

more than $20 million, we must make adjustments to preserve budget neutrality. These 

adjustments can affect the distribution of Medicare expenditures across specialties. In addition, 

several proposed changes would affect the specialty distribution of Medicare expenditures. 

When considering the combined impact of work, PE, and MP RVU changes, the projected 

payment impacts are small for most specialties; however, the impact would be larger for a few 

specialties. The most significant impacts are for radiation therapy centers and radiation oncology 

for which there would be decreases of 8 and 4 percent, respectively. These reductions primarily 

stem from a proposal discussed in section II.A. to consider an equipment item as indirect rather 

than direct practice expense. Payment for chronic care management (CCM) services is projected 

to have a positive effect on family practice, internal medicine, and geriatrics. This proposed rule 

includes new proposed MP RVUs based upon CY 2015 five-year review of MP RVUs. For most 

specialties, the proposed revisions for the five-year review of MP RVUs would result in minor 

overall changes in RVUs, with only ophthalmology (-2 percent) having a projected change of at 

least 2 percent. 

B. Background 

Since January 1, 1992, Medicare has paid for physicians’ services under section 1848 of 

the Act, “Payment for Physicians' Services.” The system relies on national relative values that 

are established for work, PE, and MP, which are adjusted for geographic cost variations. These 
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values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. The 

concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget 

Reconciliation Act of 1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA ’89), and 

the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on November 5, 

1990) (OBRA ’90). The final rule published on November 25, 1991 (56 FR 59502) set forth the 

first fee schedule used for payment for physicians’ services. 

 We note that throughout this proposed rule, unless otherwise noted, the term 

“practitioner” is used to describe both physicians and nonphysician practitioners (NPPs) who are 

permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries. 

1. Development of the Relative Values 

a. Work RVUs 

The work RVUs established for the initial fee schedule, which was implemented on 

January 1, 1992, were developed with extensive input from the physician community. A 

research team at the Harvard School of Public Health developed the original work RVUs for 

most codes under a cooperative agreement with the Department of Health and Human Services 

(HHS). In constructing the code-specific vignettes used in determining the original physician 

work RVUs, Harvard worked with panels of experts, both inside and outside the federal 

government, and obtained input from numerous physician specialty groups. 

 As specified in section 1848(c)(1)(A) of the Act, the work component of physicians’ 

services means the portion of the resources used in furnishing the service that reflects physician 

time and intensity. We establish work RVUs for new, revised and potentially misvalued codes 

based on our review of information that generally includes, but is not limited to, 

recommendations received from the American Medical Association/Specialty Society Relative 

Value Update Committee (RUC), the Health Care Professionals Advisory Committee (HCPAC), 

the Medicare Payment Advisory Commission (MedPAC), and other public commenters; medical 
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literature and comparative databases; as well as a comparison of the work for other codes within 

the Medicare PFS, and consultation with other physicians and health care professionals within 

CMS and the federal government. We also assess the methodology and data used to develop the 

recommendations submitted to us by the RUC and other public commenters, and the rationale for 

their recommendations. 

b. Practice Expense RVUs 

Initially, only the work RVUs were resource-based, and the PE and MP RVUs were 

based on average allowable charges. Section 121 of the Social Security Act Amendments 

of 1994 (Pub. L. 103-432, enacted on October 31, 1994), amended section 1848(c)(2)(C)(ii) of 

the Act and required us to develop resource-based PE RVUs for each physicians’ service 

beginning in 1998. We were required to consider general categories of expenses (such as office 

rent and wages of personnel, but excluding malpractice expenses) comprising PEs. The PE 

RVUs continue to represent the portion of these resources involved in furnishing PFS services. 

Originally, the resource-based method was to be used beginning in 1998, but section 

4505(a) of the Balanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) (BBA) 

delayed implementation of the resource-based PE RVU system until January 1, 1999. In 

addition, section 4505(b) of the BBA provided for a 4-year transition period from the 

charge-based PE RVUs to the resource-based PE RVUs. 

We established the resource-based PE RVUs for each physicians’ service in a final rule, 

published on November 2, 1998 (63 FR 58814), effective for services furnished in CY 1999. 

Based on the requirement to transition to a resource-based system for PE over a 4-year period, 

payment rates were not fully based upon resource-based PE RVUs until CY 2002. This 

resource-based system was based on two significant sources of actual PE data: the Clinical 

Practice Expert Panel (CPEP) data and the AMA’s Socioeconomic Monitoring System (SMS) 
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data. (These data sources are described in greater detail in the CY 2012 final rule with comment 

period (76 FR 73033).) 

Separate PE RVUs are established for services furnished in facility settings, such as a 

hospital outpatient department (HOPD) or an ambulatory surgical center (ASC), and in 

nonfacility settings, such as a physician’s office. The nonfacility RVUs reflect all of the direct 

and indirect PEs involved in furnishing a service described by a particular HCPCS code. The 

difference, if any, in these PE RVUs generally results in a higher payment in the nonfacility 

setting because in the facility settings some costs are borne by the facility. Medicare’s payment 

to the facility (such as the outpatient prospective payment system (OPPS) payment to the HOPD) 

would reflect costs typically incurred by the facility. Thus, payment associated with those 

facility resources is not made under the PFS. 

Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113, enacted 

on November 29, 1999) (BBRA) directed the Secretary of Health and Human Services (the 

Secretary) to establish a process under which we accept and use, to the maximum extent 

practicable and consistent with sound data practices, data collected or developed by entities and 

organizations to supplement the data we normally collect in determining the PE component. On 

May 3, 2000, we published the interim final rule (65 FR 25664) that set forth the criteria for the 

submission of these supplemental PE survey data. The criteria were modified in response to 

comments received, and published in the Federal Register (65 FR 65376) as part of a 

November 1, 2000 final rule. The PFS final rules published in 2001 and 2003, respectively, 

(66 FR 55246 and 68 FR 63196) extended the period during which we would accept these 

supplemental data through March 1, 2005. 

In the CY 2007 PFS final rule with comment period (71 FR 69624), we revised the 

methodology for calculating direct PE RVUs from the top-down to the bottom-up methodology 

beginning in CY 2007. We adopted a 4-year transition to the new PE RVUs. This transition was 
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completed for CY 2010. In the CY 2010 PFS final rule with comment period, we updated the 

practice expense per hour (PE/HR) data that are used in the calculation of PE RVUs for most 

specialties (74 FR 61749). In CY 2010, we began a 4-year transition to the new PE RVUs using 

the updated PE/HR data, which was completed for CY 2013. 

c. Malpractice RVUs 

Section 4505(f) of the BBA amended section 1848(c) of the Act to require that we 

implement resource-based MP RVUs for services furnished on or after CY 2000. The 

resource-based MP RVUs were implemented in the PFS final rule with comment period 

published November 2, 1999 (64 FR 59380). The MP RVUs are based on commercial and 

physician-owned insurers’ malpractice insurance premium data from all the states, the District of 

Columbia, and Puerto Rico. For more information on MP RVUs, see section II.C. of this 

proposed rule. 

d. Refinements to the RVUs 

Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than 

every 5 years. Prior to CY 2013, we conducted periodic reviews of work RVUs and PE RVUs 

independently. We completed five-year reviews of work RVUs that were effective for calendar 

years 1997, 2002, 2007, and 2012. 

Although refinements to the direct PE inputs initially relied heavily on input from the 

RUC Practice Expense Advisory Committee (PEAC), the shifts to the bottom-up PE 

methodology in CY 2007 and to the use of the updated PE/HR data in CY 2010 have resulted in 

significant refinements to the PE RVUs in recent years. 

In the CY 2012 PFS final rule with comment period (76 FR 73057), we finalized a 

proposal to consolidate reviews of work and PE RVUs under section 1848(c)(2)(B) of the Act 

and reviews of potentially misvalued codes under section 1848(c)(2)(K) of the Act into one 

annual process. 
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With regard to MP RVUs, we completed five-year reviews of MP that were effective in 

CY 2005 and CY 2010. This proposed rule includes a proposal for a five-year review for CY 

2015. 

In addition to the five-year reviews, beginning for CY 2009, CMS and the RUC have 

identified and reviewed a number of potentially misvalued codes on an annual basis based on 

various identification screens. This annual review of work and PE RVUs for potentially 

misvalued codes was supplemented by the amendments to section 1848 of the Act, as enacted by 

section 3134 of the Affordable Care Act, which requires the agency to periodically identify, 

review and adjust values for potentially misvalued codes. 

e. Application of Budget Neutrality to Adjustments of RVUs 

 As described in section VI.C.1. of this proposed rule, in accordance with section 

1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs would cause expenditures for the year 

to change by more than $20 million, we make adjustments to ensure that expenditures do not 

increase or decrease by more than $20 million. 

2. Calculation of Payments Based on RVUs 

To calculate the payment for each physicians’ service, the components of the fee 

schedule (work, PE, and MP RVUs) are adjusted by geographic practice cost indices (GPCIs) to 

reflect the variations in the costs of furnishing the services. The GPCIs reflect the relative costs 

of physician work, PE, and MP in an area compared to the national average costs for each 

component. (See section II.D of this proposed rule for more information about GPCIs.) 

RVUs are converted to dollar amounts through the application of a CF, which is 

calculated based on a statutory formula by CMS’s Office of the Actuary (OACT). The CF for a 

given year is calculated using (a) the productivity-adjusted increase in the Medicare Economic 

Index (MEI) and (b) the Update Adjustment Factor (UAF), which is calculated by taking into 

account the Medicare Sustainable Growth Rate (SGR), an annual growth rate intended to control 
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growth in aggregate Medicare expenditures for physicians’ services, and the allowed and actual 

expenditures for physicians’ services. The formula for calculating the Medicare fee schedule 

payment amount for a given service and fee schedule area can be expressed as: 

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI 

MP)] x CF. 

3. Separate Fee Schedule Methodology for Anesthesia Services 

Section 1848(b)(2)(B) of the Act specifies that the fee schedule amounts for anesthesia 

services are to be based on a uniform relative value guide, with appropriate adjustment of an 

anesthesia conversion factor, in a manner to assure that fee schedule amounts for anesthesia 

services are consistent with those for other services of comparable value. Therefore, there is a 

separate fee schedule methodology for anesthesia services. Specifically, we establish a separate 

conversion factor for anesthesia services and we utilize the uniform relative value guide, or base 

units, as well as time units, to calculate the fee schedule amounts for anesthesia services. Since 

anesthesia services are not valued using RVUs, a separate methodology for locality adjustments 

is also necessary. This involves an adjustment to the national anesthesia CF for each payment 

locality. 

4. Most Recent Changes to the Fee Schedule 

The CY 2014 PFS final rule with comment period (78 FR 74230) implemented changes 

to the PFS and other Medicare Part B payment policies. It also finalized many of the CY 2013 

interim final RVUs and established interim final RVUs for new and revised codes for CY 2014 

to ensure that our payment system is updated to reflect changes in medical practice, coding 

changes, and the relative values of services. It also implemented section 635 of the American 

Taxpayer Relief Act of 2012 (Pub. L. 112-240, enacted on January 2, 2013) (ATRA), which 

revised the equipment utilization rate assumption for advanced imaging services furnished on or 

after January 1, 2014. 
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Also, in the CY 2014 PFS final rule with comment period, we announced the following 

for CY 2014: the total PFS update of -20.1 percent; the initial estimate for the SGR of -

16.7 percent; and a CF of $27.2006. These figures were calculated based on the statutory 

provisions in effect on November 27, 2013, when the CY 2014 PFS final rule with comment 

period was issued. 

The Pathway for SGR Reform Act of 2013 (Pub. L. 113-67, enacted on December 26, 

2013) established a 0.5 percent update to the PFS CF through March 31, 2014 and the Protecting 

Access to Medicare Act of 2014 (Pub. L. 113-93, enacted on April 1, 2014) (PAMA) extended 

this 0.5 percent update through December 31, 2014. As a result, the CF for CY 2014 that was 

published in the CY 2014 final rule with comment period (78 FR 74230) was revised to 

$35.8228 for services furnished on or after January 1, 2014 and on or before December 31, 2014. 

The PAMA provides for a 0.0 percent update to the PFS for services furnished on or after 

January 1, 2015 and on or before March 31, 2015. 

The Pathway for SGR Reform Act extended through March 31, 2014 several provisions 

of Medicare law that would have otherwise expired on December 31, 2013. The PAMA 

extended these same provisions further through March 31, 2015. A list of these provisions 

follows. 

● The 1.0 floor on the work geographic practice cost index 

● The exceptions process for outpatient therapy caps 

● The manual medical review process for therapy services 

● The application of the therapy caps and related provisions to services furnished in 

HOPDs 

 In addition, section 220 of the PAMA included several provisions affecting the 

valuation process for services under the PFS. Section 220(a) of the PAMA amended section 

1848(c)(2) of the Act to add a new subparagraph (M). The new subparagraph (M) provides that 
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the Secretary may collect or obtain information from any eligible professional or any other 

source on the resources directly or indirectly related to furnishing services for which payment is 

made under the PFS, and that such information may be used in the determination of relative 

values for services under the PFS. Such information may include the time involved in furnishing 

services; the amounts, types and prices of practice expense inputs; overhead and accounting 

information for practices of physicians and other suppliers, and any other elements that would 

improve the valuation of services under the PFS. This information may be collected or obtained 

through surveys of physicians or other suppliers, providers of services, manufacturers and 

vendors; surgical logs, billing systems, or other practice or facility records; EHRs; and any other 

mechanism determined appropriate by the Secretary. If we use this information, we are required 

to disclose the source and use of the information in rulemaking, and to make available 

aggregated information that does not disclose individual eligible professionals, group practices, 

or information obtained pursuant to a nondisclosure agreement. Beginning with fiscal year 2014, 

the Secretary may compensate eligible professionals for submission of data. 

Section 220(c) of the PAMA amended section 1848(c)(2)(K)(ii) of the Act to expand the 

categories of services that the Secretary is directed to examine for the purpose of identifying 

potentially misvalued codes. The nine new categories are as follows: 

• Codes that account for the majority of spending under the PFS. 

• Codes for services that have experienced a substantial change in the hospital length of 

stay or procedure time. 

• Codes for which there may be a change in the typical site of service since the code was 

last valued. 

• Codes for which there is a significant difference in payment for the same service 

between different sites of service. 
 23 

• Codes for which there may be anomalies in relative values within a family of codes. 

• Codes for services where there may be efficiencies when a service is furnished at the 

same time as other services. 

• Codes with high intra-service work per unit of time. 

• Codes with high PE RVUs. 

• Codes with high cost supplies. 

(See section II.B.2 of this final rule with comment period for more information about misvalued 

codes.). 

 Section 220(i) of the PAMA also requires the Secretary to make publicly available the 

information we considered when establishing the multiple procedure payment reduction (MPPR) 

policy for the professional component of advanced imaging procedures. The policy reduces the 

amount paid for the professional component when two advanced imaging procedures are 

furnished in the same session. The policy was effective for individual physicians on January 1, 

2012 and for physicians in the same group practice on January 1, 2013. 

In addition, section 220 of the PAMA includes other provisions regarding valuation of 

services under the PFS that take effect in future years. Section 220(d) of the PAMA establishes 

an annual target from CY 2017 through CY 2020 for reductions in PFS expenditures resulting 

from adjustments to relative values of misvalued services. The target is calculated as 0.5 percent 

of the estimated amount of expenditures under the fee schedule for the year. If the net reduction 

in expenditures for the year is equal to or greater than the target for the year, the funds shall be 

redistributed in a budget-neutral manner within the PFS. The amount by which such reduced 

expenditures exceed the target for the year shall be treated as a reduction in expenditures for the 

subsequent year, for purposes of determining whether the target has or has not been met. The 

legislation includes an exemption from budget neutrality if the target is not met. Other 

provisions of section 220 of the PAMA include a 2-year phase-in for reductions in RVUs of at 
 24 

least 20 percent for potentially misvalued codes that do not involve coding changes and certain 

adjustments to the fee schedule areas in California. These provisions will be addressed as we 

implement them in future rulemaking. 

On March 5, 2014, we submitted to MedPAC an estimate of the SGR and CF applicable 

to Medicare payments for physicians’ services for CY 2015, as required by section 1848(d)(1)(E) 

of the Act. The actual values used to compute physician payments for CY 2015 will be based on 

later data and are scheduled to be published by November 1, 2014, as part of the CY 2015 PFS 

final rule with comment period. 

C. Health Information Technology 

The Department of Health and Human Services (HHS) believes all patients, their 

families, and their health care providers should have consistent and timely access to their health 

information in a standardized format that can be securely exchanged between the patient, 

providers, and others involved in the patient’s care. (HHS August 2013 Statement, “Principles 

and Strategies for Accelerating Health Information Exchange,” see 

http://www.healthit.gov/sites/default/files/acceleratinghieprinciples_strategy.pdf) HHS is 

committed to accelerating health information exchange (HIE) through the use of electronic 

health records (EHRs) and other types of health information technology (HIT) across the broader 

care continuum through a number of initiatives including: (1) alignment of incentives and 

payment adjustments to encourage provider adoption and optimization of HIT and HIE services 

through Medicare and Medicaid payment policies; (2) adoption of common standards and 

certification requirements for interoperable HIT; (3) support for privacy and security of patient 

information across all HIE-focused initiatives; and (4) governance of health information 

networks. These initiatives are designed to encourage HIE among health care providers, 

including professionals and hospitals eligible for the Medicare and Medicaid EHR Incentive 

Programs and those who are not eligible for the EHR Incentive Programs, and are designed to 
 25 

improve care delivery and coordination across the entire care continuum. For example, the 

Transition of Care Measure #2 in Stage 2 of the Medicare and Medicaid EHR Incentive 

Programs requires HIE to share summary records for more than 10 percent of care transitions. In 

addition, to increase flexibility in ONC’s HIT Certification Program and expand HIT 

certification, ONC has issued a proposed rule concerning a voluntary 2015 Edition of EHR 

certification criteria, which would more easily accommodate the certification of HIT used in all 

health care settings where health care providers are not typically eligible for incentive payments 

under the EHR Incentive Programs, to facilitate greater HIE across the entire care continuum. 

We believe that HIE and the use of certified EHRs can effectively and efficiently help providers 

improve internal care delivery practices, support management of patient care across the 

continuum, and support the reporting of electronically specified clinical quality measures 

(eCQMs). More information on the Voluntary 2015 Edition EHR Certification Criteria proposed 

rule is available at http://healthit.gov/policy-researchers-implementers/standards-andcertification-regulations.

 
 26 

II. Provisions of the Proposed Rule for PFS 

A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs) 

1. Overview 

Practice expense (PE) is the portion of the resources used in furnishing a service 

that reflects the general categories of physician and practitioner expenses, such as office 

rent and personnel wages, but excluding MP expenses, as specified in section 

1848(c)(1)(B) of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a 

resource-based system for determining PE RVUs for each physician’s service. We 

develop PE RVUs by considering the direct and indirect practice resources involved in 

furnishing each service. Direct expense categories include clinical labor, medical 

supplies, and medical equipment. Indirect expenses include administrative labor, office 

expense, and all other expenses. The sections that follow provide more detailed 

information about the methodology for translating the resources involved in furnishing 

each service into service-specific PE RVUs. We refer readers to the CY 2010 PFS final 

rule with comment period (74 FR 61743 through 61748) for a more detailed explanation 

of the PE methodology. 

2. Practice Expense Methodology 

a. Direct Practice Expense 

 We determine the direct PE for a specific service by adding the costs of the direct 

resources (that is, the clinical staff, medical supplies, and medical equipment) typically involved 

with furnishing that service. The costs of the resources are calculated using the refined direct PE 

inputs assigned to each CPT code in our PE database, which are generally based on our review of 

recommendations received from the RUC and those provided in response to public comment 

periods. For a detailed explanation of the direct PE methodology, including examples, we refer 
 27 

readers to the Five-Year Review of Work Relative Value Units under the PFS and Proposed 

Changes to the Practice Expense Methodology proposed notice (71 FR 37242) and the CY 2007 

PFS final rule with comment period (71 FR 69629). 

b. Indirect Practice Expense per Hour Data 

 We use survey data on indirect PEs incurred per hour worked in developing the indirect 

portion of the PE RVUs. Prior to CY 2010, we primarily used the practice expense per hour 

(PE/HR) by specialty that was obtained from the AMA’s Socioeconomic Monitoring Surveys 

(SMS). The AMA administered a new survey in CY 2007 and CY 2008, the Physician Practice 

Expense Information Survey (PPIS). The PPIS is a multispecialty, nationally representative, PE 

survey of both physicians and nonphysician practitioners (NPPs) paid under the PFS using a 

survey instrument and methods highly consistent with those used for the SMS and the 

supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 

physician specialty and health care professional groups. We believe the PPIS is the most 

comprehensive source of PE survey information available. We used the PPIS data to update the 

PE/HR data for the CY 2010 PFS for almost all of the Medicare-recognized specialties that 

participated in the survey. 

 When we began using the PPIS data in CY 2010, we did not change the PE RVU 

methodology itself or the manner in which the PE/HR data are used in that methodology. We 

only updated the PE/HR data based on the new survey. Furthermore, as we explained in the 

CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnitude of 

payment reductions for some specialties resulting from the use of the PPIS data, we transitioned 

its use over a 4-year period from the previous PE RVUs to the PE RVUs developed using the 

new PPIS data. As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), 

the transition to the PPIS data was complete for CY 2013. Therefore, PE RVUs from CY 2013 
 28 

forward are developed based entirely on the PPIS data, except as noted in this section. 

 Section 1848(c)(2)(H)(i) of the Act requires us to use the medical oncology supplemental 

survey data submitted in 2003 for oncology drug administration services. Therefore, the PE/HR 

for medical oncology, hematology, and hematology/oncology reflects the continued use of these 

supplemental survey data. 

 Supplemental survey data on independent labs from the College of American 

Pathologists were implemented for payments beginning in CY 2005. Supplemental survey data 

from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), representing 

independent diagnostic testing facilities (IDTFs), were blended with supplementary survey data 

from the American College of Radiology (ACR) and implemented for payments beginning in 

CY 2007. Neither IDTFs, nor independent labs, participated in the PPIS. Therefore, we 

continue to use the PE/HR that was developed from their supplemental survey data. 

Consistent with our past practice, the previous indirect PE/HR values from the 

supplemental surveys for these specialties were updated to CY 2006 using the MEI to put them 

on a comparable basis with the PPIS data. 

 We also do not use the PPIS data for reproductive endocrinology and spine surgery since 

these specialties currently are not separately recognized by Medicare, nor do we have a method 

to blend the PPIS data with Medicare-recognized specialty data. 

Previously, we established PE/HR values for various specialties without SMS or 

supplemental survey data by crosswalking them to other similar specialties to estimate a proxy 

PE/HR. For specialties that were part of the PPIS for which we previously used a crosswalked 

PE/HR, we instead used the PPIS-based PE/HR. We continue previous crosswalks for 

specialties that did not participate in the PPIS. However, beginning in CY 2010 we changed the 

PE/HR crosswalk for portable x-ray suppliers from radiology to IDTF, a more appropriate 
 29 

crosswalk because these specialties are more similar to each other with respect to work time. 

 For registered dietician services, the resource-based PE RVUs have been calculated in 

accordance with the final policy that crosswalks the specialty to the “All Physicians” PE/HR 

data, as adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) and 

discussed in more detail in the CY 2011 PFS final rule with comment period (75 FR 73183). 

c. Allocation of PE to Services 

To establish PE RVUs for specific services, it is necessary to establish the direct 

and indirect PE associated with each service. 

(1) Direct Costs 

 The relative relationship between the direct cost portions of the PE RVUs for any 

two services is determined by the relative relationship between the sum of the direct cost 

resources (that is, the clinical staff, equipment, and supplies) typically involved with 

furnishing each of the services. The costs of these resources are calculated from the 

refined direct PE inputs in our PE database. For example, if one service has a direct cost 

sum of $400 from our PE database and another service has a direct cost sum of $200, the 

direct portion of the PE RVUs of the first service would be twice as much as the direct 

portion of the PE RVUs for the second service. 

(2) Indirect Costs 

 Section II.A.2.b. of this proposed rule describes the current data sources for 

specialty-specific indirect costs used in our PE calculations. We allocated the indirect 

costs to the code level on the basis of the direct costs specifically associated with a code 

and the greater of either the clinical labor costs or the physician work RVUs. We also 

incorporated the survey data described earlier in the PE/HR discussion. The general 

approach to developing the indirect portion of the PE RVUs is as follows: 
 30 

• For a given service, we use the direct portion of the PE RVUs calculated as 

previously described and the average percentage that direct costs represent of total costs 

(based on survey data) across the specialties that furnish the service to determine an 

initial indirect allocator. In other words, the initial indirect allocator is calculated so that 

the direct costs equal the average percentage of direct costs of those specialties furnishing 

the service. For example, if the direct portion of the PE RVUs for a given service is 2.00 

and direct costs, on average, represented 25 percent of total costs for the specialties that 

furnished the service, the initial indirect allocator would be calculated so that it equals 75 

percent of the total PE RVUs. Thus, in this example, the initial indirect allocator would 

equal 6.00, resulting in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75 

percent of 8.00). 

• Next, we add the greater of the work RVUs or clinical labor portion of the 

direct portion of the PE RVUs to this initial indirect allocator. In our example, if this 

service had work RVUs of 4.00 and the clinical labor portion of the direct PE RVUs was 

1.50, we would add 4.00 (since the 4.00 work RVUs are greater than the 1.50 clinical 

labor portion) to the initial indirect allocator of 6.00 to get an indirect allocator of 10.00. 

In the absence of any further use of the survey data, the relative relationship between the 

indirect cost portions of the PE RVUs for any two services would be determined by the 

relative relationship between these indirect cost allocators. For example, if one service 

had an indirect cost allocator of 10.00 and another service had an indirect cost allocator 

of 5.00, the indirect portion of the PE RVUs of the first service would be twice as great as 

the indirect portion of the PE RVUs for the second service. 

• Next, we incorporate the specialty-specific indirect PE/HR data into the 

calculation. In our example, if, based on the survey data, the average indirect cost of the 
 31 

specialties furnishing the first service with an allocator of 10.00 was half of the average 

indirect cost of the specialties furnishing the second service with an indirect allocator of 

5.00, the indirect portion of the PE RVUs of the first service would be equal to that of the 

second service. 

d. Facility and Nonfacility Costs 

For procedures that can be furnished in a physician’s office, as well as in a 

hospital or other facility setting, we establish two PE RVUs: facility and nonfacility. 

The methodology for calculating PE RVUs is the same for both the facility and 

nonfacility RVUs, but is applied independently to yield two separate PE RVUs. Because 

in calculating the PE RVUs for services furnished in a facility, we do not include 

resources that would generally not be provided by physicians when furnishing the service 

in a facility, the facility PE RVUs are generally lower than the nonfacility PE RVUs. 

Medicare makes a separate payment to the facility for its costs of furnishing a service. 

e. Services with Technical Components (TCs) and Professional Components (PCs) 

Diagnostic services are generally comprised of two components: a professional 

component (PC); and a technical component (TC). The PC and TC may be furnished 

independently or by different providers, or they may be furnished together as a “global” 

service. When services have separately billable PC and TC components, the payment for 

the global service equals the sum of the payment for the TC and PC. To achieve this we 

use a weighted average of the ratio of indirect to direct costs across all the specialties that 

furnish the global service, TCs, and PCs; that is, we apply the same weighted average 

indirect percentage factor to allocate indirect expenses to the global service, PCs, and 

TCs for a service. (The direct PE RVUs for the TC and PC sum to the global under the 

bottom-up methodology.) 
 32 

f. PE RVU Methodology 

For a more detailed description of the PE RVU methodology, we refer readers to 

the CY 2010 PFS final rule with comment period (74 FR 61745 through 61746). 

(1) Setup File 

First, we create a setup file for the PE methodology. The setup file contains the 

direct cost inputs, the utilization for each procedure code at the specialty and 

facility/nonfacility place of service level, and the specialty-specific PE/HR data 

calculated from the surveys. 

(2) Calculate the Direct Cost PE RVUs 

Sum the costs of each direct input. 

Step 1: Sum the direct costs of the inputs for each service. Apply a scaling 

adjustment to the direct inputs. 

Step 2: Calculate the aggregate pool of direct PE costs for the current year. This 

is the product of the current aggregate PE (direct and indirect) RVUs, the CF, and the 

average direct PE percentage from the survey data used for calculating the PE/HR by 

specialty. 

Step 3: Calculate the aggregate pool of direct PE costs for use in ratesetting. This 

is the product of the aggregated direct costs for all services from Step 1 and the utilization 

data for that service. 

Step 4: Using the results of Step 2 and Step 3, calculate a direct PE scaling 

adjustment to ensure that the aggregate pool of direct PE costs calculated in Step 3 does 

not vary from the aggregate pool of direct PE costs for the current year. Apply the 

scaling factor to the direct costs for each service (as calculated in Step 1). 

Step 5: Convert the results of Step 4 to an RVU scale for each service. To do 
 33 

this, divide the results of Step 4 by the CF. Note that the actual value of the CF used in 

this calculation does not influence the final direct cost PE RVUs, as long as the same CF 

is used in Step 2 and Step 5. Different CFs will result in different direct PE scaling 

factors, but this has no effect on the final direct cost PE RVUs since changes in the CFs 

and changes in the associated direct scaling factors offset one another. 

(3) Create the Indirect Cost PE RVUs 

Create indirect allocators. 

Step 6: Based on the survey data, calculate direct and indirect PE percentages for 

each physician specialty. 

Step 7: Calculate direct and indirect PE percentages at the service level by taking 

a weighted average of the results of Step 6 for the specialties that furnish the service. 

Note that for services with TCs and PCs, the direct and indirect percentages for a given 

service do not vary by the PC, TC, and global service. 

Step 8: Calculate the service level allocators for the indirect PEs based on 

the percentages calculated in Step 7. The indirect PEs are allocated based on the three 

components: the direct PE RVUs; the clinical PE RVUs; and the work RVUs. 

For most services the indirect allocator is: indirect PE percentage * (direct PE 

RVUs/direct percentage) + work RVUs. 

There are two situations where this formula is modified: 

• If the service is a global service (that is, a service with global, professional, and 

technical components), then the indirect PE allocator is: indirect percentage (direct 

PE RVUs/direct percentage) + clinical PE RVUs + work RVUs. 

• If the clinical labor PE RVUs exceed the work RVUs (and the service is not a 

global service), then the indirect allocator is: indirect PE percentage (direct 
 34 

PE RVUs/direct percentage) + clinical PE RVUs. 

(Note: For global services, the indirect PE allocator is based on both the work RVUs and 

the clinical labor PE RVUs. We do this to recognize that, for the PC service, indirect PEs 

will be allocated using the work RVUs, and for the TC service, indirect PEs will be 

allocated using the direct PE RVUs and the clinical labor PE RVUs. This also allows the 

global component RVUs to equal the sum of the PC and TC RVUs.) 

For presentation purposes in the examples in Table 1, the formulas were divided 

into two parts for each service. 

• The first part does not vary by service and is the indirect percentage (direct PE 

RVUs/direct percentage). 

• The second part is either the work RVU, clinical labor PE RVU, or both 

depending on whether the service is a global service and whether the clinical PE RVUs 

exceed the work RVUs (as described earlier in this step). 

Apply a scaling adjustment to the indirect allocators. 

Step 9: Calculate the current aggregate pool of indirect PE RVUs by multiplying 

the current aggregate pool of PE RVUs by the average indirect PE percentage from the 

survey data. 

Step 10: Calculate an aggregate pool of indirect PE RVUs for all PFS services by 

adding the product of the indirect PE allocators for a service from Step 8 and the 

utilization data for that service. 

Step 11: Using the results of Step 9 and Step 10, calculate an indirect PE 

adjustment so that the aggregate indirect allocation does not exceed the available 

aggregate indirect PE RVUs and apply it to indirect allocators calculated in Step 8. 

Calculate the indirect practice cost index. 
 35 

Step 12: Using the results of Step 11, calculate aggregate pools of 

specialty-specific adjusted indirect PE allocators for all PFS services for a specialty by 

adding the product of the adjusted indirect PE allocator for each service and the 

utilization data for that service. 

Step 13: Using the specialty-specific indirect PE/HR data, calculate 

specialty-specific aggregate pools of indirect PE for all PFS services for that specialty by 

adding the product of the indirect PE/HR for the specialty, the work time for the service, 

and the specialty’s utilization for the service across all services furnished by the specialty. 

Step 14: Using the results of Step 12 and Step 13, calculate the specialty-specific 

indirect PE scaling factors. 

Step 15: Using the results of Step 14, calculate an indirect practice cost index at 

the specialty level by dividing each specialty-specific indirect scaling factor by the 

average indirect scaling factor for the entire PFS. 

Step 16: Calculate the indirect practice cost index at the service level to ensure 

the capture of all indirect costs. Calculate a weighted average of the practice cost index 

values for the specialties that furnish the service. (Note: For services with TCs and PCs, 

we calculate the indirect practice cost index across the global service, PCs, and TCs. 

Under this method, the indirect practice cost index for a given service (for example, 

echocardiogram) does not vary by the PC, TC, and global service.) 

Step 17: Apply the service level indirect practice cost index calculated in Step 16 

to the service level adjusted indirect allocators calculated in Step 11 to get the indirect PE 

RVUs. 

(4) Calculate the Final PE RVUs 

Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs from 
 36 

Step 17 and apply the final PE budget neutrality (BN) adjustment. The final PE BN 

adjustment is calculated by comparing the results of Step 18 to the current pool of PE 

RVUs. This final BN adjustment is required to redistribute RVUs from step 18 to all PE 

RVUs in the PFS, and because certain specialties are excluded from the PE RVU 

calculation for ratesetting purposes, but we note that all specialties are included for 

purposes of calculating the final BN adjustment. (See “Specialties excluded from 

ratesetting calculation” later in this section.) 

(5) Setup File Information 

• Specialties excluded from ratesetting calculation: For the purposes of 

calculating the PE RVUs, we exclude certain specialties, such as certain NPPs paid at 

a percentage of the PFS and low-volume specialties, from the calculation. These 

specialties are included for the purposes of calculating the BN adjustment. They are 

displayed in Table 1. 

 

TABLE 1: Specialties Excluded From Ratesetting Calculation 

Specialty 

Code 

Specialty Description 

49 Ambulatory surgical center 

50 Nurse practitioner 

51 Medical supply company with certified orthotist 

52 Medical supply company with certified prosthetist 

53 Medical supply company with certified prosthetist-orthotist 

54 Medical supply company not included in 51, 52, or 53. 

55 Individual certified orthotist 

56 Individual certified prosthetist 

57 Individual certified prosthetist-orthotist 

58 Medical supply company with registered pharmacist 

59 Ambulance service supplier, e.g., private ambulance companies, funeral homes, 

etc. 

60 Public health or welfare agencies 

61 Voluntary health or charitable agencies 

73 Mass immunization roster biller 

74 Radiation therapy centers 
 37 

Specialty 

Code 

Specialty Description 

87 All other suppliers (e.g., drug and department stores) 

88 Unknown supplier/provider specialty 

89 Certified clinical nurse specialist 

96 Optician 

97 Physician assistant 

A0 Hospital 

A1 SNF 

A2 Intermediate care nursing facility 

A3 Nursing facility, other 

A4 HHA 

A5 Pharmacy 

A6 Medical supply company with respiratory therapist 

A7 Department store 

B2 Pedorthic personnel 

B3 Medical supply company with pedorthic personnel 

● Crosswalk certain low volume physician specialties: Crosswalk the utilization 

of certain specialties with relatively low PFS utilization to the associated specialties. 

• Physical therapy utilization: Crosswalk the utilization associated with all 

physical therapy services to the specialty of physical therapy. 

• Identify professional and technical services not identified under the usual TC 

and 26 modifiers: Flag the services that are PC and TC services, but do not use TC and 

26 modifiers (for example, electrocardiograms). This flag associates the PC and TC with 

the associated global code for use in creating the indirect PE RVUs. For example, the 

professional service, CPT code 93010 (Electrocardiogram, routine ECG with at least 12 

leads; interpretation and report only), is associated with the global service, CPT code 

93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and 

report). 

• Payment modifiers: Payment modifiers are accounted for in the creation of the file 

consistent with current payment policy as implemented in claims processing. For example, 
 38 

services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for 

that service; therefore, the utilization file is modified to only account for 16 percent of any 

service that contains the assistant at surgery modifier. Similarly, for those services to which 

volume adjustments are made to account for the payment modifiers, time adjustments are applied 

as well. For time adjustments to surgical services, the intraoperative portion in the work time file 

is used; where it is not present, the intraoperative percentage from the payment files used by 

contractors to process Medicare claims is used instead. Where neither is available, we use the 

payment adjustment ratio to adjust the time accordingly. Table 2 details the manner in which the 

modifiers are applied. 

 
 39 

TABLE 2: Application of Payment Modifiers to Utilization Files

Modifier Description Volume Adjustment Time Adjustment 

80,81,82 Assistant at Surgery 16% Intraoperative 

portion 

AS Assistant at Surgery – 

Physician Assistant 

14% (85% * 16%) Intraoperative 

portion 

50 or 

LT and RT 

Bilateral Surgery 150% 150% of work time 

51 Multiple Procedure 50% Intraoperative 

portion 

52 Reduced Services 50% 50% 

53 Discontinued Procedure 50% 50% 

54 Intraoperative Care only Preoperative + 

Intraoperative 

Percentages on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Preoperative + 

Intraoperative 

portion 

55 Postoperative Care only Postoperative 

Percentage on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Postoperative 

portion 

62 Co-surgeons 62.5% 50% 

66 Team Surgeons 33% 33% 

We also make adjustments to volume and time that correspond to other payment rules, 

including special multiple procedure endoscopy rules and multiple procedure payment reductions 

(MPPRs). We note that section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments 

for multiple imaging procedures and multiple therapy services from the BN calculation under 

section 1848(c)(2)(B)(ii)(II) of the Act. These MPPRs are not included in the development of 

the RVUs. 

For anesthesia services, we do not apply adjustments to volume since the average 

allowed charge is used when simulating RVUs, and therefore, includes all adjustments. 

A time adjustment of 33 percent is made only for medical direction of two to four cases 
 40 

since that is the only situation where time units are duplicative. 

● Work RVUs: The setup file contains the work RVUs from this proposed rule with 

comment period.

(6) Equipment Cost Per Minute 

The equipment cost per minute is calculated as: 

(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 + interest rate)^ 

life of equipment)))) + maintenance) 

Where: 

minutes per year = maximum minutes per year if usage were continuous (that is, 

usage = 1); generally 150,000 minutes. 

usage = variable, see discussion below. 

price = price of the particular piece of equipment. 

life of equipment = useful life of the particular piece of equipment. 

maintenance = factor for maintenance; 0.05. 

interest rate = variable, see discussion below. 

Usage: We currently use an equipment utilization rate assumption of 50 percent 

for most equipment, with the exception of expensive diagnostic imaging equipment, for 

which we use a 90 percent assumption as required by Section 1848(b)(4)(C) of the Act. 

Maintenance: This factor for maintenance was proposed and finalized during 

rulemaking for CY 1998 PFS (62 FR 33164). Several stakeholders have suggested that 

this maintenance factor assumption should be variable. We solicit comment regarding 

reliable data on maintenance costs that vary for particular equipment items. 

 Per-use Equipment Costs: Several stakeholders have also suggested that our PE 

methodology should incorporate usage fees and other per-use equipment costs as direct 
 41 

costs. We also solicit comment on adjusting our cost formula to include equipment costs 

that do not vary based on the equipment time. 

Interest Rate: In the CY 2013 final rule with comment period (77 FR 68902), we 

updated the interest rates used in developing an equipment cost per minute calculation. 

The interest rate was based on the Small Business Administration (SBA) maximum 

interest rates for different categories of loan size (equipment cost) and maturity (useful 

life). The interest rates are listed in Table 3. (See 77 FR 68902 for a thorough discussion 

of this issue.) 

TABLE 3: SBA Maximum Interest Rates 

Price Useful Life Interest Rate 

<$25K <7 Years 7.50% 

$25K to $50K <7 Years 6.50% 

>$50K <7 Years 5.50% 

<$25K 7+ Years 8.00% 

$25K to $50K 7+ Years 7.00% 

>$50K 7+ Years 6.00% 
 42 

TABLE 4: Calculation of PE RVUs under Methodology for Selected Codes 

 Step Source Formula 99213 

Office 

visit, est 

Nonfacility 

33533 

CABG, 

arterial, 

single 

Facility 

71020 

Chest xray 

 Nonfacility 

71020-

TC 

Chest xray, 

Nonfacility 

71020-26 

Chest xray, 

Nonfacility 

9

E

com

N

fa

(1) Labor cost (Lab) 

Step 1 AMA 

13.32 77.52 5.74 5.74 0.00 

(2) Supply cost (Sup) 

Step 1 AMA 

2.98 7.34 .53 .53 0.00 

(3) Equipment cost (Eqp) 

Step 1 AMA 

0.17 0.58 6.92 6.92 0.00 

(4) Direct cost (Dir) 

Step 1 =(1)+(2)+ 

(3) 16.48 85.45 13.19 13.19 0.00 

(5) Direct adjustment (Dir. Adj.) 

Steps 2-4 See 

footnote* 

0.5898 0.5898 0.5898 0.5898 0.5898 

(6) Adjusted Labor Steps 2-4 =Lab * Dir 

Adj 

=(1)*(5) 

7.86 45.72 3.39 3.39 0.00 

(7) Adjusted Supplies 

Steps 2-4 =Eqp * Dir 

Adj 

=(2)*(5) 

1.76 4.33 .31 .31 0.00 

(8) Adjusted Equipment 

Steps 2-4 =Sup * Dir 

Adj 

=(3)*(5) 

.10 0.34 4.08 4.08 0.00 

(9) Adjusted Direct Steps 2-4 =(6)+(7)+ 

(8) 9.72 50.40 7.78 7.78 0.00 

(10) Conversion Factor (CF) 

Step 5 PFS 

35.8228 35.8228 35.8228 35.8228 35.8228 3

(11) Adj. labor cost converted 

Step 5 =(Lab * Dir 

Adj)/CF 

=(6)/(10) 

0.22 1.28 0.09 0.09 0.00 

(12) Adj. supply cost converted 

Step 5 =(Sup * Dir 

Adj)/CF 

=(7)/(10) 

0.05 0.12 0.01 0.01 0.00 

(13) Adj. equipment cost converted 

Step 5 =(Eqp * Dir 

Adj)/CF 

=(8)/(10) 

0.00 0.01 0.11 0.11 0.00 

(14) Adj. direct cost converted 

Step 5 =(11)+(12)

+(13) 0.27 1.41 0.22 0.22 0.00 
 43 

 Step Source Formula 99213 

Office 

visit, est 

Nonfacility 

33533 

CABG, 

arterial, 

single 

Facility 

71020 

Chest xray 

 Nonfacility 

71020-

TC 

Chest xray, 

Nonfacility 

71020-26 

Chest xray, 

Nonfacility 

9

E

com

N

fa

(15) Work RVU Setup File PFS 0.97 33.75 0.22 0.00 0.22 (16) Dir_pct Steps 6,7 Surveys 0.25 0.17 0.29 0.29 .29 (17) Ind_pct Steps 6,7 Surveys 0.75 .83 .71 .71 .71 (18) Ind. Alloc. Formula (1st part) 

Step 8 See Step 8 ((14)/(16

))*(17)

((14)/(16))

*(17)

((14)/(16

))*(17) 

((14)/(1

6))*(17)

((14)/(16

))*(17)

((1

)

(19) Ind. Alloc.(1st part) 

Step 8 See 18 

0.82 6.67 .53 .53 0 

(20) Ind. Alloc. Formula (2nd part) 

Step 8 See Step 8 

(15) (15) (15+11) (11) (15) (

(21) Ind. Alloc.(2nd part) 

Step 8 See 20 

0.97 33.75 0.31 0.09 0.22 

(22) Indirect Allocator (1st + 2nd) 

Step 8 =(19)+ (21) 

1.79 40.42 .84 .62 0.22 

(23) Indirect Adjustment (Ind. Adj.) 

Steps 9-11 See 

Footnote** 

.3813 .3813 .3813 .3813 .3813 

(24) Adjusted Indirect Allocator 

Steps 9-11 =Ind Alloc * 

Ind Adj 0.68 15.41 .32 .24 0.08 

(25) Ind. Practice Cost Index (IPCI) 

Steps 12-16 1.07 0.75 .99 .99 .99 

(26) Adjusted Indirect 

Step 17 = Adj.Ind 

Alloc * PCI 

=(24)*(25) 

0.73 11.59 .32 .24 0.08 

(27) PE RVU Step 18 =(Adj Dir + 

Adj Ind) * Other Adj 

=((14)+ (26)) * Other Adj) 1.01 13.05 .53 .45 .08 

*The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3] **The indirect adj = [current pe rvus * avg ind pct]/[sum of ind allocators] = [step9]/[step10] Note: The use of any particular conversion factor (CF) in this table to illustrate the PE calculation has no effect on the resulting RVUs. 
 44 

3. Changes to Direct PE Inputs for Specific Services 

In this section, we discuss other CY 2015 proposals and revisions related to direct PE 

inputs for specific services. The proposed direct PE inputs are included in the proposed rule 

CY 2015 direct PE input database, which is available on the CMS website under downloads for 

the CY 2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. 

a. RUC Recommendation for Monitoring Time following Moderate Sedation 

We received a recommendation from the RUC regarding appropriate clinical labor 

minutes for post-procedure moderate sedation monitoring and post-procedure monitoring. The 

RUC recommended 15 minutes of RN time for one hour of monitoring following moderate 

sedation and 15 minutes of RN time per hour for post-procedure monitoring (unrelated to 

moderate sedation). For 17 procedures listed in Table 5, the recommended clinical labor minutes 

differed from the clinical labor minutes in the direct PE database. We propose to accept, without 

refinement, the RUC recommendation to adjust these clinical labor minutes as indicated in Table 

5 as “Change to Clinical Labor Time.” The CY 2015 direct PE database reflects these proposed 

changes and is available on the CMS website under the supporting data files for the CY 2015 

PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. 

 
 45 

TABLE 5: Codes with Proposed Changes to Post-Procedure Clinical Labor Monitoring 

Time 

CPT 

Code 

Current 

Monitoring 

Time (Min) 

RUC Recommended 

Total Post-Procedure 

Monitoring Time (Min) 

Change to 

Clinical 

Labor Time 

(Min) 

32553 30 60 30 

35471 21 60 39 

35475 60 30 -30 

35476 60 30 -30 

36147 18 30 12 

37191 60 30 -30 

47525 6 15 9 

49411 30 60 30 

50593 30 60 30 

50200 15 60 45 

31625 20 15 -5 

31626 25 15 -10 

31628 25 15 -10 

31629 25 15 -10 

31634 25 15 -10 

31645 10 15 5 

31646 10 15 5 

b. RUC Recommendation for Standard Moderate Sedation Package 

We received a RUC recommendation to modify PE inputs included in the standard 

moderate sedation package. Specifically, the RUC indicated that several specialty societies have 

pointed to the need for a stretcher during procedures for which moderate sedation is inherent in 

the procedure. Although the RUC did not recommend that we make changes to PE inputs for 

codes at this time, the RUC indicated that its future recommendations would include the stretcher 

as a direct input for procedures including moderate sedation. 

The RUC recommended three scenarios that future recommendations would use to 

allocate the equipment time for the stretcher based on the procedure time and whether the 

stretcher would be available for other patients to use during a portion of the procedure. Although 

we appreciate the RUC’s attention to the differences in the time required for the stretcher based 
 46 

on the time for the procedure, we believe that one of the purposes of standard PE input packages 

is to reduce the complexity associated with assigning appropriate PE inputs to individual 

procedures while, at the same time, maintaining relativity between procedures. Since we 

generally allocate inexpensive equipment items to the entire service period when they are likely 

to be unavailable for another use during the full service period, we believe it is preferable to treat 

the stretcher consistently across these services. Therefore, we propose to modify the standard 

moderate sedation input package to include a stretcher for the same length of time as the other 

equipment items in the moderate sedation package. The proposed revised moderate sedation 

input package would be applied to relevant codes as we review them through future notice and 

comment rulemaking. It would be useful to hear stakeholders’ views and the reasoning behind 

them on this issue, especially from those who think that the stretcher, as expressed through the 

allocation of equipment minutes, should be allocated with more granularity than the equipment 

costs that are allocated to other similar items. 

c. RUC Recommendation for Migration from Film to Digital Practice Expense Inputs 

The RUC has provided a recommendation regarding the PE inputs for digital imaging 

services. Specifically, the RUC recommended that we remove a list of supply and equipment 

items associated with film technology since these items are no longer a typical resource input; 

these items are detailed in Table 6. The RUC also recommended that the Picture Archiving and 

Communication System (PACS) equipment be included for these imaging services since these 

items are now typically used in furnishing imaging services. We received a description of the 

PACS system as part of the recommendation, which included both items that appear to be direct 

PE items and items for which indirect PE RVUs are allocated in the PE methodology. As we 

have previously indicated, items that are not clinical labor, medical supplies, or medical 

equipment, or are not individually allocable to a particular patient for a particular procedure, are 
 47 

not categorized as direct costs in the PE methodology. Since we did not receive any invoices for 

the PACS system, we are unable to determine the appropriate pricing to use for the inputs. We 

propose to accept the RUC recommendation to remove the film supply and equipment items, and 

to allocate minutes for a desktop computer (ED021) as a proxy for the PACS workstation as a 

direct expense. Specifically, for the 31 services that already contain ED021, we propose to retain 

the time that is currently included in the direct PE input database. For the remaining services 

that are valued in the nonfacility setting, we propose to allocate the full clinical labor intraservice 

time to ED021, except when there is no clinical labor, in which case we propose to allocate the 

intraservice work time to ED021. For services valued only in the facility setting, we propose to 

allocate the post-service clinical labor time to ED021, since the film supply and/or equipment 

inputs were previously associated with the post-service period. 

 
 48 

TABLE 6: RUC-Recommended Supply and Equipment Items Proposed to be Removed for 

Digital Imaging Services

CMS Code Description 

SK013 computer media, dvd 

SK014 computer media, floppy disk 1.44mb 

SK015 computer media, optical disk 128mb 

SK016 computer media, optical disk 2.6gb 

SK022 film, 8inx10in (ultrasound, MRI) 

SK025 film, dry, radiographic, 8in x 10in 

SK028 film, fluoroscopic 14 x 17 

SK033 film, x-ray 10in x 12in 

SK034 film, x-ray 14in x 17in 

SK035 film, x-ray 14in x 36in 

SK037 film, x-ray 8in x 10in 

SK038 film, x-ray 8in x 10in (X-omat, Radiomat) 

SK086 video tape, VHS 

SK089 x-ray developer solution 

SK090 x-ray digitalization separator sheet 

SK091 x-ray envelope 

SK092 x-ray fixer solution 

SK093 x-ray ID card (flashcard) 

SK094 x-ray marking pencil 

SK098 film, x-ray, laser print 

SM009 cleaner, x-ray cassette-screen 

ED014 computer workstation, 3D reconstruction CT-MR 

ED016 computer workstation, MRA post processing 

ED023 film processor, PET imaging 

ED024 film processor, dry, laser 

ED025 film processor, wet 

ED027 film processor, x-omat (M6B) 

ER018 densitometer, film 

ER029 film alternator (motorized film viewbox) 

ER067 x-ray view box, 4 panel 

 We note that the RUC exempted certain procedures from its recommendation because (a) 

the dominant specialty indicated that digital technology is not yet typical or (b) the procedure 

only contained a single input associated with film technology, and it was determined that the 

sharing of images, but not actual imaging, may be involved in the service. However, we do not 

believe that the most appropriate approach in establishing relative values for services that 
 49 

involve imaging is to exempt services from the transition from film to digital PE inputs based on 

information reported by individual specialties. Although we understand that the migration from 

film technology to digital technology may progress at different paces for particular specialties, 

we do not have information to suggest that the migration is not occurring for all procedures that 

require the storage of images. Just as it was appropriate to use film inputs as a proxy for some 

services for which digital inputs were typical pending these proposed changes in the direct PE 

input database, we believe it is appropriate to use digital inputs as a proxy for the services that 

may still use film, pending their migration to digital technology. In addition, since the RUC 

conducted its collection of information from the specialties over several years, we believe the 

migration process from film to digital inputs has likely continued over the time period during 

which the information was gathered, and that the digital PE inputs will reflect typical use of 

technology for most if not all of these services before the proposed change to digital inputs 

would take effect beginning January 1, 2015. We also believe that for the sake of relativity, we 

should remove the equipment and supply inputs noted below from all procedures in the direct PE 

database, including those listed in Table 7. We seek comment on whether the computer 

workstation, which we propose to use as a proxy for the PACS workstation, is the appropriate 

input for the services listed in Table 7, or whether an alternative input is a more appropriate 

reflection of direct PE costs. 

TABLE 7: Codes Containing Film Inputs But Excluded From the RUC Recommendation 

HCPCS Short Descriptor 

21077 Prepare face/oral prosthesis 

28293 Correction of bunion 

61580 Craniofacial approach skull 

61581 Craniofacial approach skull 

61582 Craniofacial approach skull 

61583 Craniofacial approach skull 

61584 Orbitocranial approach/skull 

61585 Orbitocranial approach/skull 
 50 

HCPCS Short Descriptor 

61586 Resect nasopharynx skull 

64517 N block inj hypogas plxs 

64681 Injection treatment of nerve 

70310 X-ray exam of teeth 

77326 Brachytx isodose calc simp 

77327 Brachytx isodose calc interm 

77328 Brachytx isodose plan compl 

91010 Esophagus motility study 

91020 Gastric motility studies 

91034 Gastroesophageal reflux test 

91035 G-esoph reflx tst w/electrod 

91037 Esoph imped function test 

91038 Esoph imped funct test > 1hr 

91040 Esoph balloon distension tst 

91120 Rectal sensation test 

91122 Anal pressure record 

91132 Electrogastrography 

91133 Electrogastrography w/test 

92521 Evaluation of speech fluency 

92523 Speech sound lang comprehend 

92524 Behavioral qualit analys voice 

92601 Cochlear implt f/up exam <7 

92603 Cochlear implt f/up exam 7/> 

92611 Motion fluoroscopy/swallow 

92612 Endoscopy swallow tst (fees) 

92614 Laryngoscopic sensory test 

92616 Fees w/laryngeal sense test 

95800 Slp stdy unattended 

95801 Slp stdy unatnd w/anal 

95803 Actigraphy testing 

95805 Multiple sleep latency test 

95806 Sleep study unatt&resp efft 

95807 Sleep study attended 

95808 Polysom any age 1-3> param 

95810 Polysom 6/> yrs 4/> param 

95811 Polysom 6/>yrs cpap 4/> parm 

95812 Eeg 41-60 minutes 

95813 Eeg over 1 hour 

95829 Surgery electrocorticogram 

95950 Ambulatory eeg monitoring 

95953 Eeg monitoring/computer 

95954 Eeg monitoring/giving drugs 
 51 

HCPCS Short Descriptor 

95955 Eeg during surgery 

95956 Eeg monitor technol attended 

95957 Eeg digital analysis 

96904 Whole body photography 

G0270 Mnt subs tx for change dx 

G0271 Group mnt 2 or more 30 mins 

 Finally, we note that the RUC recommendation also indicated that given the laborintensive nature of reviewing all clinical labor tasks associated with film technology, these times 

would be addressed as these codes are reviewed. We agree with the RUC that reviewing and 

adjusting the times for each code would be difficult and labor-intensive since the direct PE input 

database does not allow for a comprehensive adjustment of the clinical labor time based on 

changes in particular clinical labor tasks. To make broad adjustments such as this across codes, 

the PE database would need to contain the time associated with individual clinical labor tasks 

rather than reflecting only the sum of times for the pre-service period, service period, and postservice period, as it does now. We recognize this situation presents a challenge in implementing 

RUC recommendations such as this one, and makes it difficult to understand the basis of both the 

RUC’s recommended clinical labor times and our refinements of those recommendations. 

Therefore, we are considering revising the direct PE input database to include task-level clinical 

labor time information for every code in the database. As an example, we refer readers to the 

supporting data files for the direct PE inputs, which include public use files that display clinical 

labor times as allocated to each individual clinical labor task for a sample of procedures. We are 

displaying this information as we attempt to increase the transparency of the direct PE database. 

We hope that this modification could enable us to more accurately allocate equipment minutes to 

clinical labor tasks in a more consistent and efficient manner. Given the number of procedures 

and the volume of information involved, we are seeking comments on the feasibility of this 
 52 

approach. We note that we are not proposing to make any changes to PE inputs for CY 2015 

based on this proposed modification to the design of the direct PE input database. 

 The CY 2015 direct PE database reflects these proposed changes and is available on the 

CMS website under the supporting data files for the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. 

d. Inputs for Digital Mammography Services 

 Mammography services are currently reported by and paid for using both CPT codes and 

G-codes. To meet the requirements of the Medicare, Medicaid, and SCHIP Benefits 

Improvement and Protection Act of 2000 (BIPA), we established the G-codes for CY 2002 to 

pay for mammography services using new digital technologies (G0202 screening mammography 

digital; G0204 diagnostic mammography digital; G0206 diagnostic mammography digital). We 

continued to pay for mammography billed using the CPT codes when the services were furnished 

with film technology (77055 mammogram one breast; 77056 mammogram both breasts; 77057 

mammogram screening). As we discussed previously in this section, the RUC has recommended 

that all imaging codes, including mammography, be valued using digital rather than film inputs 

because film is no longer typical. A review of Medicare claims data shows that the 

mammography CPT codes are billed extremely infrequently, and that the G-codes are billed for 

the vast majority of mammography claims, confirming what the RUC has indicated regarding the 

use of digital technology. It appears that the typical mammography service is furnished using 

digital technology. As such, we do not believe there is a reason to continue the separate use of 

the CPT codes and the G-codes for mammography services since both sets of codes would have 

the same values when priced based upon the typical digital technology. Accordingly, we are 

proposing to delete the mammography G-codes beginning for CY 2015 and to pay all 

mammography using the CPT codes. 
 53 

 Although we believe that the CPT codes should now be used to report all mammography 

services, we have concerns about whether the current values for the CPT codes accurately reflect 

the resource inputs associated with furnishing the services. Because the CPT codes have not 

been recently reviewed and significant technological changes have occurred during this time, we 

do not believe it would be appropriate to retain the current values for the CPT codes. Therefore, 

we are proposing to value the CPT codes using the RVUs previously established for the G-codes. 

We believe these values would be most appropriate since they were established to reflect the use 

of digital technology, which is now typical. 

 As discussed in section II.B.3.b.(4) of this proposed rule, we are proposing these CPT 

codes as potentially misvalued and requesting that the RUC and other interested stakeholders 

review these services in terms of appropriate work RVUs, work time assumptions and direct PE 

inputs. 

e. Radiation Treatment Vault 

In previous rulemaking (77 FR 68922; 78 FR 74346), we indicated that we included the 

radiation treatment vault as a direct PE input for several recently reviewed radiation treatment 

codes for the sake of consistency with its previous inclusion as a direct PE input for some other 

radiation treatment services, but that we intended to review the radiation treatment vault input 

and address whether or not it should be included in the direct PE input database for all services in 

future rulemaking. Specifically, we questioned whether it was consistent with the principles 

underlying the PE methodology to include the radiation treatment vault as a direct cost given that 

it appears to be more similar to building infrastructure costs than to medical equipment costs. 

Moreover, it is difficult to distinguish the cost of the vault from the cost of the building. In 

response to this action, we received comments and invoices from stakeholders who indicated that 

the vault should be classified as a direct cost. However, upon review of the information 
 54 

received, we believe that the specific structural components required to house the linear 

accelerator are similar in concept to components required to house other medical equipment such 

as expensive imaging equipment. In general, the electrical, plumbing, and other building 

specifications are often unique to the intended functionality of a given building, including costs 

that are attributable to the specific medical equipment housed in the building, but do not 

represent direct medical equipment costs in our established PE methodology. Therefore we 

believe that the special building requirements indicated for the radiation treatment vault to house 

a linear accelerator do not represent a direct cost in our PE methodology, and that the vault 

construction is instead accounted for in the indirect PE methodology, just as the building and 

infrastructure costs are treated for other PFS services including those with infrastructure costs 

based on equipment needs Therefore, we propose to remove the radiation treatment vault as a 

direct PE input from the radiation treatment procedures listed in Table 8, because we believe that 

the vault is not, itself, medical equipment, and therefore, is accounted for in the indirect PE 

methodology. 

TABLE 8: HCPCS Codes Affected by Proposed Removal of Radiation Treatment Vault 

HCPCS Short Descriptor 

77373 Sbrt delivery 

77402 Radiation treatment delivery 

77403 Radiation treatment delivery 

77404 Radiation treatment delivery 

77406 Radiation treatment delivery 

77407 Radiation treatment delivery 

77408 Radiation treatment delivery 

77409 Radiation treatment delivery 

77411 Radiation treatment delivery 

77412 Radiation treatment delivery 

77413 Radiation treatment delivery 

77414 Radiation treatment delivery 

77416 Radiation treatment delivery 

77418 Radiation tx delivery imrt 
 55 

f. Clinical Labor Input Errors 

Subsequent to the publication of the CY 2014 PFS final rule with comment period, it 

came to our attention that, due to a clerical error, the clinical labor type for CPT code 77293 

(Respiratory Motion Management Simulation (list separately in addition to code for primary 

procedure)) was entered as L052A (Audiologist) instead of L152A (Medical Physicist), which 

has a higher cost per minute. We are proposing a correction to the clinical labor type for this 

service. 

In conducting a routine data review of the database, we also discovered that, due to a 

clerical error, the RN time allocated to CPT codes 33620 (Apply r&l pulm art bands), 33621 

(Transthor cath for stent), and 33622 (Redo compl cardiac anomaly) was entered in the 

nonfacility setting, rather than in the facility setting where the code is valued. When a service is 

not valued in a particular setting, any inputs included in that setting are not included in the 

calculation of the PE RVUs for that service. Therefore, we are proposing to move the RN time 

allocated to these procedures to the facility setting. The PE RVUs listed in Addendum B reflect 

these technical corrections. 

g. Work Time 

Subsequent to the publication of the CY PFS 2014 final rule with comment period, 

several inconsistencies in the work time file came to our attention. First, for some services, the 

total work time, which is used in our PE methodology, did not equal the sum of the component 

parts (pre-service, intra-service, post-service, and times associated with global period visits). 

The times in the CY 2015 work time file reflect our proposed corrected values for total work 

time. Second, for a subset of services, the values in the pre-positioning time, pre-evaluation 

time, and pre-scrub-dress-wait time, were inadvertently transposed. We note that this error had 

no impact on calculation of the total times, but has been corrected in the CY 2015 work time file. 
 56 

Third, minor discrepancies for a series of interim final codes were identified between the work 

time file and the way we addressed these codes in the preamble text. Therefore, we have made 

adjustments to the work time file to reflect the decisions indicated in the preamble text. The 

work time file is available on the CMS website under the supporting data files for the CY 2015 

PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. Note that for comparison 

purposes, the CY 2014 work time file is located at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-

FC.html. 

h. Updates to Price for Existing Direct Inputs. 

In the CY 2011 PFS final rule with comment period (75 FR 73205), we finalized a 

process to act on public requests to update equipment and supply price and equipment useful life 

inputs through annual rulemaking beginning with the CY 2012 PFS proposed rule. During 2013, 

we received a request to update the price of SD216 (catheter, balloon, esophageal or rectal 

(graded distention test)) from $217 to $237.50. We also received a request to update the price of 

SL196 (kit, HER-2/neu DNA Probe) from $105 to $144.50. We received invoices that 

documented updated pricing for each of these supply items. We propose to increase the price 

associated with these supply items. 

We continue to believe it is important to maintain a periodic and transparent process to 

update the price of items to reflect typical market prices in our ratesetting methodology, and we 

continue to study the best way to improve our current process. We remind stakeholders that we 

have previously stated our difficulty in obtaining accurate pricing information. We have also 

made clear that the goal of the current transparent process is to offer the opportunity for the 

community to both request supply price updates by providing us copies of paid invoices, and to 

object to proposed changes in price inputs for particular items by providing additional 
 57 

information about prices available to the practitioner community. We remind stakeholders that 

PFS payment rates are developed within a budget neutral, relative value system, and any 

increases in price inputs for particular supply items result in corresponding decreases to the 

relative values of all other direct PE inputs. 

We note that we continue to have difficulty determining the best way to use the invoices 

that we receive. In all cases, we attempt to use the price that appears most representative, but it 

can be difficult to ascertain whether the prices on particular invoices are typical. For example, in 

some cases, we receive multiple invoices, but are only able to use one of them because the other 

invoices include additional items and do not separately identify the price of the item in question. 

In other cases, we receive multiple invoices at one price, which suggests that this price is likely a 

typical one. In other cases, we receive invoices for items already in the direct PE database that 

are based on a recent invoice. In these cases, it is not clear whether the new, usually higher 

priced, invoice reflects a more accurate price than the current price, but we need to determine 

whether to substitute the new price for the existing price, maintain the existing price, or average 

the two prices. We continue to seek stakeholder input on the best approach to using the small 

sample of invoices that are provided to us through this process. 

 We also received a RUC recommendation to update the prices associated with two supply 

items. Specifically, the RUC recommended that we increase the price of SA042 (pack, cleaning 

and disinfecting, endoscope) from $15.52 to $17.06 to reflect the addition of supply item SJ009 

(basin, irrigation) to the pack, and increase the price of SA019 (kit, IV starter) from $1.37 to 

$1.60 to reflect the addition of supply item SA044 (underpad 2 ft. x 3 ft. (Chux)) to the kit. We 

are proposing to update the prices for both of these items based on these recommendations. The 

CY 2015 direct PE database reflects these proposed changes and is available on the CMS 
 58 

website under the supporting data files for the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. 

i. New Standard Supply Package for Contrast Imaging 

 The RUC recommended creating a new direct PE input standard supply package 

“Imaging w/contrast, standard package” for contrast enhanced imaging, with a price of $6.82. 

This price reflects the combined prices of the medical supplies included in the package; these 

items are listed in Table 9. We propose to accept this recommendation, but seek comment on 

whether all of the items included in the package are used in the typical case. The CY 2015 direct 

PE database reflects this proposed change and is available on the CMS website under the 

supporting data files for the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. 

TABLE 9: Standard Contrast Imaging Supply Package 

Imaging w/Contrast - Standard Package 

Medical Supply Description CMS 

Supply 

Code 

Unit Quantity Price 

Kit, IV starter SA019 Kit 1 $1.368 

Gloves, non-sterile SB022 Pair 1 0.084 

Angiocatheter 14g-24g SC001 Item 1 1.505 

Heparin lock SC012 Item 1 0.917 

IV tubing (extension) SC019 Foot 3* 1.590 

Needle, 18-27g SC029 Item 1 0.089 

Syringe 20ml SC053 Item 1 0.558 

Sodium chloride 0.9% inj. bacteriostatic (30ml uou) SH068 Item 1 0.700 

Swab-pad, alcohol SJ053 Item 1 0.013 

TOTAL $6.824 

* The price for SC019 (IV tubing, (extension)) is $0.53 per foot. 

j. Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT Codes 77372 and 77373) 

In the CY 2014 PFS final rule with comment period (78 FR 74245), we summarized 

comments received about whether CPT codes 77372 and 77373 would accurately reflect the 

resources used in furnishing the typical SRS delivery if there were no coding distinction between 

robotic and non-robotic delivery methods. Until now, SRS services furnished using robotic 
 59 

methods were billed using contractor-priced G-codes G0339 (Image-guided robotic linear 

accelerator based stereotactic radiosurgery, complete course of therapy in one session or first 

session of fractionated treatment), and G0340 (Image-guided robotic linear accelerator-based 

stereotactic radiosurgery, delivery including collimator changes and custom plugging, 

fractionated treatment, all lesions, per session, second through fifth sessions, maximum five 

sessions per course of treatment). We indicated that we would consider these codes in future 

rulemaking. 

Most commenters suggested that the CPT codes accurately described both services, and 

the RUC stated that the direct PE inputs for the CPT codes accurately accounted for the resource 

costs of the described services. One commenter objected to the deletion of the G-codes but did 

not include any information to suggest that the CPT codes did not describe the services or that 

the direct PE inputs for the CPT codes were inaccurate. Based on a review of the comments 

received, we have no indication that the direct PE inputs included in the CPT codes do not reflect 

the typical resource inputs involved in furnishing an SRS service. Therefore, we propose to 

recognize only the CPT codes for payment of SRS services, and to delete the G-codes used to 

report robotic delivery of SRS. 

k. Inclusion of Capnograph for Pediatric Polysomnography Services 

 We are proposing to include equipment item EQ358, Sleep capnograph, 

polysomnography (pediatric), for CPT codes 95782 (Polysomnography; younger than 6 years, 

sleep staging with 4 or more additional parameters of sleep, attended by a technologist) and 

95783 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional 

parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level 

ventilation, attended by a technologist). We understand that capnography is a required element 

of sleep studies for patients younger than 6 years, and propose to allocate this equipment item to 
 60 

95782 for 602 minutes, and 95783 for 647 minutes. Based on the invoice we received for this 

equipment item, we propose to price EQ358 at $4,534.23. 

l. Nonfacility Direct PE Inputs for Intravascular Ultrasound 

A stakeholder requested that we establish nonfacility PE RVUs for CPT code 37250 

(Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic 

intervention; each additional vessel (List separately in addition to code for primary procedure)) 

and 37251 (Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or 

therapeutic intervention; each additional vessel (List separately in addition to code for primary 

procedure)). We seek comment regarding whether it is appropriate to have nonfacility PE RVUs 

for this code and if so what inputs should assigned to this code. 

4. Using OPPS and ASC Rates in Developing PE RVUs 

Accurate and reliable pricing information for both individual items and indirect PEs is 

critical to establish accurate PE RVUs for PFS services. As we have addressed in previous 

rulemaking, we have serious concerns regarding the accuracy of some of the information we use 

in developing PE RVUs. In particular, we have several longstanding concerns regarding the 

accuracy of direct PE inputs, including both items and procedure time assumptions, and prices of 

individual supplies and equipment (78 FR 74248 -74250). In addition to the concerns regarding 

the inputs used in valuing particular procedures, we also note that the allocation of indirect PE is 

based on information collected several years ago (as described above) and will likely need to be 

updated in the coming years. To mitigate the impact of some of these potentially problematic 

data used in developing values for individual services, in CY 2014 rulemaking we proposed to 

limit the nonfacility PE RVUs for individual codes so that the total nonfacility PFS payment 

amount would not exceed the total combined amount that Medicare would pay for the same code 

in the facility setting. In developing the proposal, we sought a reliable means for Medicare to set 
 61 

upper payment limits for office-based procedures and believed OPPS and ASC payment rates 

would provide an appropriate comparison because these rates are based on relatively more 

reliable cost information in settings with cost structures that generally would be expected to be 

higher than in the office setting. 

We received many comments regarding our proposal, the vast majority of which urged us 

to withdraw the proposal. Some commenters questioned the validity of our assumption that 

facilities’ costs for providing all services are necessarily higher than the costs of physician 

offices or other nonfacility settings. Other commenters expressed serious concerns with the 

asymmetrical comparisons between PFS payment amounts and OPPS/ASC payment amounts. 

Finally, many commenters suggested revisions to technical aspects of our proposed policy. 

In considering all the comments, however, we were persuaded that the comparison of 

OPPS (or ASC) payment amounts to PFS payment amounts for particular procedures is not the 

most appropriate or effective approach to ensuring that that PFS payment rates are based on 

accurate cost assumptions. Commenters noted several flaws with the approach. First, unlike 

PFS payments, OPPS and ASC payments for individual services are grouped into rates that 

reflect the costs of a range of services. Second, commenters suggested that since the ASC rates 

reflect the OPPS relative weights to determine payment rates under the ASC payment system, 

and are not based on cost information collected from ASCs, the ASC rates should not be used in 

the proposed policy. For these and other reasons raised by commenters, we are not proposing a 

similar policy for the CY 2015 PFS. If we consider using OPPS or ASC payment rates in 

developing PFS PE RVUs in future rulemaking, we would consider all of the comments received 

regarding the technical application of the previous proposal. 

After thorough consideration of the comments regarding the CY 2014 proposal, we 

continue to believe that there are a various possibilities for leveraging the use of available 
 62 

hospital cost data in the PE RVU methodology to ensure that the relative costs for PFS services 

are developed using data that is auditable and comprehensively and regularly updated. Although 

some commenters questioned the premise that the hospital cost data are more accurate than the 

information used to establish PE RVUs, we continue to believe that the routinely updated, 

auditable resource cost information submitted contemporaneously by a wide array of providers 

across the country is a valid reflection of “relative” resources and could be useful to supplement 

the resource cost information developed under our current methodology based upon a typical 

case that are developed with information from a small number of representative practitioners for 

a small percentage of codes in any particular year. 

Section 220(a) of the PAMA added a new subparagraph (M) under section 1848(c)(2) of 

the Act that gives us authority to collect information on resources used to furnish services from 

eligible professionals (including physicians, non-physician practitioners, PTs, OTs, SLPs and 

qualified audiologists), and other sources. It also authorizes us to pay eligible professionals for 

submitting solicited information. We will be exploring ways of collecting better and updated 

resource data from physician practices, including those that are provider-based, and other nonfacility entities paid through the PFS. We believe such efforts will be challenging given the wide 

variety of practices, and that any effort will likely impose some burden on eligible professionals 

paid through the PFS regardless of the scope and manner of data collection. Currently, through 

one of the validation contracts discussed in section II.B. of this proposed rule, we have been 

gathering time data directly from physician practices. Through this project, we have learned 

much about the challenges for both CMS and the eligible professionals of collecting data directly 

from practices. Our experience has also shown that is difficult to obtain invoices for supply and 

equipment items that we can use in pricing direct PE inputs. Many specialty societies also have 

noted the challenges in obtaining recent invoices for medical supplies and equipment (78 FR 
 63 

74249). Further, PE calculations also rely heavily on information from the Physician Practice 

Expense Information Survey (PPIS) survey, which, as discussed earlier, was conducted in 2007 

and 2008. When we implemented the results of the survey, many in the community expressed 

serious concerns over the accuracy of this or other PE surveys as a way of gathering data on PE 

inputs from the diversity of providers paid under the PFS. 

Section 220 of the PAMA also provides authority to use alternative approaches to 

establish practice expense relative values, including the use of data from other suppliers and 

providers of services. We are exploring the best approaches for exercising this authority, 

including with respect to use of hospital outpatient cost data. We understand that many 

stakeholders will have concerns regarding the possibility of using hospital outpatient cost data in 

developing PFS PE RVUs, and we want to be sure we are aware of these prior to considering or 

developing any future proposal relying on those data. Therefore, we are seeking comment on the 

possible uses of the Medicare hospital outpatient cost data (not the APC payment amount) in 

potential revisions of the PFS PE methodology. This could be as a means to validate or, perhaps, 

in setting the relative resource cost assumptions within the PFS PE methodology. We note that 

the resulting PFS payment amounts would not necessarily conform to OPPS payment amounts 

since OPPS payments are grouped into APCs, while PFS payments would continue to be valued 

individually and would remain subject to the relativity inherent in establishing PE RVUs, budget 

neutrality adjustments, and PFS updates. We are particularly interested in comments that 

compare such possibilities to other broad-based, auditable, mechanisms for data collection, 

including any we might consider under the authority provided under section 220(a) of the 

PAMA. We urge commenters to consider a wide range of options for gathering and using the 

data, including using the data to validate or set resource assumptions for only a subset of PFS 

services, or as a base amount to be adjusted by code or specialty-level recommended 
 64 

adjustments, or other potential uses. 

In addition to soliciting comments as noted above, we continue to seek a better 

understanding regarding the growing trend toward hospital acquisition of physician offices and 

subsequent treatment of those locations as off-campus provider-based outpatient departments 

affects payments under PFS and beneficiary cost-sharing. MedPAC continues to question the 

appropriateness of increased Medicare payment and beneficiary cost-sharing when physician 

offices become hospital outpatient departments, and to recommend that Medicare pay selected 

hospital outpatient services at PFS rates (MedPAC March 2012 and June 2013 Report to 

Congress). We also remain concerned about the validity of the resource data as more physician 

practices become provider-based. Our survey data reflects the PE costs for particular PFS 

specialties, including a proportion of practices that may have become provider-based since the 

survey was conducted. Additionally, as the proportion of provider-based offices varies among 

physician specialties, so does the relative accuracy of the PE survey data. Our current PE 

methodology primarily distinguishes between the resources involved in furnishing services in 

two sites of service: the non-facility setting and the facility setting. In principle, when services 

are furnished in the non-facility setting, the costs associated with furnishing services include all 

direct and indirect PEs associated with the work and the PE of the service. In contrast, when 

services are furnished in the facility setting, some costs that would be PEs in the office setting 

are incurred by the facility. Medicare makes a separate payment to the facility to account for 

some portion of these costs, and we adjust PEs accordingly under the PFS. As more physician 

practices become hospital-based, it is difficult to know which PE costs typically are actually 

incurred by the physician, which are incurred by the hospital, and whether our bifurcated site-of 

service differential adequately accounts for the typical resource costs given these relationships. 
 65 

We also have addressed this issue as it relates to accurate valuation of visits within the postoperative period of 10- and 90-day global codes in section II.B.4 of this proposed rule. 

To understand how this trend is affecting Medicare, including the accuracy of payments 

made through the PFS, we need to develop data to assess the extent to which this shift toward 

hospital-based physician practices is occurring. To that end, during CY 2014 rulemaking we 

sought comment regarding the best method for collecting information that would allow us to 

analyze the frequency, type, and payment for services furnished in off-campus provider-based 

hospital departments (73 FR 43302). We received many thoughtful comments. However, the 

commenters did not present a consensus opinion regarding the options we presented in last year’s 

rule. Based on our analysis of the comments, we believe the most efficient and equitable means 

of gathering this important information across two different payment systems would be to create 

a HCPCS modifier to be reported with every code for physician and hospital services furnished 

in an off-campus provider-based department of a hospital. The modifier would be reported on 

both the CMS-1500 claim form for physicians’ services and the UB-04 (CMS form 1450) for 

hospital outpatient claims. (We note that the requirements for a determination that a facility or 

an organization has provider-based status are specified in §413.65 and we define a hospital 

campus to be the physical area immediately adjacent to the provider's main buildings, other areas 

and structures that are not strictly contiguous to the main buildings but are located within 250 

yards of the main buildings, and any other areas determined on an individual case basis, by the 

CMS regional office.) 

Therefore, we are proposing to collect this information on the type and frequency of 

services furnished in off-campus provider-based departments in accordance with our authority 

under section 1834(c)(2)(M) of the Act (as added by section 220(a) of the PAMA) beginning 

January 1, 2015. The collection of this information would allow us to begin to assess the 
 66 

accuracy of the PE data, including both the service-level direct PE inputs and the specialty-level 

indirect PE information that we currently use to value PFS services. Furthermore, this 

information would be critical in order to develop proposed improvements to our PE data or 

methodology that would appropriately account for the different resource costs among traditional 

office, facility, and off-campus provider-based settings. We are seeking additional comment on 

whether a code modifier is the best mechanism for collecting this service-level information. 
 67 

B. Potentially Misvalued Services Under the Physician Fee Schedule 

1. Valuing Services Under the PFS 

Section 1848(c) of the Act requires the Secretary to determine relative values for 

physicians' services based on three components: work; PE; and MP. Section 1848(c)(1)(A) of 

the Act defines the work component to include “the portion of the resources used in furnishing 

the service that reflects work time and intensity in furnishing the service.” In addition, section 

1848(c)(2)(C)(i) of the Act specifies that “the Secretary shall determine a number of work 

relative value units (RVUs) for the service based on the relative resources incorporating 

physician time and intensity required in furnishing the service.” 

Section 1848(c)(1)(B) of the Act defines the PE component as “the portion of the 

resources used in furnishing the service that reflects the general categories of expenses (such as 

office rent and wages of personnel, but excluding malpractice expenses) comprising practice 

expenses.” Section 1848 (c)(2)(C)(ii) of the Act requires that PE RVUs be determined based 

upon the relative PE resources involved in furnishing the service. (See section II.A. of this 

proposed rule for more detail on the PE component.) 

Section 1848(c)(1)(C) of the Act defines the MP component as “the portion of the 

resources used in furnishing the service that reflects malpractice expenses in furnishing the 

service.” Section 1848 (c)(2)(C)(iii) of the Act specifies that MP expense RVUs shall be 

determined based on the relative MP expense resources involved in furnishing the service. (See 

section II.C. of this proposed rule for more detail on the MP component.) 

2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued Services 

a. Background 

Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a periodic review, not 

less often than every 5 years, of the RVUs established under the PFS. Section 1848(c)(2)(K) of 
 68 

the Act requires the Secretary to periodically identify potentially misvalued services using 

certain criteria and to review and make appropriate adjustments to the relative values for those 

services. Section 1848(c)(2)(L) to the Act also requires the Secretary to develop a process to 

validate the RVUs of certain potentially misvalued codes under the PFS, using the same criteria 

used to identify potentially misvalued codes, and to make appropriate adjustments. 

As discussed in section I.B. of this proposed rule, each year we develop appropriate 

adjustments to the RVUs taking into account recommendations provided by the American 

Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), 

MedPAC, and others. For many years, the RUC has provided us with recommendations on the 

appropriate relative values for new, revised, and potentially misvalued PFS services. We review 

these recommendations on a code-by-code basis and consider these recommendations in 

conjunction with analyses of other data, such as claims data, to inform the decision-making 

process as authorized by the law. We may also consider analyses of work time, work RVUs, or 

direct PE inputs using other data sources, such as Department of Veteran Affairs (VA), National 

Surgical Quality Improvement Program (NSQIP), the Society for Thoracic Surgeons (STS), and 

the Physician Quality Reporting Initiative (PQRI) databases. In addition to considering the most 

recently available data, we also assess the results of physician surveys and specialty 

recommendations submitted to us by the RUC. We also consider information provided by other 

stakeholders. We conduct a review to assess the appropriate RVUs in the context of 

contemporary medical practice. We note that section 1848(c)(2)(A)(ii) of the Act authorizes the 

use of extrapolation and other techniques to determine the RVUs for physicians' services for 

which specific data are not available in addition to taking into account the results of 

consultations with organizations representing physicians. In accordance with section 1848(c) of 

the Act, we determine and make appropriate adjustments to the RVUs. 
 69 

In its March 2006 Report to the Congress, MedPAC discussed the importance of 

appropriately valuing physicians’ services, noting that “misvalued services can distort the price 

signals for physicians' services as well as for other health care services that physicians order, 

such as hospital services.'' In that same report MedPAC postulated that physicians' services 

under the PFS can become misvalued over time. MedPAC stated, “When a new service is added 

to the PFS, it may be assigned a relatively high value because of the time, technical skill, and 

psychological stress that are often required to furnish that service. Over time, the work required 

for certain services would be expected to decline as physicians become more familiar with the 

service and more efficient in furnishing it.'' We believe services can also become overvalued 

when PE declines. This can happen when the costs of equipment and supplies fall, or when 

equipment is used more frequently than is estimated in the PE methodology, reducing its cost per 

use. Likewise, services can become undervalued when physician work increases or PE rises. 

As MedPAC noted in its March 2009 Report to Congress, in the intervening years since 

MedPAC made the initial recommendations, “CMS and the RUC have taken several steps to 

improve the review process.” Also, since that time Congress added section 1848(c)(2)(K)(ii) to 

the Act, which augments our efforts. It directs the Secretary to specifically examine, as 

determined appropriate, potentially misvalued services in the following seven categories: 

● Codes and families of codes for which there has been the fastest growth; 

● Codes and families of codes that have experienced substantial changes in PEs; 

● Codes that are recently established for new technologies or services; 

● Multiple codes that are frequently billed in conjunction with furnishing a single 

service; 

● Codes with low relative values, particularly those that are often billed multiple times 

for a single treatment; 
 70 

● Codes which have not been subject to review since the implementation of the RBRVS 

(the so-called ‘Harvard-valued codes’); and 

● Other codes determined to be appropriate by the Secretary. 

Section 220(c) of the PAMA further expanded the categories of codes that the Secretary 

is directed to examine by adding nine additional categories. These are: 

● Codes that account for the majority of spending under the PFS; 

● Codes for services that have experienced a substantial change in the hospital length of 

stay or procedure time; 

● Codes for which there may be a change in the typical site of service since the code was 

last valued; 

● Codes for which there is a significant difference in payment for the same service 

between different sites of service; 

● Codes for which there may be anomalies in relative values within a family of codes; 

● Codes for services where there may be efficiencies when a service is furnished at the 

same time as other services; 

● Codes with high intra-service work per unit of time; 

● Codes with high PE RVUs; and 

● Codes with high cost supplies. 

Section 1848(c)(2)(K)(iii) of the Act also specifies that the Secretary may use existing 

processes to receive recommendations on the review and appropriate adjustment of potentially 

misvalued services. In addition, the Secretary may conduct surveys, other data collection 

activities, studies, or other analyses, as the Secretary determines to be appropriate, to facilitate 

the review and appropriate adjustment of potentially misvalued services. This section also 

authorizes the use of analytic contractors to identify and analyze potentially misvalued codes, 
 71 

conduct surveys or collect data, and make recommendations on the review and appropriate 

adjustment of potentially misvalued services. Additionally, this section provides that the 

Secretary may coordinate the review and adjustment of any RVU with the periodic review 

described in section 1848(c)(2)(B) of the Act. Section 1848(c)(2)(K)(iii)(V) of the Act specifies 

that the Secretary may make appropriate coding revisions (including using existing processes for 

consideration of coding changes) that may include consolidation of individual services into 

bundled codes for payment under the PFS. 

b. Progress in Identifying and Reviewing Potentially Misvalued Codes 

To fulfill our statutory mandate, we have identified and reviewed numerous potentially 

misvalued codes as specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to continue our 

work examining potentially misvalued codes in these areas over the upcoming years. As part of 

our current process, we identify potentially misvalued codes for review, and request 

recommendations from the RUC and other public commenters on revised work RVUs and direct 

PE inputs for those codes. The RUC, through its own processes, also identifies potentially 

misvalued codes for review. Through our public nomination process for potentially misvalued 

codes established in the CY 2012 PFS final rule with comment period, other individuals and 

stakeholder groups submit nominations for review of potentially misvalued codes as well. 

Since CY 2009, as a part of the annual potentially misvalued code review and the fiveyear review process, we have reviewed over 1,250 potentially misvalued codes to refine work 

RVUs and direct PE inputs. We have assigned appropriate work RVUs and direct PE inputs for 

these services as a result of these reviews. A more detailed discussion of the extensive prior 

reviews of potentially misvalued codes is included in the CY 2012 PFS final rule with comment 

period (76 FR 73052 through 73055). In the CY 2012 final rule with comment period, we 

finalized our policy to consolidate the review of physician work and PE at the same time (76 FR 
 72 

73055 through 73958), and established a process for the annual public nomination of potentially 

misvalued services. 

In the CY 2013 final rule with comment period, we built upon the work we began in CY 

2009 to review potentially misvalued codes that have not been reviewed since the 

implementation of the PFS (so-called “Harvard-valued codes”). In CY 2009, we requested 

recommendations from the RUC to aid in our review of Harvard-valued codes that had not yet 

been reviewed, focusing first on high-volume, low intensity codes (73 FR 38589). In the Fourth 

Five-Year Review, we requested recommendations from the RUC to aid in our review of 

Harvard-valued codes with annual utilization of greater than 30,000 (76 FR 32410). In the CY 

2013 final rule with comment period, we identified Harvard-valued services with annual allowed 

charges that total at least $10,000,000 as potentially misvalued. In addition to the Harvardvalued codes, in the CY 2013 final rule with comment period we finalized for review a list of 

potentially misvalued codes that have stand-alone PE (codes with physician work and no listed 

work time and codes with no physician work and have listed work time). 

In the CY 2014 final rule with comment period, we finalized for review a list of 

potentially misvalued services that included ultrasound guidance codes that had longer procedure 

times than the typical procedure with which the code is billed to Medicare. We also finalized our 

proposal to replace missing post-operative hospital evaluation and management (E/M) visit 

information and work time for approximately 100 global surgery codes. In CY 2014, we also 

considered a proposal to limit Medicare PFS payments for services furnished in a nonfacility 

setting when the PFS payment would exceed the combined Medicare payment under the PFS to 

the practitioner and facility payment made to either the ASC or hospital outpatient. Based upon 

extensive public comment we did not finalize this proposal. We address our current 
 73 

consideration of the potential use of OPPS data in establishing RVUs for PFS services in section 

II.A. of this proposed rule. 

c. Validating RVUs of Potentially Misvalued Codes 

Section 1848(c)(2)(L) of the Act requires the Secretary to establish a formal process to 

validate RVUs under the PFS. The Act specifies that the validation process may include 

validation of work elements (such as time, mental effort and professional judgment, technical 

skill and physical effort, and stress due to risk) involved with furnishing a service and may 

include validation of the pre-, post-, and intra-service components of work. The Secretary is 

directed, as part of the validation, to validate a sampling of the work RVUs of codes identified 

through any of the 16 categories of potentially misvalued codes specified in section 

1848(c)(2)(K)(ii) of the Act. Furthermore, the Secretary may conduct the validation using 

methods similar to those used to review potentially misvalued codes, including conducting 

surveys, other data collection activities, studies, or other analyses as the Secretary determines to 

be appropriate to facilitate the validation of RVUs of services. 

In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS proposed rule (76 

FR 42790), we solicited public comments on possible approaches, methodologies, and data 

sources that we should consider for a validation process. A summary of the comments along 

with our responses are included in the CY 2011 PFS final rule with comment period (75 FR 

73217) and the CY 2012 PFS final rule with comment period (73054 through 73055). 

Since that time, we have contracted with two outside entities to develop validation 

models for RVUs. Given the central role of time in establishing work RVUs and the concerns 

that have been raised about the current time values used in rate setting, we contracted with the 

Urban Institute to collect time data from several practices for services selected by the contractor 

in consultation with CMS. These data will be used to develop time estimates for PFS services. 
 74 

The Urban Institute will use a variety of approaches to develop objective time estimates, 

depending on the type of service. Objective time estimates will be compared to the current time 

values used in the fee schedule. The project team will then convene groups of physicians from a 

range of specialties to review the new time data and their potential implications for work and the 

ratio of work to time. In its efforts to collect primary data on the time involved in PFS services, 

the Urban Institute has encountered numerous challenges. An interim report, Development of a 

Model for the Valuation of Work Relative Value Units, discusses the challenges encountered in 

collecting objective time data and offers some thoughts on how these can be overcome. This 

interim report is on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-Urban-Interim-Report.pdf. 

Collection of time data under this project has just begun. A final report will be available once 

the project is complete. 

The second contract is with the RAND Corporation, which is using available data to 

build a validation model to predict work RVUs and the individual components of work RVUs, 

time, and intensity. The model design was informed by the statistical methodologies and 

approach used to develop the initial work RVUs and to identify potentially misvalued procedures 

under current CMS and RUC processes. RAND will use a representative set of CMS-provided 

codes to test the model. RAND consulted with a technical expert panel on model design issues 

and the test results. We anticipate a report from this project by the end of the year and will make 

the report available on the CMS website. 

Descriptions of both projects are available on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/RVUs-Validation-Model.pdf. 

3. CY 2015 Identification and Review of Potentially Misvalued Services 
 75 

a. Public Nomination of Potentially Misvalued Codes 

In the CY 2012 PFS final rule with comment period, we finalized a process for the public 

to nominate potentially misvalued codes (76 FR 73058). The public and stakeholders may 

nominate potentially misvalued codes for review by submitting the code with supporting 

documentation during the 60-day public comment period following the release of the annual PFS 

final rule with comment period. Supporting documentation for codes nominated for the annual 

review of potentially misvalued codes may include the following: 

● Documentation in the peer reviewed medical literature or other reliable data that there 

have been changes in physician work due to one or more of the following: technique; knowledge 

and technology; patient population; site-of-service; length of hospital stay; and work time. 

● An anomalous relationship between the code being proposed for review and other 

codes. 

● Evidence that technology has changed physician work. 

● Analysis of other data on time and effort measures, such as operating room logs or 

national and other representative databases. 

● Evidence that incorrect assumptions were made in the previous valuation of the 

service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous 

evaluation. 

● Prices for certain high cost supplies or other direct PE inputs that are used to determine 

PE RVUs are inaccurate and do not reflect current information. 

● Analyses of work time, work RVU, or direct PE inputs using other data sources (for 

example, Department of Veteran Affairs (VA) National Surgical Quality Improvement Program 

(NSQIP), the Society for Thoracic Surgeons (STS) National Database, and the Physician Quality 

Reporting System (PQRS) databases). 
 76 

● National surveys of work time and intensity from professional and management 

societies and organizations, such as hospital associations. 

We evaluate the supporting documentation submitted with the nominated codes and 

assess whether the nominated codes appear to be potentially misvalued codes appropriate for 

review under the annual process. In the following year’s PFS proposed rule, we publish the list 

of nominated codes and indicate whether we are proposing each nominated code as a potentially 

misvalued code. The public has the opportunity to comment on these and all other proposed 

potentially misvalued codes. In that year’s final rule, we finalize our list of potentially 

misvalued codes. 

During the comment period on the CY 2014 final rule with comment period, we received 

nominations and supporting documentation for two codes to be considered as potentially 

misvalued codes. We evaluated the supporting documentation for each nominated code to 

ascertain whether the submitted information demonstrated that the code should be proposed as 

potentially misvalued. 

CPT code 41530 (submucosal ablation of the tongue base, radiofrequency, 1 or more 

sites, per session) was nominated for review as a potentially misvalued code. The nominator 

stated that CPT code 41530 is misvalued because there have been changes in the PE items used 

in furnishing the service. The nominator specifically requested that the SD109 probe (probe, 

radiofrequency, 3 array (StarBurstSDE)) be replaced with a more typically used probe, which 

costs less, and that a replacement be used for equipment code EQ214 (radiofrequency generator) 

to reflect a more appropriate input based on current invoices. We are proposing this code as a 

potentially misvalued code. 

CPT code 99174 (instrument-based ocular screening (eg, photoscreening, automatedrefraction), bilateral) was also nominated for review as a potentially misvalued code. The 
 77 

nominator asserted that CPT code 99174 is misvalued because of outdated capital equipment 

inputs and the removal of supply code SK110 (fee, image analysis) from the code’s direct PE 

inputs. (The latter change was proposed and finalized during CY 2014 notice and comment 

rulemaking). In establishing our public nomination process, we specified that the we would only 

consider nominations of active codes that are covered by Medicare at the time of the nomination 

stating, “We also are limiting the review of RVUs to codes that are active, covered by Medicare, 

and for which the RVUs are used for payment purposes under the PFS so that resources are not 

expended on the review of codes with RVUs that have no financial impact on the PFS.” (76 FR 

73059). CPT code 99174 is non-covered on the PFS and therefore does not meet the criteria for 

review as a potentially misvalued code. Accordingly, we are not proposing CPT code 99174 as a 

potentially misvalued code. 

b. Potentially Misvalued Codes 

(1) Review of High Expenditure Services across Specialties with Medicare Allowed Charges of 

$10,000,000 or More 

We are proposing the approximately 65 codes listed in Table 10 as potentially misvalued 

codes as a prioritized subset of codes of the newly established statutory category, “codes that 

account for the majority of spending under the physician fee schedule.” As we identify 

potentially misvalued codes, we prioritize codes that are important to the Medicare program and 

its beneficiaries, and codes that account for a high level of Medicare expenditures meet this 

criterion. However, through our usual identification potentially misvalued codes it is possible to 

miss certain services that are important to a segment of Medicare practitioners and beneficiaries 

because the specialty that typically furnishes the service does not have high volume relative to 

the overall PFS utilization. To capture such services in developing this list, we looked at high 
 78 

expenditure services by specialty using a similar approach to the one we used in CY 2012. We 

believe it is appropriate to repeat this type of analysis periodically. 

To develop the CY 2015 proposed list in this category, we began by identifying the top 

20 codes by specialty in terms of allowed charges. For this analysis, we used the same 

specialties as used for the impact analysis in section VI. of this proposed rule. We excluded 

codes from our proposed potentially misvalued list that we have reviewed since CY 2009, with 

fewer than $10 million in allowed charges, and that describe anesthesia or E/M services. We 

excluded E/M services from the list of proposed potentially misvalued codes for the same 

reasons that we excluded them in the CY 2012 analysis, which we explained in the CY 2012 

final rule with comment period (76 FR 73062 through 73065). 

We believe that a review of the codes in Table 10 is warranted to assess changes in 

physician work and to update direct PE inputs since these codes have not been reviewed since 

CY 2009 or earlier. Furthermore, since these codes have significant impact on PFS payment at 

the specialty level, a review of the relativity of the codes is essential to ensure that the work and 

PE RVUs are appropriately relative within the specialty and across specialties, as discussed 

previously. For these reasons, we are proposing the codes listed in Table 10 as potentially 

misvalued. 

TABLE 10: Proposed Potentially Misvalued Codes Identified Through High Expenditure 

Specialty Screen 

HCPCS Short Descriptor 

11100 Biopsy skin lesion 

11101 Biopsy skin add-on 

11730 Removal of nail plate 

11750 Removal of nail bed 

14060 Tis trnfr e/n/e/l 10 sq cm/< 

17110 Destruct b9 lesion 1-14 

31575 Diagnostic laryngoscopy 

31579 Diagnostic laryngoscopy 

36215 Place catheter in artery 
 79 

HCPCS Short Descriptor 

36475 Endovenous rf 1st vein 

36478 Endovenous laser 1st vein 

36870 Percut thrombect av fistula 

51720 Treatment of bladder lesion 

51728 Cystometrogram w/vp 

51798 Us urine capacity measure 

52000 Cystoscopy 

55700 Biopsy of prostate 

65855 Laser surgery of eye 

66821 After cataract laser surgery 

67228 Treatment of retinal lesion 

68761 Close tear duct opening 

71010 Chest x-ray 1 view frontal 

71020 Chest x-ray 2vw frontal&latl 

71260 Ct thorax w/dye 

73560 X-ray exam of knee 1 or 2 

73562 X-ray exam of knee 3 

73564 X-ray exam knee 4 or more 

74183 Mri abdomen w/o & w/dye 

75978 Repair venous blockage 

76536 Us exam of head and neck 

76700 Us exam abdom complete 

76770 Us exam abdo back wall comp

76775 Us exam abdo back wall lim 

77263 Radiation therapy planning 

77334 Radiation treatment aid(s) 

78452 Ht muscle image spect mult 

88185 Flowcytometry/tc add-on 

91110 Gi tract capsule endoscopy 

92136 Ophthalmic biometry 

92250 Eye exam with photos 

92557 Comprehensive hearing test 

93280 Pm device progr eval dual 

93306 Tte w/doppler complete 

93351 Stress tte complete 

93978 Vascular study 

94010 Breathing capacity test 

95004 Percut allergy skin tests 

95165 Antigen therapy services 

95957 Eeg digital analysis 
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HCPCS Short Descriptor 

96101 Psycho testing by psych/phys 

96118 Neuropsych tst by psych/phys 

96372 Ther/proph/diag inj sc/im 

96375 Tx/pro/dx inj new drug addon 

96401 Chemo anti-neopl sq/im 

96409 Chemo iv push sngl drug 

97032 Electrical stimulation 

97035 Ultrasound therapy 

97110 Therapeutic exercises 

97112 Neuromuscular reeducation 

97113 Aquatic therapy/exercises 

97116 Gait training therapy 

97140 Manual therapy 1/> regions 

97530 Therapeutic activities 

G0283 Elec stim other than wound 

(2) Epidural Injection and Fluoroscopic Guidance − CPT Codes 62310, 62311, 62318, 62319, 

77001, 77002 and 77003 

For CY 2014, we established interim final values for four epidural injection procedures, 

CPT codes 62310 (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, 

antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 

needle or catheter placement, includes contrast for localization when performed, epidural or 

subarachnoid; cervical or thoracic), 62311 (Injection(s), of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 

substances, including needle or catheter placement, includes contrast for localization when 

performed, epidural or subarachnoid; lumbar or sacral (caudal)), 62318 (Injection(s), including 

indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or 

therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, includes contrast for localization when performed, epidural or 

subarachnoid; cervical or thoracic) and 62319 (Injection(s), including indwelling catheter 
 81 

placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 

substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar 

or sacral (caudal)). These interim final values resulted in CY 2014 payment reductions from the 

CY 2013 rates for all four procedures. 

In the CY 2014 final rule with comment period (78 FR 74340), we described in detail our 

interim valuation of these codes. We indicated we established interim final work RVUs for these 

codes below those recommended by the RUC because we did not believe that the RUCrecommended work RVUs accounted for the substantial decrease in time it takes to furnish these 

services since the last time they were valued as reflected in the RUC survey data for these four 

codes. Since the RUC provided no indication that the intensity of the procedures had changed, 

we believed that the work RVUs should reflect the reduction in time. We also established 

interim final direct PE inputs for these four codes based on the RUC-recommended inputs 

without any refinement. These recommendations included the removal of the radiographicfluoroscopy room for 62310, 62311, and 62318 and a portable C-arm for 62319. 

We received thousands of comments objecting to the CY 2014 interim final values for 

these codes, many citing concerns with patient access and with the potential for the payment 

reductions under the PFS to inappropriately incentivize the use of the hospital setting or to 

encourage the use of other injections. Some suggested these payment rates might affect the rate 

of opioid use. Although most comments did not address the accuracy of the relative value inputs 

used in determining PFS payment rates, those that did most often objected to our valuations of 

the work RVUs and recommended that we instead accept the RUC recommendations. Several 

commenters objected to our rationale for setting the interim final work RVUs lower than the 

RUC-recommended values primarily based upon the reduction in time. Commenters gave two 
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primary reasons why this reduction was inappropriate. Some pointed out that a reduction in 

work based upon a reduction in time presumes that the existing time is correct. These 

commenters asserted that the existing times were not correct for these codes. For example, the 

RUC noted that the CY 2013 survey times were from the original 1999 survey and were an 

outlier when compared to the previously reported code’s original Harvard-valued total time of 42 

minutes. One commenter noted that CMS indicates that in setting work values, the agency 

considers time, mental effort, professional judgment, technical skill, physical effort and stress 

due to risk; but in this case, rather than following our process, we only considered time. Others 

also said that we did not take into account the intensity, complexity, or risk of performing 

epidural injections. Commenters disagreed with the use of the lowest RUC survey value as the 

basis for the work valuation. One commenter said that we failed to explain adequately why our 

work RVUs were below those recommended by the RUC. One recommended that we assign 

values more similar to those used for paravertebral injections. 

Two commenters stated that critical PE inputs, including an epidural needle, loss or 

resistance syringe and spinal needle, were missing from the valuation. One commenter indicated 

that a radiographic-fluoroscopic room should be included for CPT codes 62310, 62311 and 

62318; and a mobile C-Arm should be included for CPT code 62319. Another commenter 

requested the decreases in the PE RVUs be phased in over a period of years. 

Several commenters objected to the use of the interim final process for valuing these 

codes, citing the lack of opportunity for public comment and the lack of time to adequately 

prepare before the cuts to reimbursement took effect. Some suggested a delay in 

implementation. 

Lastly, several commenters requested refinement panel review of these codes. 

After analyzing the comments and considering valuation of these codes, we believe that 
 83 

we need to reassess our valuation of these codes and require additional information in order to do 

so. Our data show that these epidural codes are frequently billed with imaging guidance. For 

example, CPT code 62310 was billed with CPT code 77003 (Fluoroscopic guidance and 

localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection 

procedures (epidural or subarachnoid)) 79 percent of the time in the nonfacility setting in CY 

2013. CPT code 62319, which is the epidural injection code that is least frequently billed with 

CPT code 77003 in the nonfacility setting, was still billed with this guidance code 40 percent of 

the time. These codes were also frequently billed with image guidance in the facility setting. 

CPT codes 62310 and 62311 were billed with CPT code 77003, 79 percent and 74 percent of the 

time, respectively in CY 2013. However, in the facility setting CPT codes 62318 and 62319 

were much less frequently billed with CPT code 77003, only 3 percent and 11 percent, 

respectively. In addition, these four epidural injection codes are sometimes billed with other 

fluoroscopic or imaging guidance codes. Based on the frequency with which these codes are 

reported with fluoroscopic guidance codes, it appears that fluoroscopic guidance is both typically 

used and typically reported separately in conjunction with the epidural injection services. 

As we considered the concerns raised regarding the CY 2014 payment changes for the 

epidural injection procedures, we looked at the values for other injection procedures. Other 

injection procedures, including some recommended by commenters for use as a reference in 

valuing these epidural injection codes, include the work and PEs of image guidance in the 

injection code. For example, transforaminal injections, CPT codes 64479 (Injection(s), 

anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 

CT); cervical or thoracic, single level), 64480 (Injection(s), anesthetic agent and/or steroid, 

transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each 

additional level (List separately in addition to code for primary procedure)), 64483 (Injection(s), 
 84 

anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 

CT); lumbar or sacral, single level) and 64484 (Injection(s), anesthetic agent and/or steroid, 

transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each 

additional level (List separately in addition to code for primary procedure)) include the image 

guidance in the injection code. Similarly, the paravertebral injections, CPT code 64490 

(Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 

innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single 

level), 64491 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 

joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 

thoracic; second level (List separately in addition to code for primary procedure)), 64492 

(Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 

innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and 

any additional level(s) (List separately in addition to code for primary procedure)), 64493 

(Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 

innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level), 

64494 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 

nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second 

level (List separately in addition to code for the primary procedure)) and 64495 (Injection(s), 

diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 

that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional 

level(s)( List separately in addition to code for primary procedure)) each include the image 

guidance bundled in the injection CPT code. 

Based upon our analysis of the Medicare claims data and comments received on the CY 

2014 final rule with comment period, it appears that these codes are typically furnished with 
 85 

imaging guidance. Thus, we believe it would be appropriate for the injection and imaging 

guidance codes to be bundled and the inputs for image guidance to be included in the valuation 

of the epidural injection codes as it is for transforaminal and paravertebral codes. We do not 

believe the epidural injection codes can be appropriately valued without considering the typical 

use of image guidance. We also believe this will help assure relativity with other injection codes 

that include the image guidance. To determine how to appropriately value resources for the 

combined codes, we believe more information is needed. Accordingly, we propose to include 

CPT codes 62310, 62311, 62318 and 62319 on the potentially misvalued code list so that we can 

obtain information to support their valuation with the image guidance included. In the 

meantime, we are proposing to revert to the CY 2013 input values for CPT codes 62310, 62311, 

62318 and 62319 for CY 2015. Specifically, we will use the CY 2013 work RVUs, work times, 

and direct PE inputs to establish payment rates for CY 2015. The work, PE, and MP RVUs for 

these codes are listed in Addendum B and the time values for all CY 2015 codes are listed in the 

file “CY 2015 PFS Work Time,” available on the CMS website under downloads for the CY 

2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The direct PE inputs are 

displayed the file “CY 2015 PFS Direct PE Inputs,” available on the CMS website under 

downloads for the CY 2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. 

Because it is clear that the proposed PE inputs for the epidural injection codes include 

items that are specifically related to image guidance, such as the radiographic fluoroscopic room, 

we believe separate reporting of the image guidance codes would overestimate the resources 

used in furnishing the two services together. To avoid this situation, we are also proposing to 

prohibit the billing of image guidance codes in conjunction with these four epidural injection 
 86 

codes. We believe our two-tiered proposal to utilize CY 2013 input values for this code family, 

while prohibiting the separate billing of imaging guidance codes in conjunction with epidural 

injection, would best ensure that appropriate reimbursement continues to be made while we 

gather additional information and consider the best way to value these services. 

With regard to comments about the time for responding to the interim values, we would 

refer to section II.F of this proposed rule, which discusses a proposal to make changes in the 

process used for establishing revised values for codes such as these. 

With regard to the request for refinement, we are denying this request as the comments 

do not demonstrate that the requirements for refinement were met. Moreover, since we are 

proposing different values for these codes for CY 2015 (using CY 2013 inputs) there would be 

no purpose for refinement as the public comment period for this proposed rule will provide the 

opportunity for the public to share any relevant information on our proposed values. 

(3) Neurostimulator Implantation − CPT codes 64553 and 64555 

A stakeholder raised questions regarding whether CPT codes 64553 (Percutaneous 

implantation of neurostimulator electrode array; cranial nerve) and 64555 (Percutaneous 

implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)) 

included the appropriate direct PE inputs when furnished in the nonfacility setting. It appears 

that these inputs have not been evaluated recently and, therefore, we are nominating these codes 

as potentially misvalued for the purpose of ascertaining whether or not there are nonfacility 

direct PE inputs that are not included in the direct PE inputs that are typical supply costs for 

these services. 

(4) Mammography − CPT codes 77055, 77056, and 77057, and HCPCS codes G0202, G0204, 

and G0206 

Medicare currently pays for mammography services through both CPT codes, (77055 
 87 

(mammography; unilateral), 77056 (mammography; bilateral) and 77057 (screening 

mammography, bilateral (2-view film study of each breast)) and HCPCS G-codes, (G0202 

(screening mammography, producing direct digital image, bilateral, all views), G0204 

(diagnostic mammography, producing direct digital image, bilateral, all views), and G0206 

(diagnostic mammography, producing direct digital image, unilateral, all views)). The CPT 

codes were designed to be used for mammography regardless of whether film or digital 

technology is used. However, for Medicare purposes, the HCPCS G-codes were created to be 

used for digital technology in response to special payment rules for digital mammography 

included in the Medicare Benefit Improvements and Protection Act of 2000. 

As discussed in section II.A., the RUC recommended that CMS update the direct PE 

inputs for all imaging codes to reflect the migration from film-to-digital storage technologies 

since digital storage is now the typically used in imaging. 

Our data confirms that the overwhelming majority of all mammography is digital. As a 

result, we are proposing that the CPT codes 77055, 77056 and 77057 be used for reporting 

mammography to Medicare regardless of whether film or digital technology is used, and to 

delete the HCPCS G-codes G0202, G0204, and G0206. We are proposing, for CY 2015, to 

value the CPT codes using the values established for the digital mammography G-codes since 

digital technology is now the typical service. (See section II.A. of this proposed rule for more 

discussion of this proposal.) In addition, since the G-codes values that we propose to use for the 

CPT codes for CY 2015 have not been reviewed since they were created in CY 2002, we are 

proposing to include CPT codes 77055, 77056, and 77057 on the list of potentially misvalued 

codes. 

(5) Abdominal Aortic Aneurysm Ultrasound Screening − G0389 

 When Medicare began paying for abdominal aortic aneurysm (AAA) ultrasound 
 88 

screening in CY 2007, we created HCPCS code G0389 (Ultrasound, B-scan and/or real time with 

image documentation; for abdominal aortic aneurysm (AAA) screening), and set the RVUs at the 

same level as CPT code 76775 (Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan 

and/or real time with image documentation; limited). We noted in the CY 2007 final rule with 

comment period that CPT code 76775 was used to report the service when furnished as a 

diagnostic test and that we believed the service reflected by G0389 used equivalent resources and 

work intensity to those contained in CPT code 76775 (71 FR 69664 through 69665). 

In the CY 2014 proposed rule, based on a RUC recommendation, we proposed to replace 

the ultrasound room included as a direct PE input for CPT code 76775 with a portable ultrasound 

unit. Since all the RVUs (including the PE RVUs) for G0389 were crosswalked from CPT code 

76775, the proposed PE RVUs for G0389 in the CY 2014 proposed rule were reduced 

significantly as a result of this change to the direct PE inputs for 76775. However, we did not 

discuss the applicability of this change to G0389 in the proposed rule’s preamble and did not 

receive any comments on G0389 in response to the proposed rule. We finalized the change to 

CPT code 76775 in the CY 2014 final rule with comment period and the corresponding PE 

RVUs for G0389 were also reduced. 

Subsequent to the publication of the CY 2014 final rule, a stakeholder suggested that the 

reduction in the RVUs for G0389 did not accurately reflect the resources involved in furnishing 

the service and asked that CMS consider using an alternative crosswalk. Specifically, the 

stakeholder stated that the type of equipment typically used in furnishing G0389 is different than 

that used for CPT code 76775, the time involved in furnishing G0389 is greater than that of CPT 

code 76775, and the specialty that typically furnishes G0389 is different than the one that 

typically furnishes CPT code 76775. The stakeholder suggested an alternative crosswalk of CPT 

code 76705 (Ultrasound, abdominal, real time with image documentation; limited (eg, single 
 89 

organ, quadrant, follow-up)). 

After considering the issue, we are proposing G0389 as a potentially misvalued code and 

seeking recommendations regarding the appropriate inputs that should be used to develop RVUs 

for this code. We have not reviewed the inputs used to develop RVUs for this code since it was 

established in CY 2007 and the RVUs were directly crosswalked from 76705. Based on the 

issues raised by stakeholders, we believe that we should value this code through our standard 

methodologies, including the full PE RVU methodology. In order to do so, we are proposing to 

include this code on our list of proposed potentially misvalued codes and seek input from the 

public and other stakeholders, including the RUC, regarding the appropriate work RVU, time, 

and direct PE inputs that reflect the typical resources involved in furnishing the service. 

Until we receive the information needed to revalue this service, we are proposing to 

maintain the work RVU for this code and revert to the same PE RVUs we used for CY 2013, 

adjusted for budget neutrality. We are proposing MP RVUs based on the five-year review 

update process as described in section II.C of this proposed rule. We believe this valuation will 

ameliorate the effect of the CY 2014 reduction in G0389 that resulted from reflection of the 

change in RVUs for the crosswalked code while we assess the valuation of this code through our 

usual methodologies. The proposed PE RVUs are contained in Addendum B available on the 

CMS website under downloads for the CY 2015 PFS proposed rule at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. 

(6) Prostate Biopsy Codes – HCPCS codes G0416, G0417, G0418, and G0419 

For CY 2014, we modified the code descriptors of G0416 through G0419 so that these 

codes could be used for any method of prostate needle biopsy services, rather than only for 

prostate saturation biopsies. The CY 2014 descriptions are: 
 90 

● G0416 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 10–20 specimens). 

● G0417 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 21–40 specimens). 

● G0418 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 41–60 specimens). 

● G0419 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; greater than 60 specimens). 

Subsequently, we have discussed prostate biopsies with stakeholders, and reviewed 

medical literature and Medicare claims data in considering how best to code and value prostate 

biopsy pathology services. In considering these discussions and our review, we have become 

aware that the current coding structure may be confusing, especially since the number of 

specimens associated with prostate biopsies is relatively homogenous. For example, G0416 (10-

20 specimens) represents the overwhelming majority of all Medicare claims submitted for the 

four G-codes. Therefore, in the interest of both establishing straightforward coding and 

maintaining accurate payment, we believe it would be appropriate to use only one code to report 

prostate biopsy pathology services. Therefore, we propose to revise the descriptor for G0416 to 

define the service regardless of the number of specimens, and to delete codes G0417, G0418, and 

G0419. We propose to revise G0416 for use to report all prostate biopsy pathology services, 

regardless of the number of specimens, because we believe this will eliminate the possible 

confusion caused by the coding while maintaining payment accuracy. 

Based on our review of medical literature and examination of Medicare claims data, we 

believe that the typical number of specimens evaluated for prostate biopsies is between 10 and 
 91 

12. Since G0416 is the code that currently is valued and used for between 10 and 12 specimens, 

we are proposing to use the existing values for G0416 for CY 2015. 

In addition, we are proposing G0416 as a potentially misvalued code for CY 2015. We 

seek public comment on the appropriate work RVUs, work time, and direct PE inputs. 

(7) Obesity Behavioral Group Counseling – GXXX2 and GXXX3 

Under section 1861(ddd) of the Act, we added coverage for a new preventive benefit, 

Intensive Behavioral Therapy for Obesity, effective November 29, 2011, and created HCPCS 

code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) for reporting and 

payment of individual behavioral counseling for obesity. Coverage requirements specific to this 

service are delineated in the Medicare National Coverage Determinations Manual, Pub. 100–03, 

Chapter 1, Section 210, available at 

http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. 

It has been brought to our attention that behavioral counseling for obesity is sometimes 

furnished in group sessions, and questions were raised about whether group sessions could be 

billed using HCPCS code G0447. To improve payment accuracy, we are creating two new 

HCPCS codes for the reporting and payment of group behavioral counseling for obesity. 

Specifically, we are creating GXXX2 (Face-to-face behavioral counseling for obesity, group (2-

4), 30 minutes) and GXXX3 (Face-to-face behavioral counseling for obesity, group (5-10), 30 

minutes). The coverage requirements for these services would remain in place, as described in 

the National Coverage Determination for Intensive Behavioral Therapy for Obesity cited in this 

section of the proposed rule. The practitioner furnishing these services would report the relevant 

group code for each beneficiary participating in a group therapy session. 

We believe that the face-to-face behavioral counseling for obesity services described by 

GXXX2 and GXXX3 would require similar per minute work and intensity as HCPCS code 
 92 

G0447, which is a 15-minute code with a work RVU of 0.45. Therefore, to develop proposed 

work RVUs for HCPCS codes GXXX2 and GXXX3 we scaled the work RVU of HCPCS code 

G0447 to reflect the differences in the codes in terms of the time period covered by the code and 

the typical number of beneficiaries per session. Adjusting the work RVU for the longer time of 

the group codes results in a work RVU of 0.90 for a 30-minute session. Since the services 

described by GXXX2 and GXXX3 will be billed per beneficiary receiving the service, the work 

RVUs and work time that we are proposing for these codes are based upon the typical number of 

beneficiaries per session, 4 and 9, respectively. Accordingly, we are proposing a work RVU of 

0.23 with a work time of 8 minutes for GXXX2 and a work RVU of 0.10 with a work time of 3 

minutes for GXXX3. 

Using the same logic, we are proposing to use the direct PE inputs for GXXX2 and 

GXXX3 currently included for G0447, prorated to account for the differences in time and 

number of beneficiaries described by the new codes. The proposed direct PE inputs for these 

codes are included in the CY 2015 proposed direct PE input database, available on the CMS 

website under the downloads for the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. We are also proposing to crosswalk the malpractice 

risk factor from HCPCS code G0447 to both HCPCS codes GXXX2 and GXXX3, as we believe 

the same specialty mix will furnish these services. We request public comment on these 

proposed values for HCPCS codes GXXX2 and GXXX3. 

4. Improving the Valuation and Coding of the Global Package 

a. Overview 

Since the inception of the PFS, we have valued and paid for certain services, such as 

surgery, as part of global packages that include the procedure and the services typically provided 

in the periods immediately before and after the procedure (56 FR 59502). For each of these 
 93 

codes (usually referred to as global surgery codes), we establish a single PFS payment that 

includes payment for particular services that we assume to be typically furnished during the 

established global period. 

There are three primary categories of global packages that are labeled based on the 

number of post-operative days included in the global period: 0-day; 10-day; and 90-day. The 0-

day global codes include the surgical procedure and the pre-operative and post-operative 

physicians’ services on the day of the procedure, including visits related to the service. The 10-

day global codes include these services and, in addition, visits related to the procedure during the 

10 days following the procedure. The 90-day global codes include the same services as the 0-

day global codes plus the pre-operative services furnished one day prior to the procedure and 

post-operative services during the 90 days immediately following the day of the procedure. 

Section 40.1 of the Claims Processing Manual (Pub. 100–04, Chapter 12 

Physician/Nonphysician Practitioners) defines the global surgical package to include the 

following services when furnished during the global period: 

● Preoperative Visits − Preoperative visits after the decision is made to operate 

beginning with the day before the day of surgery for major procedures and the day of 

surgery for minor procedures; 

● Intra-operative Services − Intra-operative services that are normally a usual and 

necessary part of a surgical procedure; 

● Complications Following Surgery − All additional medical or surgical services 

required of the surgeon during the postoperative period of the surgery because of 

complications that do not require additional trips to the operating room; 

● Postoperative Visits − Follow-up visits during the postoperative period of the 

surgery that are related to recovery from the surgery; 
 94 

● Postsurgical Pain Management − By the surgeon; 

● Supplies − Except for those identified as exclusions; and 

● Miscellaneous Services − Items such as dressing changes; local incisional care; 

removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, 

drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine 

peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of 

tracheostomy tubes. 

b. Concerns with the 10- and 90-Day Global Packages 

 CMS supports bundled payments as a mechanism to incentivize high-quality, efficient 

care. Although on the surface, the PFS global codes appear to function as bundled payments 

similar to those Medicare uses to make single payments for multiple services to hospitals under 

the inpatient and outpatient prospective payment systems, the practical reality is that these global 

codes function significantly differently than other bundled payments. First, the global surgical 

codes were established several decades ago when surgical follow-up care was far more 

homogenous than today. Today, there is more diversity in the kind of procedures covered by 

global periods, the settings in which the procedures and the follow-up care are furnished, the 

health care delivery system and business arrangements used by Medicare practitioners, and the 

care needs of Medicare beneficiaries. Despite these changes, the basic structures of the global 

surgery packages are the same as the packages that existed prior to the creation of the resourcebased relative value system in 1992. Another significant difference between this and other 

typical models of bundled payments is that the payment rates for the global surgery packages are 

not updated regularly based on any reporting of the actual costs of patient care. For example, the 

hospital inpatient and outpatient prospective payment systems (the IPPS and OPPS, respectively) 

derive payment rates from hospital cost and charge data reported through annual Medicare 
 95 

hospital cost reports and the most recent year of claims data available for an inpatient stay or 

primary outpatient service. Because payment rates are based on consistently updated data, over 

time, payment rates adjust to reflect the average resource costs of current practice. Similarly, 

many of the new demonstration and innovation models track costs and make adjustments to 

payments. Another significant difference is that payment for the PFS global packages relies on 

valuing the combined services together. This means that there are no separate PFS values 

established for the procedures or the follow-up care, making it difficult to estimate the costs of 

the individual global code component services. 

These unique characteristics have contributed to the significant and numerous concerns 

that have been raised regarding the accuracy of payment for global codes – especially those that 

include 10- and 90-day post-operative periods. In the following paragraphs, we address a series 

of concerns regarding these codes, including: the fundamental difficulties in establishing 

appropriate relative values for these packages, the potential inaccuracies in the current 

information used to price these services, the limitations on appropriate pricing in the future, the 

potential for these packages to create unwarranted payment differentials among specialties, the 

possibility that the current codes are incompatible with current medical practice, and the 

potential for these codes to present obstacles to the adoption of new payment models. 

 Independently, concerns such as these could be seen as issues that arise when developing 

many different payment mechanisms, for example: making fee-for-service payment rates, 

making single payments for multiple services, or paying practitioners for episodes of care over a 

period of time. However, in the case of the post-operative portion of the 10- and 90-day global 

codes, we believe these multi-layered concerns create substantial barriers to accurate valuation of 

these services relative to other PFS services. 
 96 

(1) Fundamental Limitations in the Appropriate Valuation of the Global Packages with Postoperative days. 

In general, we face many challenges in valuing PFS services as accurately as possible. 

However, the unique nature of global surgery packages with 10- and 90-day post-operative 

periods presents additional challenges distinct from those presented in valuing other PFS 

services. Our valuation methodology for PFS services generally relies on assumptions regarding 

the resources involved in furnishing the “typical case” for each individual service unlike other 

payment systems that rely on actual data on the costs of furnishing services. Consistent with this 

valuation methodology, the RVUs for a global code should reflect the typical number and level 

of E/M services furnished in connection with the procedure. However, it is much easier to 

maintain relativity among the services that are valued on this basis when each of the services is 

described by codes of similar unit sizes. In other words, because codes with long post-operative 

periods include such a large number of services, any variations between the “typical” resource 

costs used to value the service and the actual resource costs associated with particular services 

are multiplied. The effects of this problem can be two-fold, skewing the accuracy of both the 

RVUs for individual global codes and the Medicare payment made to individual practitioners. 

The RVUs of the individual global service codes are skewed whenever there is any inaccuracy in 

the assumption of the typical number or kind of services in the post-operative periods. This 

inaccuracy has a greater impact than inaccuracies in assumptions for other PFS services because 

it affects a greater number of service units over a period of time than for individually priced 

services. Furthermore, in contrast to prospective payment systems, such inaccuracies under the 

PFS are not corrected over time through an annual ratesetting process that makes year-to-year 

adjustments based on data on actual costs. For example, if a 90-day global code is valued based 

on an assumption that ten post-operative visits is typical, but practitioners reporting the code 
 97 

typically only furnish six visits, then the resource assumptions are overestimated by the value of 

the four visits multiplied by the number of the times the procedure code is reported. In contrast, 

when our assumptions are incorrect about the typical resources involved in furnishing a PFS 

code that describes a single service, any inaccuracy in the RVUs is limited to the difference 

between the resource costs assumed for the typical service and the actual resource costs in 

furnishing one individual service. Such a variation between the assumptions used in calculating 

payment rates and the actual resource costs could be corrected if the payments for packaged 

services were updated regularly using data on actual services furnished. Although such a 

mechanism is common in other bundled payment systems, there is no such mechanism under the 

PFS. To make adjustments to the RVUs to account for inaccurate assumptions under the current 

PFS methodology, the global surgery code would need to be identified as potentially misvalued, 

survey data would have to reflect an accurate account of the number and level of typical postoperative visits, and we (with or without a corresponding recommendation from the RUC or 

others) would have to implement a change in RVUs based on the change in the number and level 

of visits to reflect the typical service. 

These amplified inaccuracies may also occur whenever Medicare pays an individual 

practitioner reporting a 10- or 90-day global code. Practitioners may furnish a wide range of 

post-operative services to individual Medicare beneficiaries, depending on individual patient 

needs, changes in medical practice, and dynamic business models. Due to the way the 10- and 

90-day global codes are constructed, the number and level of services included for purposes of 

calculating the payment for these services may vary greatly from the number and level of 

services that are actually furnished in any particular case. In contrast, the variation between the 

“typical” and the actual resource cost for the practitioner reporting an individually valued PFS 
 98 

services is constrained because the practitioner is only reporting and being paid for a specific 

service furnished on a particular date. 

For most PFS services, any difference between the “typical” case on which RVUs are 

based and the actual case for a particular service is limited to the variation between the resources 

assumed to be involved in furnishing the typical case and the actual resources involved in 

furnishing the single specific service. When the global surgical package includes more or a 

higher level of E/M services than are actually furnished in the typical post-operative period, the 

Medicare payment is based on an overestimate of the quantity or kind of services furnished, not 

merely an overestimation of the resources involved in furnishing an individual service. The 

converse is true if the RVUs for the global surgical package are based on fewer or a lower level 

of services than are typically furnished for a particular code. 

(2) Questions Regarding Accuracy of Current Assumptions 

In previous rulemaking (77 FR 68911 through 68913), we acknowledged evidence 

suggesting that the values included in the post-operative period for global codes may not reflect 

the typical number and level of post-operative E/M visits actually furnished. 

In 2005, the OIG examined whether global surgical packages are appropriately valued. 

In its report on eye and ocular surgeries, “National Review of Evaluation and Management 

Services Included in Eye and Ocular Adnexa Global Surgery Fees for Calendar Year 2005” (A05-07-00077), the OIG reviewed a sample of 300 eye and ocular surgeries, and counted the 

actual number of face-to-face services recorded in the patients’ medical records to establish 

whether and, if so, how many post-operative E/M services were furnished by the surgeons. For 

about two-thirds of the claims sampled by the OIG, surgeons provided fewer E/M services in the 

post-operative period than were included in the global surgical package payment for each 

procedure. A small percentage of the surgeons furnished more E/M services than were included 
 99 

in the global surgical package payment. The OIG identified the number of face-to-face services 

recorded in the medical record, but did not review the medical necessity of the surgeries or the 

related E/M services. The OIG concluded that the RVUs for these global surgical packages are 

too high because they include a higher number of E/M services than typically are furnished 

within the global period for the reviewed procedures. 

Following that report, the OIG continued to investigate E/M services furnished during 

global surgical periods. In May 2012, the OIG published a report entitled “Musculoskeletal 

Global Surgery Fees Often Did Not Reflect the Number of Evaluation and Management Services 

Provided” (A-05-09-00053). For this investigation, the OIG sampled 300 musculoskeletal global 

surgeries and again found that, for the majority of sampled surgeries, physicians furnished fewer 

E/M services than were included as part of the global period payment for that service. Once 

again, a small percentage of surgeons furnished more E/M services than were included in the 

global surgical package payment. The OIG concluded that the RVUs for these global surgical 

packages are too high because they include a higher number of E/M services than typically are 

furnished within the global period for the reviewed procedures. 

In both reports, the OIG recommended that we adjust the number of E/M services 

identified with the studied global surgical payments to reflect the number of E/M services that 

are actually being furnished. However, since it is not necessary under our current global surgery 

payment policy for a surgeon to report the individual E/M services actually furnished during the 

global surgical period, we do not have objective data upon which to assess whether the RVUs for 

global period surgical services reflect the typical number or level of E/M services that are 

furnished. In the CY 2013 PFS proposed rule (77 FR 44738), we previously sought public 

comments on collecting these data. As summarized in the CY 2013 PFS final rule (77 FR 

68913) we did not discover a consensus among stakeholders regarding either the most 
 100 

appropriate means to gather the data, or the need for, or the appropriateness of using such data in 

valuing these services. In response to our comment solicitation, some commenters urged us to 

accept the RUC survey data as accurate in spite of the OIG reports and other concerns that have 

been expressed regarding whether the visits included in the global periods reflected the typical 

case. Others suggested that we should conduct new surveys using the RUC approach or that we 

should mine hospital data to identify the typical number of visits furnished. Some comments 

suggested eliminating the 10- and 90-day global codes. 

(3) Limitations on Appropriate Future Valuations of 10- and 90-day Global Codes 

Historically, our attempts to adjust RVUs for global services based on changes in the 

typical resource costs (especially with regard to site of service assumptions or changes to the 

number of post-surgery visits) have been difficult and controversial. At least in part, this is 

because the relationship between the work RVUs for the 10- and 90-day global codes (which 

includes the work RVU associated with the procedure itself) and the number of included postoperative visits in the existing values is not always clear. Some services with global periods 

have been valued by adding the work RVU of the surgical procedure and all pre- and postoperative E/M services included in the global period. However, in other cases, as many 

stakeholders have noted, the total work RVUs for surgical procedures and post-operative visits in 

global periods are estimated as a single value without any explicit correlation to the time and 

intensity values for the individual service components. Although we would welcome more 

objective information to improve our determination of the “typical” case, we believe that even if 

we engaged in the collection of better data on the number and level of E/M services typically 

furnished during the global periods for global surgery services, the valuation of individual codes 

with post-operative periods would not be straightforward. Furthermore, we believe it would be 

important to frequently update the data on the number and level of visits furnished during the 
 101 

post-operative periods in order to account for any changes in the patient population, medical 

practice, or business arrangements. Although such information would be available for 

developing payment rates for bundled services through other Medicare payment systems, 

practitioners paid through the PFS do not report such data. 

(4) Unwarranted Payment Disparities 

Subsequent to our last comment solicitation regarding the valuation of the post-operative 

periods (77 FR 68911 through 68913), some stakeholders have raised concerns that global 

surgery packages contribute to unwarranted payment disparities between practitioners who do 

and do not furnish these services. These stakeholders have addressed several ways the 10- and 

90-day global packages may contribute to unwarranted payment disparities. 

The stakeholders noted that, through the global surgery packages, Medicare pays 

practitioners who furnish E/M services during post-surgery periods regardless of whether the 

services are actually furnished, while practitioners who do not furnish global procedures with 

post-operative visits are only paid for E/M services that are actually furnished. In some cases, it 

is possible that the practitioner furnishing the global surgery procedure may not furnish any postoperative visits. Although we have policies to address the situation when post-operative care is 

transferred from one practitioner to another, the beneficiary might simply choose to seek care 

from another practitioner without a formal transfer of care. The other practitioner would then 

bill Medicare separately for E/M services for which payment was included in the global payment 

to the original practitioner. Those services would not have been separately billable if furnished 

by the original practitioner. 

These circumstances can lead to unwarranted payment differences, allowing some 

practitioners to receive payment for fewer services than reflected in the Medicare payment. 

Practitioners who do not furnish global surgery services bill and are paid only for each individual 
 102 

service furnished. When global surgery values are based on inaccurate assumptions about the 

typical services furnished in the post-operative periods, these payment disparities can contribute 

to differences in aggregate RVUs across specialties. Since the RVUs are intended to reflect 

differences in the relative resource costs involved in furnishing a service, any disparity between 

assumed and actual costs results not only in paying some practitioners for some services that are 

not furnished, it also skews relativity between specialties. 

Stakeholders have also pointed out that payment disparities can arise because E/M 

services reflected in global periods generally include higher PE values than the same services 

when billed separately. The difference in PE values between separately billed visits and those 

included in global packages result primarily from two factors that are both inherent in the PFS 

pricing methodology. 

First, there is a different mix of PE inputs (clinical labor/supplies/ equipment) included in 

the direct PE inputs for a global period E/M service and a separately billed E/M service. For 

example, the clinical labor inputs for separately reportable E/M codes includes a staff blend 

listed as “RN/LPN/MTA” (L037D) and priced at $0.37 per minute. Instead of this input, some 

codes with post-operative visits include the staff type “RN” (L051A) priced at a higher rate of 

$0.51 per minute. For these codes, the higher resource cost may accurately reflect the typical 

resource costs associated with those particular visits. However, the different direct PE inputs 

may drive unwarranted payment disparities among specialties who report global surgery codes 

with post-operative periods and those that do not. The only way to correct these potential 

discrepancies under the current system, which result from the specialty-based differences in 

resource costs, would be to include standard direct PE inputs for these services regardless of 

whether or not the standard inputs are typical for the specialties furnishing the services. 
 103 

Second, the indirect PE allocated to the E/M visits included in global surgery codes is 

higher than that allocated to separately furnished E/M visits. This occurs because the range of 

specialties furnishing a particular global service is generally not as broad as range of specialties 

that report separate individual E/M services. Since the specialty mix for a service is a key factor 

in determining the allocation of indirect PE to each code, a higher amount of indirect PE can be 

allocated to the E/M services that are valued as part of the global surgery codes than to the 

individual E/M codes. Practitioners who use E/M codes to report visits separately are paid based 

on PE RVUs that reflect the amount of indirect PE allocated across a wide range of specialties, 

which has the tendency to lower the amount of indirect PE. For practitioners who are paid for 

visits primarily through post-operative periods, indirect PE is generally allocated with greater 

specificity. Two significant steps would be required to alleviate the impact of this disparity. 

First, we would have to identify the exact mathematical relationship between the work RVU and 

the number and level of post-operative visits for each global code; and second, we would have to 

propose a significant alteration of the PE methodology in order to allocate indirect PE that does 

not correlate to the specialties reporting the code in the Medicare claims data. 

Furthermore, stakeholders have pointed out that the PE RVUs for codes with 10- or 90-

day post-operative periods reflect the assumption that all outpatient visits occur in the higherpaid non-facility office setting, when many of these visits are likely to be furnished in providerbased departments, which would be paid at the lower, PFS facility rate if they were billable 

separately. As we note elsewhere in this proposed rule, we do not have data on the volume of 

physicians’ services furnished in provider-based departments, but public information suggests 

that it is not insignificant and that it is growing. When these services are paid as part of a global 

package, there is no adjustment made based on the site of service. Therefore, even though the 

PFS payment for services furnished in post-operative global periods might include clinical labor, 
 104 

disposable supply, and medical equipment costs (and additional indirect PE allocation) that are 

incurred by the facility and not the practitioner reporting the service, the RVUs for global codes 

reflect all of these costs associated with the visits. 

(5) Incompatibility of Current Packages with Current Practice and Unreliability of RVUs for Use 

in New Payment Models 

In addition to these issues, the 10- and 90-day global periods reflect a long-established 

but no longer exclusive model of post-operative care that assumes the same practitioner who 

furnishes the procedure typically furnishes the follow-up visits related to that procedure. In 

many cases, we believe that models of post-operative care are increasingly heterogeneous, 

particularly given the overall shift of patient care to larger practices or team-based environments. 

We believe that RVUs used to establish PFS payments are likely to serve as critical 

building blocks to developing, testing, and implementing a number of new payment models, 

including those that focus on bundled payments to practitioners or payments for episodes of care. 

Therefore, we believe it is critical for us to ensure that the PFS RVUs accurately reflect the 

resource costs for individual PFS services instead of reflecting potentially skewed assumptions 

regarding the number of services furnished over a long period of time in the “typical” case. To 

the extent that the 10- and 90-day global periods reflect inaccurate assumptions regarding 

resource costs associated with individual PFS services, we believe they are likely to be obstacles 

to a wide range of potential improvements to PFS payments, including the potential 

incorporation of payment bundling designed to foster efficiency and quality care for Medicare 

beneficiaries. 

c. Proposed Transition of 10- and 90-day Global Packages into 0-day Global Packages 

Although we have marginally addressed some of the concerns noted above with global 

packages in previous rulemaking, we do not believe that we have made significant progress in 
 105 

addressing the fundamental issues with the 10- and 90-day post-operative global packages. In 

the context of the misvalued code initiative, we believe it is critical for the RVUs used to develop 

PFS payment rates reflect the most accurate resource costs associated with PFS services. Based 

on the issues discussed above, we do not believe we can effectively address the issues inherent in 

establishing values for the 10- and 90-day global packages under our existing methodologies and 

with available data. As such, we do not believe that maintaining the post-operative 10-and 90-

day global periods is compatible with our continued interest in using more objective data in the 

valuation of PFS services and accurately valuing services relative to each other. Because the 

typical number and level of post-operative visits during global periods may vary greatly across 

Medicare practitioners and beneficiaries, we believe that continued valuation and payment of 

these face-to-face services as a multi-day package may skew relativity and create unwarranted 

payment disparities within PFS payment. We also believe that the resource based valuation of 

individual physicians’ services will continue to serve as a critical foundation for Medicare 

payment to physicians, whether through the current PFS or in any number of new payment 

models. Therefore, we believe it is critical that the RVUs under the PFS be based as closely and 

accurately as possible on the actual resources involved in furnishing the typical occurrence of 

specific services 

To address the issues discussed above, we are proposing to retain global bundles for 

surgical services, but to refine bundles by transitioning over several years all 10- and 90-day 

global codes to 0-day global codes. Medically reasonable and necessary visits would be billed 

separately during the pre- and post-operative periods outside of the day of the surgical procedure. 

We propose to make this transition for current 10-day global codes in CY 2017 and for the 

current 90-day global codes in CY 2018, pending the availability of data on which to base 

updated values for the global codes. 
 106 

We believe that transitioning all 10- and 90-day global codes to 0-day global codes 

would: 

• Increase the accuracy of PFS payment by setting payment rates for individual services 

based more closely upon the typical resources used in furnishing the procedures; 

• Avoid potentially duplicative or unwarranted payments when a beneficiary receives 

post-operative care from a different practitioner during the global period; 

• Eliminate disparities between the payment for E/M services in global periods and those 

furnished individually; 

• Maintain the same-day packaging of pre- and post-operative physicians’ services in the 

0-day global; and 

• Facilitate availability of more accurate data for new payment models and quality 

research. 

As we transition these codes, we would need to establish RVUs that reflect the change in 

the global period for all the codes currently valued as 10- and 90-day global surgery services. 

We seek assistance from stakeholders on various aspects of this task. Prior to implementing 

these changes, we intend to gather objective data on the number of E/M and other services 

furnished during the current post-operative periods and use those data to inform both the 

valuation of particular services and the overall budget neutrality adjustments required to 

implement this proposal. We seek comment on the most efficient means of acquiring accurate 

data regarding the number of visits and other services actually being furnished by the practitioner 

during the current post-operative periods. For all the reasons stated above, we do not believe that 

survey data reflecting assumptions of the “typical case” meets the standards required to measure 

the resource costs of the wide range of services furnished during the post-operative periods. We 

acknowledge that collecting information on these services through claims submission may be the 
 107 

best approach, and we would propose such a collection through future rulemaking. However, we 

are also interested in alternatives. For example, we seek information on the extent to which 

individual practitioners or practices may currently maintain their own data on services furnished 

during the post-operative period, and how we might collect and objectively evaluate that data. 

We also seek comment on the best means to ensure that allowing separate payment of 

E/M visits during post-operative periods does not incentivize otherwise unnecessary office visits 

during post-operative periods. If we adopt this proposal, we intend to monitor any changes in the 

utilization of E/M visits following its implementation but we are also seeking comment on 

potential payment policies that will mitigate such a change in behavior. 

In developing this proposal, we considered several alternatives to the transformation of 

all global codes to 0-day global codes. First, we again considered the possibility of gathering 

data and using the data to revalue the 10- and 90- day global codes. While this option would 

have maintained the status quo in terms of reporting services, it would have required much of the 

same effort as this proposal without alleviating many of the problems associated with the 10- and 

90-day global periods. For example, collecting accurate data would allow for more accurate 

estimates of the number and kind of visits included in the post-operative periods at the time of 

the survey. However, this alternative approach would only mitigate part of the potential for 

unwarranted payment disparities. For example, the values for the visits in the global codes 

would continue to include different amounts of PE RVUs than separately reportable visits and 

would continue to provide incentives to some practitioners to minimize patient visits. 

Additionally, it would not address the changes in practice patterns that we believe have been 

occurring whereby the physician furnishing the procedure is not necessarily the same physician 

conducting the post-procedure follow up. 
 108 

This alternative option would also rest extensively on the effectiveness of using the new 

data to revalue the codes accurately. Given the unclear relationship between the assigned work 

RVUs and the post-operative visits across all of these services, incorporating objective data on 

the number of visits to adjust work RVUs would still necessitate extensive review of individual 

codes or families of codes by CMS and stakeholders, including the RUC. We believe the 

investment of resources for such an effort would be better made to solve a broader range of 

problems. 

We also considered other possibilities, such as altering our PE methodology to ensure 

that the PE inputs and indirect PE for visits in the global period were valued the same as 

separately reportable E/M codes or requiring reporting of the visits for all 10- and 90-day global 

services while maintaining the 10- and 90-day global period payment rates. However, we 

believe this option would require all of the same effort by practitioners, CMS, and other 

stakeholders without alleviating most of the problems addressed in the preceding paragraphs. 

We also considered maintaining the status quo and identifying each of the 10- and 90-day 

global codes as potentially misvalued through our potentially misvalued code process for review 

as 10 and 90 day globals. Inappropriate valuations of these services has a major effect on the fee 

schedule due to the percentage of PFS dollars paid through 10- and 90-day global codes (3 

percent and 11 percent, respectively), and thus, valuing them appropriately is critical to 

appropriate valuation and relativity throughout the PFS. Through the individual review 

approach, we could review the appropriateness of the global period and the accurate number of 

visits for each service. Yet revaluing all 3,000 global surgery codes through the potentially 

misvalued codes approach would not address many of the problems identified above. Unless 

such an effort was combined with changes in the PE methodology, it would only partially 

address the valuation and accuracy issues and would leave all the other issues unresolved. 
 109 

Moreover, the valuation and accuracy issues that could be addressed through this approach 

would rapidly be out of date as medical practice continues to change. Therefore, such an 

approach would be only partially effective and would impede our ability to address other 

potentially misvalued codes. 

We seek stakeholder input on an accurate and efficient means to revalue or adjust the 

work RVUs for the current 10- and 90-day global codes to reflect the typical resources involved 

in furnishing the services including both the pre- and post-operative care on the day of the 

procedure. We believe that collecting data on the number and level of post-operative visits 

furnished by the practitioner reporting current 10-and 90-day global codes will be essential to 

ensuring work RVU relativity across these services. We also believe that these data will be 

necessary to determine the relationship between current work RVUs and current number of postoperative visits, within categories of codes and code families. However, we believe that once we 

collect those data, there are a wide range of possible approaches to the revaluation of the large 

number of individual global services, some of which may deviate from current processes like 

those undertaken by the RUC. To date, the potentially misvalued code initiative has focused on 

several hundred, generally high-volume codes per year. This proposal requires revaluing a larger 

number of codes over a shorter period of time and includes many services with relatively low 

volume in the Medicare population. Given these circumstances, it does not seem practical to 

survey time and intensity information on each of these procedures. Absent any new survey data 

regarding the procedures themselves, we believe that data regarding the number and level of 

post-service office visits can be used in conjunction with other methods of valuation, such as: 

• Using the current potentially misvalued code process to identify and value the 

relatively small number of codes that represent the majority of the volume of services that are 

currently reported with codes with post-operative periods, and then adjusting the aggregate 
 110 

RVUs to account for the number of visits and using magnitude estimation to value the remaining 

services in the family; 

• Valuing one code within a family through the current valuation process and then using 

magnitude estimation to value the remaining services in the family; 

• Surveying a sample of codes across all procedures to create an index that could be used 

to value the remaining codes. 

While we believe these are plausible options for the revaluation of these services, we 

believe there may be others. Therefore, we seek input on the best approach to achieve this 

proposed transition from 10- and 90-day, to 0-day global periods, including the timing of the 

changes, the means for revaluation, and the most effective and least burdensome means to collect 

objective, representative data regarding the actual number of visits currently furnished in the 

post-operative global periods. We also seek comment on whether the effective date for the 

transition to 0-day global periods should be staggered across families of codes or other 

categories. For example, while we are proposing to transition 10-day global periods in 2017 and 

90-day global periods in 2018, we seek comment on whether we should consider implementing 

the transition more or less quickly and over one or several years. We also seek comment 

regarding the appropriate valuation of new, revised, or potentially misvalued 10- or 90-day 

global codes before implementation of this proposal. 

5. Improving the Valuation of the Global Package 

In the CY 2013 proposed rule, we sought comments on methods of obtaining accurate 

and current data on E/M services furnished as part of a global surgical package. In addition to 

receiving the broader comments on measuring post-operative work, we also received a comment 

from the RUC saying that the hospital inpatient and discharge day management services included 

in the global period for many surgical procedures were inadvertently removed from the time file 
 111 

in 2007. With its comment letter, the RUC sent us a data file with updated times for these postoperative visits for some services that displayed zero hospital inpatient or discharge day visits in 

the CMS time file. After extensive review, we concluded that the data were deleted from the 

time file due to an inadvertent error as noted by the RUC. Therefore, during CY 2014 PFS 

rulemaking we finalized a proposal to replace the missing postoperative hospital inpatient and 

discharge day visits for the more than 100 codes that were identified by the RUC. 

Since then, the AMA has identified additional codes with data in the work time file that 

reflects a similar error. Since we believe these global surgery codes are missing postoperative 

hospital inpatient and discharge day visits due to an inadvertent error, we are proposing to 

include a corrected number of visits for the codes displayed in Table 11. This proposal would 

also alter the total time associated with the codes in the work time file. 

TABLE 11: Proposed Work Time Changes in Selected Global Surgical Package Visits 

CPT 

code Short Descriptor 

Visits included in Global Package 

CY 2014 

Time 

CY 2015 

99231 99232 99233 99238 99291 99292 Time 

19367 

Breast 

reconstruction 3.00 ---- ---- 1.00 ---- ---- 552.00 590.00 

20802 

Replantation arm 

complete 6.00 ---- ---- 1.00 ---- ---- 1047.00 1041.00 

20805 

Replant forearm 

complete 6.00 ---- ---- 1.00 ---- ---- 1017.00 1012.00 

20808 

Replantation hand 

complete 5.00 ---- ---- 1.00 ---- ---- 1177.00 1112.00 

20972 

Bone/skin graft 

metatarsal 5.00 ---- ---- 1.00 ---- ---- 918.00 898.00 

21137 

Reduction of 

forehead ---- ---- ---- 1.00 ---- ---- 272.00 310.00 

21138 

Reduction of 

forehead ---- ---- ---- 1.00 ---- ---- 362.00 400.00 

21150 

Lefort ii anterior 

intrusion 1.00 ---- ---- 1.00 1.00 ---- 542.00 623.00 

21159 

Lefort iii w/fhdw/o 

lefort i 3.00 ---- ---- 1.00 2.00 ---- 784.00 986.00 

21160 

Lefort iii w/fhd w/ 

lefort i ---- 2.50 ---- 1.00 2.50 ---- 844.00 1121.00 

21172 

Reconstruct 

orbit/forehead ---- 1.50 ---- 1.00 1.50 ---- 474.00 641.00 
 112 

CPT 

code Short Descriptor 

Visits included in Global Package 

CY 2014 

Time 

CY 2015 

99231 99232 99233 99238 99291 99292 Time 

21175 

Reconstruct 

orbit/forehead ---- 1.00 ---- 1.00 2.00 ---- 767.00 731.00 

21179 

Reconstruct entire 

forehead ---- ---- ---- 1.00 2.00 ---- 412.00 590.00 

21180 

Reconstruct entire 

forehead ---- ---- ---- 1.00 2.00 ---- 492.00 670.00 

21181 

Contour cranial 

bone lesion 1.00 ---- ---- 1.00 ---- ---- 338.00 396.00 

21182 

Reconstruct cranial 

bone ---- 1.00 ---- 1.00 2.00 ---- 856.00 801.00 

21183 

Reconstruct cranial 

bone ---- 2.00 ---- 1.00 2.00 ---- 669.00 891.00 

21184 

Reconstruct cranial 

bone ---- 2.00 ---- 1.00 2.00 ---- 774.00 996.00 

22102 

Remove part lumbar 

vertebra 3.00 ---- ---- 1.00 ---- ---- 392.00 387.00 

22310 

Closed tx vert fx 

w/o manj 3.50 ---- ---- 1.00 ---- ---- 167.00 236.00 

28122 

Partial removal of 

foot bone ---- ---- ---- 1.00 ---- ---- 230.00 249.00 

33470 

Revision of 

pulmonary valve 1.50 ---- ---- 1.00 3.50 ---- 890.00 769.00 

33471 

Valvotomy 

pulmonary valve 4.00 ---- ---- 1.00 1.00 ---- 603.00 572.00 

33476 

Revision of heart 

chamber ---- ---- ---- 1.00 5.00 ---- 725.00 859.00 

33478 

Revision of heart 

chamber ---- ---- ---- 1.00 5.00 ---- 740.00 882.00 

33610 

Repair by 

enlargement 7.00 ---- ---- 1.00 ---- ---- 770.00 648.00 

33720 

Repair of heart 

defect ---- ---- ---- 1.00 4.00 ---- 633.00 770.00 

33737 

Revision of heart 

chamber 2.00 ---- ---- 1.00 3.00 ---- 603.00 706.00 

33755 Major vessel shunt 1.50 ---- ---- 1.00 3.50 ---- 680.00 750.00 

33762 Major vessel shunt 1.50 ---- ---- 1.00 3.50 ---- 740.00 755.00 

33766 Major vessel shunt 1.50 ---- ---- 1.00 3.50 ---- 740.00 756.00 

33775 

Repair great vessels 

defect 0.50 ---- ---- 1.00 6.50 ---- 860.00 1043.00 

33776 

Repair great vessels 

defect 1.50 ---- ---- 1.00 6.50 ---- 950.00 1096.00 

33777 

Repair great vessels 

defect 3.50 ---- ---- 1.00 4.50 ---- 950.00 993.00 

33813 Repair septal defect 1.00 ---- ---- 1.00 3.00 ---- 603.00 664.00 

33814 Repair septal defect ---- ---- ---- 1.00 5.00 ---- 710.00 838.00 
 113 

CPT 

code Short Descriptor 

Visits included in Global Package 

CY 2014 

Time 

CY 2015 

99231 99232 99233 99238 99291 99292 Time 

33822 Revise major vessel ---- ---- ---- 1.00 2.00 ---- 430.00 463.00 

50360 

Transplantation of 

kidney 1.00 2.00 2.00 1.00 ---- ---- 664.00 774.00 

61556 Incise skull/sutures 3.00 3.00 1.00 1.00 ---- ---- 749.00 692.00 

61558 

Excision of 

skull/sutures 5.00 ---- ---- 1.00 ---- ---- 669.00 661.00 

61559 

Excision of 

skull/sutures 4.00 ---- ---- 1.00 ---- ---- 662.00 665.00 

61563 

Excision of skull 

tumor 1.00 2.00 1.00 1.00 ---- ---- 762.00 656.00 

61564 

Excision of skull 

tumor 4.00 ---- ---- 1.00 ---- ---- 629.00 623.00 

61580 

Craniofacial 

approach skull ---- 3.00 4.00 1.00 1.00 ---- 1313.30 1078.30 

61581 

Craniofacial 

approach skull 1.00 1.00 5.00 1.00 1.00 ---- 1419.40 1214.40 

61582 

Craniofacial 

approach skull 4.00 3.00 1.00 1.00 1.00 ---- 1185.30 1010.30 

61583 

Craniofacial 

approach skull 8.00 ---- 1.00 1.00 1.00 ---- 1100.40 906.40 

61584 

Orbitocranial 

approach/skull 2.00 3.00 2.00 1.00 1.00 ---- 1066.40 842.40 

61585 

Orbitocranial 

approach/skull 1.00 3.00 3.00 1.00 2.00 ---- 1377.70 1101.70 

61590 

Infratemporal 

approach/skull 1.00 ---- 7.00 1.00 2.00 ---- 1732.40 1418.40 

61591 

Infratemporal 

approach/skull 3.00 4.00 ---- 1.00 2.00 ---- 1478.85 1254.85 

61592 

Orbitocranial 

approach/skull 1.00 3.00 2.00 1.00 2.00 ---- 1256.80 1002.80 

61595 

Transtemporal 

approach/skull ---- 3.00 4.00 1.00 1.00 ---- 1312.80 1077.80 

61596 

Transcochlear 

approach/skull 1.00 4.00 3.00 1.00 1.00 ---- 1442.30 1188.30 

61597 

Transcondylar 

approach/skull 5.00 2.00 1.00 1.00 2.00 ---- 1284.40 1041.40 

61598 

Transpetrosal 

approach/skull 2.00 3.00 1.00 1.00 2.00 ---- 1253.10 1048.10 

61600 

Resect/excise 

cranial lesion ---- ---- 6.00 1.00 1.00 ---- 1328.40 1101.40 

61601 

Resect/excise 

cranial lesion 2.00 2.00 2.00 1.00 2.00 ---- 1078.90 854.90 

61605 

Resect/excise 

cranial lesion 3.00 2.00 1.00 1.00 2.00 ---- 1238.60 1052.60 

61606 

Resect/excise 

cranial lesion 3.00 3.00 1.00 1.00 2.00 ---- 1161.90 926.90 
 114 

CPT 

code Short Descriptor 

Visits included in Global Package 

CY 2014 

Time 

CY 2015 

99231 99232 99233 99238 99291 99292 Time 

61607 

Resect/excise 

cranial lesion ---- 1.00 6.00 1.00 2.00 ---- 1526.20 1201.20 

61608 

Resect/excise 

cranial lesion 3.00 3.00 2.00 1.00 2.00 ---- 1326.00 1042.00 

61613 

Remove aneurysm 

sinus 1.00 ---- 6.00 1.00 2.00 ---- 1416.00 1102.00 

61615 

Resect/excise lesion 

skull 2.00 4.00 2.00 1.00 1.00 ---- 1327.20 1092.20 

61616 

Resect/excise lesion 

skull 5.00 2.00 1.00 1.00 2.00 ---- 1329.80 1116.80 

61618 Repair dura ---- 1.00 2.00 1.00 ---- ---- 647.10 573.10 

61619 Repair dura 1.00 2.00 1.00 1.00 ---- ---- 683.60 587.60 

62115 

Reduction of skull 

defect 4.50 ---- ---- 1.00 ---- ---- 672.00 678.00 

62116 

Reduction of skull 

defect 1.00 2.00 1.00 1.00 ---- ---- 737.00 616.00 

62117 

Reduction of skull 

defect ---- 2.00 2.00 1.00 ---- ---- 854.00 714.00 

62120 

Repair skull cavity 

lesion 3.00 ---- ---- 1.00 ---- ---- 512.00 523.00 

6. Valuing Services that Include Moderate Sedation as an Inherent Part of Furnishing the 

Procedure 

The CPT manual includes more than 300 diagnostic and therapeutic procedures, listed in 

Appendix G, for which CPT has determined that moderate sedation is an inherent part of 

furnishing the procedure and, therefore, only the single procedure code is appropriately reported 

when furnishing the service and the moderate sedation. The work of moderate sedation has been 

included in the work RVUs for these diagnostic and therapeutic procedures based upon their 

inclusion in Appendix G. Similarly, the direct PE inputs for these services include those inputs 

associated with furnishing a typical moderate sedation service. To the extent that moderate 

sedation is typically furnished as part of the diagnostic or therapeutic service, the inclusion of 

moderate sedation in the valuation of the procedure is appropriate. 
 115 

 It appears that practice patterns for endoscopic procedures are changing, and anesthesia is 

increasingly being separately reported for these procedures. For example, one study shows that 

while the use of a separate anesthesia professional for colonoscopies and upper endoscopies was 

just 13.5 percent in 2003, the rate more than doubled to 30.2 percent in 2009. An analysis of 

Medicare claims data shows that a similar pattern is occurring in the Medicare program. We find 

that, for certain types of procedures such as digestive surgical procedures, a separate anesthesia 

service is furnished 53 percent of the time. For some of these digestive surgical procedures, the 

claims analysis shows that this rate is as high as 80 percent. 

 Our data clearly indicate that moderate sedation is no longer typical for all of the 

procedures listed in CPT’s Appendix G, and, in fact, the data suggest that the percent of cases in 

which it is used is declining. For many of these procedures in Appendix G, moderate sedation 

continues to be furnished. The trend away from the use of moderate sedation toward a separately 

billed anesthesia service is not universal. It differs by the class of procedures, sometimes at the 

procedure code level, and is one that continues to evolve over time. Due to the changing nature 

of medical practice in this area, we are considering establishing a uniform approach to valuation 

for all Appendix G services for which moderate sedation is no longer inherent, rather than 

addressing this issue at the procedure level as individual procedures are revalued. 

 We are seeking public comment on approaches to address the appropriate valuation of 

these services. Specifically, we are interested in approaches to valuing Appendix G codes that 

would allow Medicare to pay accurately for moderate sedation when it is furnished while 

avoiding potential duplicative payments when separate anesthesia is furnished and billed. To the 

extent that Appendix G procedure values are adjusted to no longer include moderate sedation, we 

request suggestions as to how moderate sedation should be reported and valued, and how to 

remove from existing valuations the RVUs and inputs related to moderate sedation. 
 116 

 We note that in the CY 2014 PFS final rule with comment period, we established 

values for many upper gastrointestinal procedures, 58 of which were included in Appendix G. 

For those interim final values, we included the inputs related to moderate sedation. In the CY 

2015 PFS final rule with comment period, we will address these interim final values, and we 

anticipate establishing CY 2015 inputs for the lower gastrointestinal procedures, many of which 

are also listed in Appendix G. It is our expectation that we will not change existing policies for 

valuing moderate sedation as inherent in these procedures until we have the opportunity to assess 

and respond to the comments on this proposed rule on the overall valuation of Appendix G 

codes. 
 117 

C. Malpractice Relative Value Units (RVUs) 

1. Overview 

 Section 1848(c) of the Act requires that each service paid under the PFS be comprised 

of three components: work; PE; and malpractice (MP) expense. As required by section 

1848(c) of the Act, beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs 

for new codes after 1991 were extrapolated from similar existing codes or as a percentage of the 

corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also requires that we review, 

and if necessary adjust, RVUs no less often than every 5 years. For CY 2015, we are proposing 

to implement the third comprehensive review and update of MP RVUs. For details about prior 

updates, see the CY 2010 final rule with comment period (74 FR 33537). 

2. Methodology for the Proposed Revision of Resource-Based Malpractice RVUs 

a. General Discussion 

The proposed MP RVUs were calculated by a CMS contractor based on updated MP 

premium data obtained from state insurance rate filings. The methodology used in calculating 

the proposed CY 2015 review and update of resource-based MP RVUs largely parallels the 

process used in the CY 2010 update. The calculation requires using information on specialtyspecific MP premiums linked to a specific service based upon the relative risk factors of the 

various specialties that furnish a particular service. Because MP premiums vary by state and 

specialty, the MP premium information must be weighted geographically and by specialty. 

Accordingly, the proposed MP RVUs are based upon three data sources: CY 2011 and CY 2012 

MP premium data; CY 2013 Medicare payment and utilization data; and CY 2015 proposed 

work RVUs and geographic practice cost indices (GPCIs). 

Similar to the previous update, we calculated the proposed MP RVUs using 

specialty-specific MP premium data because they represent the actual expense incurred by 
 118 

practitioners to obtain MP insurance. We obtained MP premium data primarily from state 

departments of insurance. When the state insurance departments did not provide data, we used 

state rate filing data from the Perr and Knight database, which derives its data from state 

insurance departments. We used information obtained from MP insurance rate filings with 

effective dates in 2011 and 2012. These were the most current data available during our data 

collection process. 

We collected MP insurance premium data from all 50 States, the District of Columbia, 

and Puerto Rico. Rate filings were not available in American Samoa, Guam, or the Virgin 

Islands. Premiums were for $1 million/$3 million, mature, claims-made policies (policies 

covering claims made, rather than those covering services furnished, during the policy term). A 

$1 million/$3 million liability limit policy means that the most that would be paid on any claim 

is $1 million and the most that the policy would pay for claims over the timeframe of the policy 

is $3 million. We made adjustments to the premium data to reflect mandatory surcharges for 

patient compensation funds (funds to pay for any claim beyond the statutory amount, thereby 

limiting an individual physician’s liability in cases of a large suit) in states where participation in 

such funds is mandatory. We attempted to collect premium data representing at least 50 percent 

of the medical MP premiums paid. 

We included premium information for all physician and NPP specialties, and all risk 

classifications available in the collected rate filings. Most insurance companies provided 

crosswalks from insurance service office (ISO) codes to named specialties. We matched these 

crosswalks to Medicare primary specialty designations (specialty codes). We also used 

information we obtained regarding surgical and nonsurgical classes. Some companies provided 

additional surgical subclasses; for example, distinguishing family practice physicians who 

furnish obstetric services from those who do not. 
 119 

Although we collected premium data from all states and the District of Columbia, not all 

specialties had premium data in the rate filings from all states. Additionally, for some 

specialties, MP premiums were not available from the rate filings in any state. Therefore, for 

specialties for which there was not premium data for at least 35 states, and specialties for which 

there was not distinct premium data in the rate filings, we crosswalked the specialty to a similar 

specialty, conceptually or by available premium data, for which we did have sufficient and 

reliable data. Additionally, we crosswalked three specialties − physician assistant, registered 

dietitian and optometry − for which we had data from at least 35 states to a similar specialty type 

because the available data contained such extreme variations in premium amounts that we found 

it to be unreliable. The range in premium amounts for registered dietitians is $85 to $20,813 

(24,259 percent), for physician assistants is $614 to $35,404 (5,665 percent), and for optometry 

is $189 to $10,798 (5,614 percent). Given that the national average premium amount for 

registered dietitians, physician assistants and optometry is below the national average premium 

amount for allergy and immunology, we crosswalked these specialties to allergy and 

immunology, the specialty with the lowest premiums for which we had sufficient and reliable 

data. 

For the proposed CY 2015 MP RVU update, sufficient and reliable premium data were 

available for 41 specialty types, which we used to develop specialty-specific malpractice risk 

factors. (See Table 13 for a list of these specialties.) 

For specialties with insufficient or unreliable premium data, we assigned the premium 

amounts of a similar specialty type. These specialties and the specialty data that we propose to 

use are shown in Table 12. 
 120 

TABLE 12: Crosswalk of Specialties to Similar Specialties 

 

Specialty 

Code Medicare Specialty Name 

Crosswalk 

Specialty 

Code Crosswalk Specialty 

09 Interventional Pain Management 05 Anesthesiology 

12 Osteopathic Manipulative Medicine 03 Allergy Immunology 

15 Speech Language Pathology 03 Allergy Immunology 

17 Hospice and Palliative Care 03 Allergy Immunology 

19 Oral Surgery (dental only) 24 Plastic and Reconstructive Surgery 

21 Cardiac Electrophysiology 06 Cardiology 

23 Sports Medicine 01 General Practice 

27 Geriatric Psychiatry 26 Psychiatry 

32 Anesthesiologist Assistant 05 Anesthesiology 

35 Chiropractic 03 Allergy Immunology 

41 Optometry 03 Allergy Immunology 

42 Certified Nurse Midwife 16 Obstetrics Gynecology 

43 

Certified Registered Nurse 

Anesthetist 05 Anesthesiology 

50 Nurse Practitioner 01 General Practice 

60 Public Health or Welfare Agency 03 Allergy Immunology 

62 Psychologist 03 Allergy Immunology 

64 Audiologist 03 Allergy Immunology 

65 Physical Therapist 03 Allergy Immunology 

67 Occupational Therapist 03 Allergy Immunology 

68 Clinical Psychologist 03 Allergy Immunology 

71 

Registered Dietitian/Nutrition 

Professional 03 Allergy Immunology 

72 Pain Management 05 Anesthesiology 

76 Peripheral Vascular Disease 77 Vascular Surgery 

79 Addiction Medicine 03 Allergy Immunology 

80 Licensed Clinical Social Worker 03 Allergy Immunology 

83 Hematology/Oncology 90 Medical Oncology 

85 Maxillofacial Surgery 24 Plastic and Reconstructive Surgery 

86 Neuropsychiatry 26 Psychiatry 

89 Certified Clinical Nurse Specialist 01 General Practice 

91 Surgical Oncology 02 General Surgery 

94 Interventional Radiology 30 Diagnostic Radiology 

97 Physician Assistant 03 Allergy Immunology 

98 Gynecological/Oncology 16 Obstetrics Gynecology 

99 Unknown Physician Specialty 01 General Practice 

C0 Sleep Medicine 01 General Practice 
 121 

b. Steps for Calculating Proposed Malpractice RVUs 

Calculation of the proposed MP RVUs conceptually follows the specialty-weighted 

approach used in the CY 2010 final rule with comment period (74 FR 61758). The 

specialty-weighted approach bases the MP RVUs for a given service upon a weighted average of 

the risk factors of all specialties furnishing the service. This approach ensures that all specialties 

furnishing a given service are accounted for in the calculation of the MP RVUs. The steps for 

calculating the proposed MP RVUs are described below. 

Step (1): Compute a preliminary national average premium for each specialty. 

Insurance rating area MP premiums for each specialty are mapped to the county 

level. The specialty premium for each county is then multiplied by the total county RVUs for 

that specialty (from the Medicare claims data for CY 2013). The product of the MP premiums 

and total county RVUs is then summed across all counties for each specialty and then divided by 

total national RVUs for the specialty. This calculation is then divided by the average MP GPCI 

across all counties for each specialty to yield a normalized national average premium for each 

specialty. The specialty premiums are normalized for geographic variation so that the locality 

cost differences (as reflected by the GPCIs) would not be counted twice. Without the geographic 

variation adjustment, the cost differences among fee schedule areas would be reflected once 

under the methodology used to calculate the MP RVUs and again when computing the service 

specific payment amount for a given fee schedule area. 

Step (2): Determine which premium class(es) to use within each specialty. 

Some specialties had premium rates that differed for surgery, surgery with obstetrics, and 

non-surgery. To account for the presence of different classes in the MP premium data and the 

task of mapping these premiums to procedures, we calculated distinct risk factors for surgical, 

surgical with obstetrics, and nonsurgical procedures. However, the availability of data by 
 122 

surgery and nonsurgery varied across specialties. Consistent with the CY 2010 MP RVU update, 

because no single approach accurately addressed the variability in premium classes among 

specialties, we employed several methods for calculating average premiums by specialty. These 

methods are discussed below. 

(a) Substantial Data for Each Class: For 13 out of 41 specialties, we determined that 

there was sufficient data for surgery and nonsurgery premiums, as well as sufficient differences 

in rates between classes. These specialties are listed in Table 13. Therefore, we calculated a 

national average surgical premium and nonsurgical premium. 

(b) Major Surgery Dominates: For 9 surgical specialties, rate filings that included 

nonsurgical premiums were relatively rare. For most of these surgical specialties, the rate filings 

did not include an “unspecified” premium. When it did, the unspecified premium was lower 

than the major surgery rate. For these surgical specialties, we calculated only a surgical 

premium and used the premium for major surgery for all procedures furnished by this specialty. 

(c) Unspecified Dominates: Many MP rate filings did not include surgery or nonsurgery 

classes for some specialties; we refer to these instances as unspecified MP rates. For 7 specialty 

types (listed in Table 13), we selected the unspecified premium as the premium information to 

use for the specialty. For these specialties, at least 35 states (and as many as 48 states) had MP 

premium amounts that were not identified as surgery or nonsurgery in rate filings for the 

specialty. 

(d) Blend All Available: For the remaining specialties, there was wide variation across 

the rate filings in terms of whether or not premium classes were reported and which categories 

were reported. Because there was no clear strategy for these remaining specialties, we blended 

the available rate information into one general premium rate. For these specialties, we developed 

a weighted average “blended” premium at the national level, according to the percentage of work 
 123 

RVUs correlated with the premium classes within each specialty. For example, the surgical 

premiums for a given specialty were weighted by that specialty’s work RVUs for surgical 

services; the nonsurgical premiums were weighted by the work RVUs for nonsurgical services 

and the unspecified premiums were weighted by all work RVUs for the specialty type. 

The four methods for calculating premiums by specialty type are summarized in Table 

13. (See Table 14: “Risk Factors by Specialty Type” for the specialty names associated with the 

specialty codes listed in Table 13.)

TABLE 13: Proposed Premium Calculation Approach by Specialty Type 

Method Medicare Specialty Codes 

(a) Substantial Data for Each Class (13) 01, 04, 06, 07, 08 (non-OB), 10, 13, 18, 34, 38, 39, 46, 

93 

(b) Major Surgery Dominates (9) 02, 14, 20, 24, 28, 33, 40, 77, 78 

(c) Unspecified Dominates (7) 03, 05, 16 (non-OB), 25, 26, 36, 81 

(d) Blend all Available (12) 11, 22, 29, 30 , 37, 44, 48, 66, 82, 84, 90, 92 

(e) Premium Calculation for Neurosurgery: For neurosurgery, premium data were 

available from 24 states; therefore, we did not have sufficient data to calculate a national average 

premium amount for neurosurgery. As explained above, we typically crosswalk a specialty with 

insufficient premium data (less than 35 states) to a similar specialty for which we have sufficient 

data, conceptually or by reported premiums. We considered cross-walking neurosurgery directly 

to the national average premium for a similar specialty that had sufficient data such as neurology 

or to another surgical specialty. We did not crosswalk neurosurgery directly to another surgical 

specialty because no other surgical specialty had similar premium values reported in the rate 

filings. For instance, the surgical premium for neurosurgery is $123,400 while the surgical 

premium for the next highest surgical specialty (surgical oncology) is $59,808. We also did not 

crosswalk neurosurgery directly to neurology because the rate filings for neurology include 

substantial premium data for both surgery and non-surgery while the rate filings for neurosurgery 
 124 

are dominated by major surgery premiums. We do not believe that it would be appropriate to 

assign non-surgical premiums reported for neurology to neurosurgery. 

However, the national average surgical premium amount for neurology ($96,970) and the 

surgical premium amount for neurosurgery are similar. Therefore, we blended the surgical 

premium data for neurology and neurosurgery instead of crosswalking directly to neurology or 

directly to another surgical specialty. In other words, we calculated a combined national average 

surgical premium for neurosurgery and neurology. The reasons as to why we are proposing to 

blend surgical premiums for neurology and neurosurgery, instead of crosswalking neurosurgery 

directly to neurology or directly to another surgical specialty, are further explained below. 

● The rate filings for neurosurgery are dominated by major surgery premiums. 

● The rate filings identifying nonsurgical premiums for neurosurgery are sparse. 

● The rate filings for neurology include substantial premium data for both surgery and 

nonsurgery. 

● Neurology is similar to neurosurgery both conceptually and by reported surgical premium 

amounts. 

● Surgical premiums from the rate filings for other surgical specialties are lower than for 

neurosurgery and neurology. 

Given that the rate filings for neurosurgery are dominated by major surgical premiums 

and that surgical premium amounts for neurology are similar to neurosurgery, we believe that 

combining the surgical premium data for neurosurgery and neurology is a better representation 

of the MP premium amounts paid by neurosurgeons than crosswalking neurosurgery directly to 

neurology or to another surgical specialty. 

Step (3): Calculate a risk factor for each specialty. 
 125 

The relative differences in national average premiums between specialties are expressed 

in our methodology as a specialty risk factor. These risk factors are an index calculated by 

dividing the national average premium for each specialty by the national average premium for 

the specialty with the lowest premiums for which we had sufficient and reliable data, allergy 

and immunology. For specialties with sufficient surgical and nonsurgical premium data, we 

calculated both a surgical and nonsurgical risk factor. For specialties with rate filings that 

distinguished surgical premiums with obstetrics from those without, we calculated a separate 

surgical with obstetrics risk factor. For all other specialties we calculated a single risk factor 

and applied the specialty risk factor to both surgery and nonsurgery services. 

We note that for determining the risk factor for suppliers of TC-only services, we were 

not able to obtain more recent premium data than what was used for the CY 2010 update. 

Therefore, we updated the premium data for IDTFs that we used in the CY 2010 update. These 

data were obtained from a survey conducted by the Radiology Business Management 

Association (RBMA) in 2009. We updated the RBMA survey data by the change in 

non-surgical premiums for all specialty types since the previous MP RVU update and 

calculated an updated TC specialty risk factor. We applied the updated TC specialty risk factor 

to suppliers of TC-only services. Table 14 shows the risk factors by specialty type. 

TABLE 14: Risk Factors by Specialty Type 

Specialty 

Code Medicare Specialty Name Non-Surgical 

Risk Factor 

Surgical 

Risk Factor 

01 General Practice 1.83 4.11 

02 General Surgery 7.30 

03 Allergy Immunology 1.00 1.00 

04 Otolaryngology 1.95 4.47 

05 Anesthesiology 2.42 2.42 

06 Cardiology 2.11 7.10 

07 Dermatology 1.25 4.11 

08 Family Practice 1.77 4.18 
 126 

Specialty 

Code Medicare Specialty Name Non-Surgical Risk Factor 

Surgical 

Risk Factor 

08 OB Family Practice w/ OB 3.95 

09 Interventional Pain Management 2.42 2.42 

10 Gastroenterology 2.16 4.45 

11 Internal Medicine 2.07 2.07 

12 Osteopathic Manipulative Medicine 1.00 1.00 

13 Neurology 2.59 13.04 

14 Neurosurgery 13.04 

15 Speech Language Pathology 1.00 1.00 

16 Obstetrics Gynecology 3.80 3.80 

16 OB Obstetrics Gynecology w/ OB 8.05 

17 Hospice and Palliative Care 1.00 1.00 

18 Ophthalmology 1.22 2.21 

19 Oral Surgery (dental only) 5.11 

20 Orthopedic Surgery 6.38 

21 Cardiac Electrophysiology 2.11 7.10 

22 Pathology 1.79 1.79 

23 Sports Medicine 1.83 4.11 

24 Plastic and Reconstructive Surgery 5.11 

25 Physical Medicine and Rehabilitation 1.39 1.39 

26 Psychiatry 1.13 1.13 

27 Geriatric Psychiatry 1.13 1.13 

28 Colorectal Surgery (formerly Proctology) 4.08 

29 Pulmonary Disease 2.33 2.33 

30 Diagnostic Radiology 2.99 2.99 

32 Anesthesiologist Assistant 2.42 2.42 

33 Thoracic Surgery 7.27 

34 Urology 1.61 3.39 

35 Chiropractic 1.00 1.00 

36 Nuclear Medicine 1.41 1.41 

37 Pediatric Medicine 1.82 1.82 

38 Geriatric Medicine 1.78 4.83 

39 Nephrology 1.71 4.27 

40 Hand Surgery 4.71 

41 Optometry 1.00 1.00 

42 Certified Nurse Midwife 3.80 3.80 

42 OB Certified Nurse Midwife w/OB 8.05 

43 Certified Registered Nurse Anesthetist (CRNA) 2.42 2.42 

44 Infectious Disease 2.41 2.41 

45 Mammography Screening Center 0.90 

46 Endocrinology 1.65 4.23 
 127 

Specialty 

Code Medicare Specialty Name Non-Surgical Risk Factor 

Surgical 

Risk Factor 

47 Independent Diagnostic Testing Facility 0.90 

48 Podiatry 2.22 2.22 

50 Nurse Practitioner 1.83 4.11 

60 Public Health or Welfare Agency 1.00 1.00 

62 Psychologist 1.00 1.00 

63 Portable X-Ray Supplier 0.90 

64 Audiologist 1.00 1.00 

65 Physical Therapist 1.00 1.00 

66 Rheumatology 1.77 1.77 

67 Occupational Therapist 1.00 1.00 

68 Clinical Psychologist 1.00 1.00 

69 Clinical Laboratory 0.90 

71 Registered Dietitian/Nutrition Professional 1.00 1.00 

72 Pain Management 2.42 2.42 

74 Radiation Therapy Center 0.90 

75 Slide Preparation Facilities 0.90 

76 Peripheral Vascular Disease 7.19 

77 Vascular Surgery 7.19 

78 Cardiac Surgery 7.23 

79 Addiction Medicine 1.00 1.00 

80 Licensed Clinical Social Worker 1.00 1.00 

81 Critical Care (Intensivists) 2.83 2.83 

82 Hematology 1.81 1.81 

83 Hematology/Oncology 1.89 1.89 

84 Preventive Medicine 1.44 1.44 

85 Maxillofacial Surgery 5.11 

86 Neuropsychiatry 1.13 1.13 

89 Certified Clinical Nurse Specialist 1.83 4.11 

90 Medical Oncology 1.89 1.89 

91 Surgical Oncology 7.30 

92 Radiation Oncology 2.36 2.36 

93 Emergency Medicine 3.29 5.17 

94 Interventional Radiology 2.99 2.99 

97 Physician Assistant 1.00 1.00 

98 Gynecological/Oncology 3.80 3.80 

98 OB Gynecological/Oncology w/OB 8.05 

99 Unknown Physician Specialty 1.83 4.11 

C0 Sleep Medicine 1.83 4.11 

TC IDTFs (TC only) 0.90 
 128 

(a) Invasive Cardiology: Consistent with the previous MP RVU update, we continued 

to classify invasive cardiology services (cardiac catheterizations and angioplasties) that are 

outside of the surgical HCPCS code range as surgery for purposes of assigning specialtyspecific risk factors. We note that since the previous MP RVU update some invasive 

cardiology service HCPCS codes have been revised. Therefore, we modified the list of 

invasive cardiology services outside the surgical HCPCS code range that are to be considered 

surgery in order to correspond conceptually to the list of service codes used for the CY 2010 

MP RVU update. We continue to believe that the malpractice risk for cardiac catheterization 

and angioplasty services are more similar to the risk of surgical procedures than most 

nonsurgical service codes. As such, we applied the higher cardiology surgical risk factor to 

cardiology catheterization and angioplasty services. 

For the CY 2015 MP RVU update, we examined the possibility of classifying injection 

procedures used in conjunction with cardiac catheterization as surgery (for purposes of 

assigning service specific risk factors). After careful consideration, we believe that injection 

procedures, when furnished in conjunction with cardiac catheterization, are more akin to the 

malpractice risk of surgical procedures than most non-surgical services. Therefore we applied 

the surgical risk factor to injection procedures used in conjunction with cardiac catheterization. 

Table 15 shows the invasive cardiology services and injection services furnished in conjunction 

with cardiac catheterization to be considered as surgery for purposes of assigning specialtyspecific risk factors. 

Table 15: Services Outside of Surgical HCPCS Code Range Considered Surgery 

HCPCS Code Short Descriptor 

92920 Prq cardiac angioplast 1 art 

92921 Prq cardiac angio addl art 

92924 Prq card angio/athrect 1 art 

92925 Prq card angio/athrect addl 

92928 Prq card stent w/angio 1 vsl 
 129 

HCPCS Code Short Descriptor 

92929 Prq card stent w/angio addl 

92933 Prq card stent/ath/angio 

92934 Prq card stent/ath/angio 

92937 Prq revasc byp graft 1 vsl 

92938 Prq revasc byp graft addl 

92941 Prq card revasc mi 1 vsl 

92943 Prq card revasc chronic 1vsl 

92944 Prq card revasc chronic addl 

92970 Cardioassist internal 

92971 Cardioassist external 

92973 Prq coronary mech thrombect 

92974 Cath place cardio brachytx 

92975 Dissolve clot heart vessel 

92977 Dissolve clot heart vessel 

92978 Intravasc us heart add-on 

92979 Intravasc us heart add-on 

93451 Right heart cath 

93452 Left hrt cath w/ventrclgrphy 

93453 R&l hrt cath w/ventriclgrphy 

93454 Coronary artery angio s&i 

93455 Coronary art/grft angio s&i 

93456 R hrt coronary artery angio 

93457 R hrt art/grft angio 

93458 L hrt artery/ventricle angio 

93459 L hrt art/grft angio 

93460 R&l hrt art/ventricle angio 

93461 R&l hrt art/ventricle angio 

93462 L hrt cath trnsptl puncture 

93503 Insert/place heart catheter 

93505 Biopsy of heart lining 

93530 Rt heart cath congenital 

93531 R & l heart cath congenital 

93532 R & l heart cath congenital 

93533 R & l heart cath congenital 

93580 Transcath closure of asd 

93581 Transcath closure of vsd 

93582 Perq transcath closure pda 

93583 Perq transcath septal reduxn 

93600 Bundle of his recording 

93602 Intra-atrial recording 

93603 Right ventricular recording 

93609 Map tachycardia add-on 

93610 Intra-atrial pacing 
 130 

HCPCS Code Short Descriptor 

93612 Intraventricular pacing 

93613 Electrophys map 3d add-on 

93618 Heart rhythm pacing 

93619 Electrophysiology evaluation 

93620 Electrophysiology evaluation 

93621 Electrophysiology evaluation 

93622 Electrophysiology evaluation 

93623 Stimulation pacing heart 

93624 Electrophysiologic study 

93631 Heart pacing mapping 

93640 Evaluation heart device 

93641 Electrophysiology evaluation 

93642 Electrophysiology evaluation 

93650 Ablate heart dysrhythm focus 

93653 Ep & ablate supravent arrhyt 

93654 Ep & ablate ventric tachy 

93655 Ablate arrhythmia add on 

93656 Tx atrial fib pulm vein isol 

93657 Tx l/r atrial fib addl 

93563 Inject congenital card cath 

93564 Inject hrt congntl art/grft 

93565 Inject l ventr/atrial angio 

93566 Inject r ventr/atrial angio 

93567 Inject suprvlv aortography 

93568 Inject pulm art hrt cath 

93571 Heart flow reserve measure 

93572 Heart flow reserve measure 

Step (4): Calculate malpractice RVUs for each HCPCS code. 

Resource-based MP RVUs were calculated for each HCPCS code that has work or PE RVUs. 

The first step was to identify the percentage of services furnished by each specialty for each 

respective HCPCS code. This percentage was then multiplied by each respective specialty’s risk 

factor as calculated in Step 3. The products for all specialties for the HCPCS code were then 

added together, yielding a specialty-weighted service specific risk factor reflecting the weighted 

malpractice costs across all specialties furnishing that procedure. The service specific risk factor 
 131 

was multiplied by the greater of the work RVU or PE clinical labor index for that service to 

reflect differences in the complexity and risk-of-service between services. 

 (a) Low volume service codes: As discussed previously in this section, service-specific 

MP RVUs are determined based on the weighted average risk factor(s) of the specialties that 

furnish the service. For rarely-billed Medicare services (that is, when CY 2013 claims data 

reflected allowed services of less than 100), we used only the risk factor of the dominant 

specialty as reflected in our claims data. Approximately 2,000 services met the criteria for “low 

volume.” The dominant specialty for each “low volume” service was also determined from CY 

2013 Medicare claims data. We continue to believe that a balanced approach between including 

all of the specialties in our claims data and the application of the dominant specialty for each low 

volume service is the most appropriate approach to the development of malpractice RVUs. 

Step (5): Rescale for budget neutrality. 

The statute requires that changes to fee schedule RVUs must be budget neutral. The 

current resource-based MP RVUs and the proposed resource-based MP RVUs were constructed 

using different malpractice premium data. Thus, the last step is to adjust for budget neutrality 

by rescaling the proposed MP RVUs so that the total proposed resource-based MP RVUs equal 

the total current resource-based MP RVUs. 

The proposed resource-based MP RVUs are shown in Addendum B, which is available 

on the CMS website under the supporting documents section of the CY 2015 PFS rule at 

http://www.cms.gov/PhysicianFeeSched/. These values have been adjusted for budget neutrality 

on the basis of the most recent 2013 utilization data available. We will make a final budget 

neutrality adjustment in the final rule on the basis of the available 2013 utilization data at that 

time. We do not believe, however, that the final values will change significantly from the 

proposed values as a result of the final budget-neutrality adjustment. 
 132 

Because of the differences in the sizes of the three fee schedule components, 

implementation of the resource-based MP RVU update will have much smaller payment effects 

than implementing updates of resource-based work RVUs and resource-based PE RVUs. On 

average, work represents about 50.9 percent of payment for a service under the fee schedule, PE 

about 44.8 percent, and MP about 4.3 percent. Therefore, a 25 percent change in PE RVUs or 

work RVUs for a service would result in a change in payment of about 11 to 13 percent. In 

contrast, a corresponding 25 percent change in MP values for a service would yield a change in 

payment of only about 1 percent. Estimates of the effects on payment by specialty type can be 

found in section VI. of this proposed rule. 

 Additional information on our proposed methodology for updating the MP RVUs may 

be found in our contractor’s report, “Report on the CY 2015 Update of the Malpractice RVUs,” 

which is available on the CMS website. It is located under the supporting documents section of 

the CY 2015 PFS proposed rule located at http://www.cms.gov/PhysicianFeeSched/. 

3. MP RVU Update for Anesthesia services 

Since payment for anesthesia services under the PFS is based upon a separate fee 

schedule, routine updates must be calculated in a different way than those for services for which 

payment is calculated based upon work, PE and MP RVUs. To apply certain updates to the 

anesthesia fee schedule, we usually develop proxy RVUs for individual anesthesia services. 

However, because work RVUs are integral to the MP RVU methodology and anesthesia services 

do not have work RVUs, the MP update process for anesthesia services is more complex than for 

services with work RVUs and clinical labor inputs. Notwithstanding these challenges, we 

believe that payment rates for anesthesia should reflect relative MP resource costs, including 

updates to reflect changes over time, as do other PFS payment rates. We are not proposing to 

include such an adjustment at this time because we believe it would be helpful to receive input 
 133 

from stakeholders on how we could address these challenges and develop a proposal to 

appropriately update the MP resource costs for anesthesia through future rulemaking. Therefore, 

we intend to propose an anesthesia adjustment for MP in the CY 2016 PFS proposed rule and are 

seeking comment in this rule about how to best do so. 

An example of one possible approach would be to calculate imputed work RVUs and MP 

RVUs for the anesthesia fee schedule services using the work, PE, and MP shares of the 

anesthesia conversion factor. To reflect differences in the complexity and risk between 

anesthesia fee schedule services we would then multiply the service-specific risk factor for each 

anesthesia fee schedule service by the imputed proxy work RVUs (both CY 2015 and Cy 2016 

would be based on the same work RVUs) developed for each anesthesia service to determine 

updated proxy MP RVUs for the CY 2016 year. The aggregate difference between the imputed 

MP RVUs for CY 2015 the proxy MP RVUs for CY 2016 (both based on the same work RVUs) 

would be applied to the portion of the anesthesia conversion factor attributable to MP. However, 

we believe there may be drawbacks to this approach since it relies heavily on the proxy work and 

MP RVUs for individual anesthesia services. We are requesting public comments on this 

approach specifically, as well as comments on alternative approaches or methods for updating 

MP for services paid on the anesthesia fee schedule. 
 134 

D. Geographic Practice Cost Indices (GPCIs) 

1. Background 

Section 1848(e)(1)(A) of the Act requires us to develop separate Geographic Practice 

Cost Indices (GPCIs) to measure relative cost differences among localities compared to the 

national average for each of the three fee schedule components (that is, work, PE, and MP). 

Although the statute requires that the PE and MP GPCIs reflect the full relative cost differences, 

section 1848(e)(1)(A)(iii) of the Act requires that the work GPCIs reflect only one-quarter of the 

relative cost differences compared to the national average. In addition, section 1848(e)(1)(G) of 

the Act sets a permanent 1.5 work GPCI floor for services furnished in Alaska beginning 

January 1, 2009, and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI floor for 

services furnished in frontier states (as defined in section 1848(e)(1)(I) of the Act) beginning 

January 1, 2011. Additionally, section 1848(e)(1)(E) of the Act provided for a 1.0 floor for the 

work GPCIs, which was set to expire on March 31, 2014. However, section 102 of the PAMA 

extended application of the 1.0 floor to the work GPCI through March 31, 2015. 

Section 1848(e)(1)(C) of the Act requires us to review and, if necessary, adjust the GPCIs 

at least every 3 years. Section 1848(e)(1)(C) of the Act requires that “if more than 1 year has 

elapsed since the date of the last previous adjustment, the adjustment to be applied in the first 

year of the next adjustment shall be 1/2 of the adjustment that otherwise would be made.” We 

completed a review and finalized updated GPCIs in the CY 2014 PFS final rule with comment 

period (78 FR 74390). Since the last GPCI update had been implemented over 2 years, CY 2011 

and CY 2012, we phased in 1/2 of the latest GPCI adjustment in CY 2014. We also revised the 

cost share weights that correspond to all three GPCIs in the CY 2014 PFS final rule. We 

calculated a corresponding geographic adjustment factor (GAF) for each PFS locality. The 

GAFs are a weighted composite of each area’s work, PE and MP GPCIs using the national GPCI 
 135 

cost share weights. Although the GAFs are not used in computing the fee schedule payment for 

a specific service, we provide them because they are useful in comparing overall areas costs and 

payments. The actual effect on payment for any actual service will deviate from the GAF to the 

extent that the proportions of work, PE and MP RVUs for the service differ from those of the 

GAF. 

As previously noted, section 102 of the PAMA extended the 1.0 work GPCI floor 

through March 31, 2015. Therefore, the CY 2015 work GPCIs and summarized GAFs have been 

revised to reflect the 1.0 work floor. Additionally, as required by sections 1848(e)(1)(G) and 

1848(e)(1)(I) of the Act, the 1.5 work GPCI floor for Alaska and the 1.0 PE GPCI floor for 

frontier states are permanent, and therefore, applicable in CY 2015. See Addenda D and E for 

the CY 2015 GPCIs and summarized GAFs. 

As discussed in the CY 2014 PFS final rule with comment period (78 FR 74380) the 

updated GPCIs were calculated by a contractor to CMS. We used updated Bureau of Labor and 

Statistics Occupational Employment Statistics (BLS OES) data (2009 through 2011) as a 

replacement for 2006 through 2008 data for purposes of calculating the work GPCI and the 

employee compensation component and purchased services component of the PE GPCI. We 

also used updated U.S. Census Bureau American Community Survey (ACS) data (2008 through 

2010) as a replacement for 2006 through 2008 data for calculating the office rent component of 

the PE GPCI. To calculate the MP GPCI we used updated malpractice premium data (2011 and 

2012) from state departments of insurance as a replacement for 2006 through 2007 premium 

data. We also noted that we do not adjust the medical equipment, supplies and other 

miscellaneous expenses component of the PE GPCI because we continue to believe there is a 

national market for these items such that there is not a significant geographic variation in relative 

costs. Additionally, we updated the GPCI cost share weights consistent with the modifications 
 136 

made to the 2006-based MEI cost share weights in the CY 2014 final rule. As discussed in the 

CY 2014 final rule with comment period, use of the revised GPCI cost share weights changed 

the weighting of the subcomponents within the PE GPCI (employee wages, office rent, 

purchased services, and medical equipment and supplies). For a detailed explanation of how the 

GPCI update was developed, see the CY 2014 final rule with comment period (78 FR 74380 

through 74391).

2. Proposed Changes to the GPCI Values for the Virgin Islands Payment Locality 

The current methodology for calculating locality level GPCIs relies on the acquisition of 

county level data (when available). Where data for a specific county are not available, we assign 

the data from a similar county within the same payment locality. The Virgin Islands have county 

level equivalents identified as districts. Specifically, the Virgin Islands are divided into 3 

districts: Saint Croix; Saint Thomas; and Saint John. These districts are, in turn, subdivided into 

20 sub-districts. Although the Virgin Islands are divided into these county equivalents, county 

level data for the Virgin Islands are not represented in the BLS OES wage data. Additionally, 

the ACS, which is used to calculate the rent component of the PE GPCI, is not conducted in the 

Virgin Islands, and we have not been able to obtain malpractice insurance premium data for the 

Virgin Islands payment locality. Given the absence of county level wage and rent data and the 

insufficient malpractice premium data by specialty type, we have historically set the three GPCI 

values for the Virgin Islands payment locality at 1.0. 

For CY 2015, we explored using the available data from the Virgin Islands to more 

accurately reflect the geographic cost differences for the Virgin Islands payment locality as 

compared to other PFS localities. Although county level data for the Virgin Islands are not 

represented in the BLS OES wage data, aggregate territory level BLS OES wage data are 

available. We believe that using aggregate territory level data is a better reflection of the relative 
 137 

cost differences of operating a medical practice in the Virgin Islands payment locality as 

compared to other PFS localities than the current approach of assigning a value of 1.0. At our 

request, our contractor calculated the work GPCI, and the employee wage component and 

purchased services component of the PE GPCI, for the Virgin Islands payment locality using 

aggregated 2009 through 2011 BLS OES data. 

As discussed above, the ACS is not conducted in the Virgin Islands and we have not been 

able to obtain malpractice premium data for the Virgin Islands payment locality. Therefore, we 

assigned a value of 1.0 for the rent index of the PE GPCI and to the MP GPCI. 

Table 16 illustrates the percentage change in GPCI values and summarized GAF for the 

Virgin Islands payment locality resulting from using BLS OES wage data to calculate the work 

GPCI and PE GPCI. 

TABLE 16: Impact of Using Territory-Level Virgin Islands Data on GPCI Values for the 

Virgin Islands Payment Locality 

1/1/2015 through 3/31/2015 4/1/2015 through 12/31/2015 

(With 1.0 Work GPCI Floor) (Without 1.0 Work GPCI Floor) 

GPCI/GAF 

Existing 

CY 2015 

GPCI Values* 

Proposed 

CY 2015 

GPCI Values 

Percent 

Change 

Existing 

CY 2015 

GPCI Values* 

Proposed 

CY 2015 

GPCI Values 

Percent 

Change

Work GPCI 1.000 1.000 0.00% 0.998 0.975 -2.30% 

PE GPCI 1.005 0.960 -4.48% 1.005 0.960 -4.48% 

MP GPCI 0.996 0.996 0.00% 0.996 0.996 0.00% 

GAF 1.002 0.982 -2.00% 1.001 0.969 -3.20% 

*CY 2015 GPCIs and GAF reflect CMS OACT BN adjustment. 

Using aggregate territory-level BLS OES wage data results in a - 2.3 percent decrease in 

the work GPCI, a -4.48 percent decrease in the PE GPCI, and a -3.2 percent decrease to the GAF 

for the Virgin Islands payment locality. However, with the application of the 1.0 work GPCI 

floor, there is no change to the work GPCI and the overall impact of using actual BLS OES wage 

data on the Virgin Islands payment locality is only reflected by the change in PE GPCI (-4.48 
 138 

percent) resulting in a - 2.00 percent decrease to the GAF. As mentioned previously in this 

section, since we have not been able to obtain malpractice premium data for the Virgin Islands 

payment locality we maintained the MP GPCI at 1.0. As such, there is no change in the MP 

GPCI. We propose to use aggregate BLS OES wage data to calculate the work GPCI and 

employee wage component of the PE GPCI for the Virgin Islands payment locality beginning for 

CY 2015, and for future GPCI updates. We are specifically requesting public comments on this 

proposal. Additional information on our proposal to calculate GPCI values for the Virgin Islands 

payment locality may be found in our contractor’s report, “Revised Final Report on the CY 2014 

Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which 

is available on the CMS website. It is located under the supporting documents section of the 

CY 2015 PFS proposed rule located at http://www.cms.gov/PhysicianFeeSched/. 
 139 

E. Medicare Telehealth Services 

1. Billing and Payment for Telehealth Services 

Generally, for Medicare payments to be made for telehealth services under the PFS 

several conditions must be met. Specifically, the service must be on the Medicare list of 

telehealth services and meet all of the following other requirements for coverage: 

• The service must be furnished via an interactive telecommunications system. 

• The practitioner furnishing the service must meet the telehealth requirements, as well 

as the usual Medicare requirements. 

• The service must be furnished to an eligible telehealth individual. 

• The individual receiving the services must be in an eligible originating site. 

When all of these conditions are met, Medicare pays an originating site fee to the originating site 

and provides separate payment to the distant site practitioner for furnishing the service. 

Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include 

consultations, office visits, office psychiatry services, and any additional service specified by the 

Secretary, when furnished via a telecommunications system. We first implemented this 

provision, which was effective October 1, 2001, in the CY 2002 PFS final rule with comment 

period (66 FR 55246). We established a process in the CY 2003 PFS final rule with comment 

period (67 FR 79988) for annual updates to the list of Medicare telehealth services as required by 

section 1834(m)(4)(F)(ii) of the Act.. 

As specified in regulations at §410.78(b), we generally require that a telehealth service be 

furnished via an interactive telecommunications system. Under §410.78(a)(3), an interactive 

telecommunications system is defined as multimedia communications equipment that includes, 

at a minimum, audio and video equipment permitting two-way, real-time interactive 

communication between the patient and distant site physician or practitioner. Telephones, 
 140 

facsimile machines, and electronic mail systems do not meet the definition of an interactive 

telecommunications system. An interactive telecommunications system is generally required as 

a condition of payment; however, section 1834(m)(1) of the Act allows the use of asynchronous 

“store-and-forward” technology when the originating site is part of a federal telemedicine 

demonstration program in Alaska or Hawaii. As specified in regulations at §410.78(a)(1), storeand-forward means the asynchronous transmission of medical information from an originating 

site to be reviewed at a later time by the practitioner at the distant site. 

Medicare telehealth services may be furnished to an eligible telehealth individual 

notwithstanding the fact that the practitioner furnishing the telehealth service is not at the same 

location as the beneficiary. An eligible telehealth individual means an individual enrolled under 

Part B who receives a telehealth service furnished at an originating site. 

Practitioners furnishing Medicare telehealth services are reminded that the telehealth 

service provision is subject to the same non-discrimination laws as other services, including the 

effective communication requirements for persons with disabilities of section 504 of the 

Rehabilitation Act and language access for persons with limited English proficiency, as required 

under Title VI of the Civil Rights Act of 1964. For more information, see 

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hosptialcommunication. 

Practitioners furnishing Medicare telehealth services submit claims for telehealth services 

to the Medicare contractors that process claims for the service area where their distant site is 

located. Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth 

service to an eligible telehealth individual be paid an amount equal to the amount that the 

practitioner would have been paid if the service had been furnished without the use of a 

telecommunications system. 
 141 

 Originating sites, which are defined as “one of the specified sites where an eligible 

telehealth individual is located at the time the service is being furnished via a 

telecommunications system,” are paid under the PFS for serving as an originating site for 

telehealth services. The statute specifies both the types of entities that can serve as originating 

sites and geographic qualifications for originating sites. With regard to geographic 

qualifications, our regulations at §410.78 (b)(4) limit originating sites to those located in rural 

health professional shortage areas (HPSAs) or in a county that is not included in a metropolitan 

statistical areas (MSAs). Historically, we have defined rural HPSAs to be those located outside 

of, MSAs. Effective January 1, 2014, we modified the regulations regarding originating sites to 

define rural HPSAs as those located in rural census tracts as determined by the Office of Rural 

Health Policy (ORHP) of the Health Resources and Services Administration (HRSA) (78 FR 

74811). Defining “rural” to include geographic areas located in rural census tracts within MSAs 

allows for broader inclusion of sites within HPSAs as telehealth originating sites. Adopting the 

more precise definition of “rural” for this purpose expands access to health care services for 

Medicare beneficiaries located in rural areas. HRSA has developed a website tool to provide 

assistance to potential originating sites to determine their geographic status. To access this tool, 

see the CMS website at www.cms.gov/teleheath/. 

An entity participating in a federal telemedicine demonstration project that has been 

approved by, or received funding from, the Secretary as of December 31, 2000 is eligible to be 

an originating site regardless of its geographic location. 

Effective January 1, 2014, we also changed our policy so that geographic eligibility for 

an originating site would be established and maintained on an annual basis, consistent with other 

telehealth payment policies (78 FR 74400). Geographic eligibility for Medicare telehealth 
 142 

originating sites for each calendar year is now based upon the status of the area as of December 

31 of the prior calendar year. 

For a detailed history of telehealth payment policy, see 78 FR 74399. 

2. Adding Services to the List of Medicare Telehealth Services 

As noted previously, in the December 31, 2002 Federal Register (67 FR 79988), we 

established a process for adding services to or deleting services from the list of Medicare 

telehealth services. This process provides the public with an ongoing opportunity to submit 

requests for adding services. We assign any qualifying request to make additions to the list of 

telehealth services to one of two categories. In the November 28, 2011 Federal Register

(76 FR 73102), we finalized revisions to criteria that we use to review requests in the second 

category. The two categories are: 

● Category 1: Services that are similar to professional consultations, office visits, and 

office psychiatry services that are currently on the list of telehealth services. In reviewing these 

requests, we look for similarities between the requested and existing telehealth services for the 

roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter, a practitioner with the beneficiary in the 

originating site. We also look for similarities in the telecommunications system used to deliver 

the proposed service; for example, the use of interactive audio and video equipment. 

● Category 2: Services that are not similar to the current list of telehealth services. Our 

review of these requests includes an assessment of whether the service is accurately described by 

the corresponding code when furnished via telehealth and whether the use of a 

telecommunications system to deliver the service produces demonstrated clinical benefit to the 

patient. In reviewing these requests, we look for evidence indicating that the use of a 

telecommunications system in furnishing the candidate telehealth service produces clinical 
 143 

benefit to the patient. Submitted evidence should include both a description of relevant clinical 

studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves 

the diagnosis or treatment of an illness or injury or improves the functioning of a malformed 

body part, including dates and findings, and a list and copies of published peer reviewed articles 

relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit 

does not include minor or incidental benefits. 

Some examples of clinical benefit include the following: 

● Ability to diagnose a medical condition in a patient population without access to 

clinically appropriate in-person diagnostic services. 

● Treatment option for a patient population without access to clinically appropriate inperson treatment options. 

● Reduced rate of complications. 

● Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due 

to reduced rate of recurrence of the disease process). 

● Decreased number of future hospitalizations or physician visits. 

● More rapid beneficial resolution of the disease process treatment. 

● Decreased pain, bleeding, or other quantifiable symptom. 

● Reduced recovery time. 

For the list of covered telehealth services, see the CMS website at 

www.cms.gov/teleheath/. Requests to add services to the list of Medicare telehealth services 

must be submitted and received no later than December 31 of each calendar year to be 

considered for the next rulemaking cycle. For example, qualifying requests submitted before the 

end of CY 2014 will be considered for the CY 2016 proposed rule. Each request to add a service 

to the list of Medicare telehealth services must include any supporting documentation the 
 144 

requester wishes us to consider as we review the request. Because we use the annual PFS 

rulemaking process as a vehicle for making changes to the list of Medicare telehealth services, 

requestors should be advised that any information submitted is subject to public disclosure for 

this purpose. For more information on submitting a request for an addition to the list of 

Medicare telehealth services, including where to mail these requests, see the CMS website at 

www.cms.gov/telehealth/. 

3. Submitted Requests to the List of Telehealth Services for CY 2015 

 Under our existing policy, we add services to the telehealth list on a category 1 basis 

when we determine that they are similar to services on the existing telehealth list with respect to 

the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter. As we stated in the CY 2012 proposed rule 

(76 FR 42826), we believe that the category 1 criteria not only streamline our review process for 

publically requested services that fall into this category, the criteria also expedite our ability to 

identify codes for the telehealth list that resemble those services already on this list. 

a. Submitted Requests 

We received several requests in CY 2013 to add various services as Medicare telehealth 

services effective for CY 2015. The following presents a discussion of these requests, and our 

proposals for additions to the CY 2015 telehealth list. Of the requests received, we find that the 

following services are sufficiently similar to psychiatric diagnostic procedures or 

office/outpatient visits currently on the telehealth list to qualify on a category one basis. 

Therefore, we propose to add the following services to the telehealth list on a category 1 basis for 

CY 2015: 

● CPT codes 90845 (Psychoanalysis); 90846 (family psychotherapy (without the patient 

present); and 90847 (family psychotherapy (conjoint psychotherapy) (with patient present); 
 145 

● CPT codes 99354 (prolonged service in the office or other outpatient setting requiring 

direct patient contact beyond the usual service; first hour (list separately in addition to code for 

office or other outpatient evaluation and management service); and, 99355 (prolonged service in 

the office or other outpatient setting requiring direct patient contact beyond the usual service; 

each additional 30 minutes (list separately in addition to code for prolonged service); and, 

● HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan 

of service (pps), initial visit; and, G0439 (annual wellness visit, includes a personalized 

prevention plan of service (pps), subsequent visit). 

We also received requests to add services to the telehealth list that do not meet our 

criteria for being on the Medicare telehealth list. We are not proposing to add the following 

procedures for the reasons noted: 

● CPT codes 92250 (fundus photography with interpretation and report); 93010 

(electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), 93307 

(echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode 

recording, when performed, complete, without spectral or color Doppler echocardiography; 

93308 (echocardiography, transthoracic, real-time with image documentation (2d), includes mmode recording, when performed, follow-up or limited study); 93320 (Doppler 

echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in 

addition to codes for echocardiographic imaging); complete); 93321 (Doppler echocardiography, 

pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for 

echocardiographic imaging); follow-up or limited study (list separately in addition to codes for 

echocardiographic imaging); and 93325 (Doppler echocardiography color flow velocity mapping 

(list separately in addition to codes for echocardiography). 
 146 

These services include a technical component (TC) and a professional component (PC). 

By definition the TC portion of these services needs to be furnished in the same location as the 

patient and thus cannot be furnished via telehealth. The PC portion of these services could be 

furnished without the patient being present in the same location. (Note: Sometimes an entirely 

different code may be used when only the PC portion of the service is being furnished and other 

times the same CPT code is used with a -26 modifier.) For example, the interpretation by a 

physician of an actual electrocardiogram or electroencephalogram tracing that has been 

transmitted electronically, can be furnished without the patient being present in the same location 

as the physician. It is not necessary to consider including the PC of these services on the 

telehealth list for these services to be covered when furnished remotely. Moreover, when these 

services are furnished remotely they do not meet the definition of Medicare telehealth services 

under section 1834(m) of the Act. Rather, these remote services are considered physicians’ 

services in the same way as services that are furnished in-person without the use of 

telecommunications technology; they are paid under the same conditions as in-person physicians’ 

services (with no requirements regarding permissible originating sites), and should be reported in 

the same way as other physicians’ services (that is, without the –GT or –GQ modifiers). 

● CPT codes 96103 (psychological testing (includes psychodiagnostic assessment of 

emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by 

a computer, with qualified health care professional interpretation and report); and, 96120 

(neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with 

qualified health care professional interpretation and report). These services involve testing by 

computer, can be furnished remotely without the patient being present, and are payable in the 

same way as other physicians’ services. These remote services are not Medicare telehealth 

services as defined under the Act, therefore, telehealth restrictions do not apply to these services. 
 147 

● CPT codes 90887 (interpretation or explanation of results of psychiatric, other medical 

examinations and procedures, or other accumulated data to family or other responsible persons, 

or advising them how to assist patient); 99090 (analysis of clinical data stored in computers (eg, 

ECGs, blood pressures, hematologic data); 99091 (collection and interpretation of physiologic 

data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/ or transmitted by the 

patient and/or caregiver to the physician or other qualified health care professional, qualified by 

education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of 

time); 99358 (prolonged evaluation and management service before and/or after direct patient 

care; first hour); and 99359 (prolonged evaluation and management service before and/or after 

direct patient care; each additional 30 minutes (list separately in addition to code for prolonged 

service). These services are not separately payable by Medicare. It would be inappropriate to 

include services as telehealth services when Medicare does not otherwise make a separate 

payment for them. 

● CPT codes 96101 (psychological testing (includes psychodiagnostic assessment of 

emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, 

WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering 

tests to the patient and time interpreting these test results and preparing the report); 96102 

(psychological testing (includes psychodiagnostic assessment of emotionality, intellectual 

abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care 

professional interpretation and report, administered by technician, per hour of technician time, 

face-to-face); 96118 (neuropsychological testing (eg, Halstead-Reitan Neuropsychological 

Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the 

psychologist’s or physician’s time, both face-to-face time administering tests to the patient and 

time interpreting these test results and preparing the report); and, 96119 (neuropsychological 
 148 

testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and 

Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, 

administered by technician, per hour of technician time, face-to-face). These services are not 

similar to other services on the telehealth list, as they require close observation of how a patient 

responds. The requestor did not submit evidence supporting the clinical benefit of furnishing 

these services on a category 2 basis. As such, we are not proposing to add these services to the 

list of telehealth services. 

● CPT codes 57452 (colposcopy of the cervix including upper/adjacent vagina; 57454 

colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and 

endocervical curettage); and, 57460 (colposcopy of the cervix including upper/adjacent vagina; 

with loop electrode biopsy(s) of the cervix). These services are not similar to other services on 

the telehealth service list. Therefore, it would not be appropriate to add them on a category 1 

basis. The requestor did not submit evidence supporting the clinical benefit of furnishing these 

services on a category 2 basis. As such, we are not proposing to add these services to the list of 

telehealth services. 

● HCPCS code M0064 (brief office visit for the sole purpose of monitoring or changing 

drug prescriptions used in the treatment of mental psychoneurotic and personality disorders) is 

being deleted for CY 2015. This code was created specifically to describe a service that is not 

subject to the statutory outpatient mental health limitation, which limited payment amounts for 

certain mental health services. Section 102 of the Medicare Improvements for Patients and 

Providers Act (Pub. L. 110-275, enacted on July 15, 2008) (MIPPA) required that the 62.5 

percent outpatient mental health treatment limitation, in effect since the inception of the 

Medicare program, be reduced over four years. This limitation limits the percentage of allowed 

charges that the Medicare program paid for mental health treatment services, thus creating a 
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larger share of beneficiary coinsurance for these services than other Medicare PFS services. 

Effective January 1, 2014, the limitation percentage is 100 percent, of which Medicare pays 80 

percent and the beneficiary pays 20 percent, resulting in the same beneficiary cost sharing as 

other PFS services. Since the statute was amended to phase out the limitation, and the phase-out 

was complete effective January 1, 2014, Medicare no longer has a need to distinguish services 

subject to the mental health limitation from those that are not. Accordingly, the appropriate CPT 

code can now be used to bill Medicare for the services that would have otherwise been reported 

using M0064 and M0064 will be eliminated as a telehealth service, effective January 1, 2015. 

● Urgent Dermatologic Problems and Wound Care - The American Telehealth 

Association (ATA) cited several studies to support adding dermatology services to the telehealth 

list. However, the request did not include specific codes. Since we did not have specific codes 

to consider for this request, we cannot evaluate whether the services are appropriate for addition 

to the Medicare telehealth services list. We note that some of the services that the requester had 

in mind may be billed under the telehealth office visit codes or the telehealth consultation Gcodes. 

In summary, we are proposing to add the following codes to the telehealth list on a 

category 1 basis: 

● Psychotherapy services CPT codes 90845, 90846 and 90847. 

● Prolonged service office CPT codes 99354 and 99355. 

● Annual wellness visit HCPCS codes G0438 and G0439. 

3. Modifying §410.78 Regarding List of Telehealth Services 

As discussed in section II.E.2.of this proposed rule, under the statute, we created an 

annual process for considering the addition of services to the Medicare telehealth list. Under this 

process, we propose services to be added to the list in the proposed rule in response to public 
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nominations or our own initiative and seek public comments on our proposals. After 

consideration of public comments, we finalize additions to the list in the final rule. We also 

amended the regulation at §410.78(b) each year to include the description of the added services. 

Because the list of Medicare telehealth services has grown quite lengthy, and given the many 

other mechanisms by which we can make the public aware of the list of Medicare telehealth 

services for each year, we are proposing to revise §410.78(b) by deleting the description of the 

individual services for which Medicare payment can be made when furnished via telehealth. We 

would continue our current policy to address requests to add to the list of telehealth services 

through the PFS rulemaking process so that the public would have the opportunity to comment 

on additions to the list. We are also proposing to revise §410.78(f) to indicate that a list of 

Medicare telehealth codes and descriptors is available on the CMS website. 
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F. Valuing New, Revised and Potentially Misvalued Codes 

Establishing valuations for newly created and revised CPT codes is a routine part of 

maintaining the PFS. Since its inception it has also been a priority to revalue services regularly 

to assure that the payment rates reflect the changing trends in the practice of medicine and 

current prices for inputs used in the PE calculations. Initially this was accomplished primarily 

through the five-year review process, which resulted in revised RVUs for CY 1997, CY 2002, 

CY 2007, and CY 2012. Under the five-year review process, revisions in RVUs were proposed 

in a proposed rule and finalized in a final rule. In addition to the five-year reviews, in each year 

beginning with CY 2009, CMS and the RUC have identified a number of potentially misvalued 

codes using various identification screens, such as codes with high growth rates, codes that are 

frequently billed together, and high expenditure codes. Section 3134 of the Affordable Care Act 

codified the potentially misvalued code initiative under section 1848(c)(2)(K) of the Act. 

In the CY 2012 rulemaking process, we proposed and finalized consolidation of the fiveyear review and the potentially misvalued code activities into an annual review of potentially 

misvalued codes in order to avoid redundancies in these efforts and better accomplish our goal of 

assuring regular assessment of code values. Under the consolidated process, we issue interim 

final RVUs for all revaluations and new codes in the PFS final rule with comment period, and 

make payment based upon those values during the calendar year covered by the final rule. 

(Changes in the PFS methodology that may affect valuations of a variety of codes are issued as 

proposals in the proposed rule.) We consider and respond to any public comments on the interim 

final values in the final rule with comment period for the subsequent year. When consolidating 

these processes, we indicated that it was appropriate to establish interim values for new, revised 

and potentially misvalued codes because of the incongruity between the PFS rulemaking cycle 

and the release of codes by the AMA CPT Editorial Panel and the RUC review process. We 
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stated that if we did not establish interim final values for revalued codes in the final rule with 

comment period, “a delay in implementing revised values for codes that have been identified as 

misvalued would perpetuate payment for the services at a rate that does not appropriately reflect 

the relative resources involved in furnishing the service and would continue unwarranted 

distortion in the payment for other services across the PFS.” We also reiterated that if we did not 

establish interim final values for new and revised codes, we would either have to delay the use of 

new and revised codes for one year, or permit each Medicare contractor to establish its own 

payment rate for these codes. We stated, “We believe it would be contrary to the public interest 

to delay adopting values for new and revised codes for the initial year, especially since we have 

an opportunity to receive significant input from the medical community [through the RUC] 

before adopting the values, and the alternatives could produce undesirable levels of uncertainty 

and inconsistency in payment for a year.” 

1. Current Process for Valuing New, Revised, and Potentially Misvalued Codes 

Under the process finalized in the CY 2012 PFS final rule with comment period, in each 

year’s proposed rule, we propose specific codes and/or groups of codes that we believe may be 

appropriate to consider under our potentially misvalued code initiative. As part of our process 

for developing the list of proposed potentially misvalued codes, we consider public nominations 

for potentially misvalued codes under a process also established in the CY 2012 PFS final rule 

with comment period. If appropriate, we include such codes in our proposed potentially 

misvalued code list. In the proposed rule, we solicit comments on the proposed potentially 

misvalued codes. We then respond to comments and establish a final list of potentially 

misvalued codes in the final rule for that year. These potentially misvalued codes are reviewed 

and revalued, if appropriate, in subsequent years. In addition, the RUC regularly identifies 
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potentially misvalued codes using screens that have previously been identified by CMS, such as 

codes performed together more than 75 percent of the time. 

Generally, the first step in revaluing codes that have been identified as potentially 

misvalued is for the RUC to review these codes through its standard process, which includes 

active involvement of national specialty societies for the specialties that ordinarily use the codes. 

Frequently, the RUC’s discussion of potentially misvalued codes will lead the CPT Editorial 

Panel to make adjustments to the codes involved, such as bundling of codes, creation of new 

codes or revisions of code descriptors. The AMA has estimated that 75 percent of all annual 

CPT coding changes result from the potentially misvalued code initiative. 

The RUC provides CMS with recommendations for the work values and direct PE inputs 

for the codes we have identified as potentially misvalued codes or, in the case of a coding 

revision, for the new or revised codes that will replace these potentially misvalued codes. (This 

process is also applied to codes that the RUC identifies using code screens that we have 

identified, and to new or revised codes that are issued for reasons unrelated to the potentially 

misvalued code process.) Generally, we receive the RUC recommendations concurrently for all 

codes in the same family as the potentially misvalued code(s). We believe it is important to 

evaluate and establish appropriate work and MP RVUs and direct PE inputs for an entire code 

family at the same time to avoid rank order anomalies and to maintain appropriate relativity 

among codes. We generally receive the RUC recommendations for the code or replacement 

code(s) within a year or two following the identification of the code as potentially misvalued. 

We consider the RUC recommendations along with other information that we have, 

including information submitted by other stakeholders, and establish interim final RVUs for the 

potentially misvalued codes, new codes, and any other codes for which there are coding changes 

in the final rule with comment period for a year. There is a 60−day period for the public to 
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comment on those interim final values after we issue the final rule. For services furnished during 

the calendar year following the publication of interim final rates, we pay for services based upon 

the interim final values established in the final rule. In the final rule with comment period for the 

subsequent year, we consider and respond to public comments received on the interim final 

values, and make any appropriate adjustments to values based on those comments. We then 

typically finalize the values for the codes. 

As we discussed in the CY 2012 PFS final rule with comment period, we adopted this 

consolidated review process to combine all coding revaluations into one annual process allowing 

for appropriate consideration of relativity in and across code families. In addition, this process 

assures that we have the benefit of the RUC recommendations for all codes being valued. 

2. Concerns with Current Process. 

Some stakeholders who have experienced reductions in payments as the result of interim 

final valuations have objected to the process by which we revise or establish values for new, 

revised, and potentially misvalued codes. Some have stated that they did not receive notice of 

the possible reductions before they occurred. Generally, stakeholders are aware that we are 

considering changes in the payment rates for particular services either because CPT has made 

changes to codes or because we have identified the codes as potentially misvalued. As the RUC 

considers the appropriate value for a service, representatives of the specialties that use the codes 

are involved in the process. The RUC usually surveys physicians or other practitioners who 

furnish the services described by the codes regarding the time it takes to furnish the services, and 

representatives of the specialty(ies) also participate in the RUC meetings where 

recommendations for work RVUs and direct PE inputs are considered. Through this process, 

representatives of the affected specialties are generally aware of the RUC recommendations. 
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Some stakeholders have asserted that even when they are aware that the RUC has made 

recommendations, they have no opportunity to respond to the RUC recommendations before we 

consider them in adopting interim final values because the RUC actions and recommendations 

are not public. Some stakeholders have also said that the individuals who participate in the RUC 

review process are not able to share the recommendations because they have signed a 

confidentiality agreement. We note, however, that at least one specialty society has raised funds 

via its website to fight a “pending cut” based upon its knowledge of RUC recommendations for 

specific codes prior to CMS action on the recommendation. Additionally, some stakeholders 

have pointed out that some types of suppliers that are paid under the PFS are not permitted to 

participate in the RUC process at all. 

We recognize that some stakeholders, including those practitioners represented by 

societies that are not participants in the RUC process, may not be aware of the specifics of the 

RUC recommendations before we consider them in establishing interim final values for new, 

revised, and potentially misvalued codes. We note that, as described above, before we review a 

service as a potentially misvalued code, we go through notice and comment rulemaking to 

identify it as a potentially misvalued code. Thus, the public has notice and an opportunity to 

comment on whether we should review the values for a code before we finalize the code as 

potentially misvalued and begin the valuation process. As a result, all stakeholders should be 

aware that a particular code is being considered as potentially misvalued and that we may 

establish revised interim final values in a subsequent final rule with comment period. As noted 

above, there may be some codes for which we receive RUC recommendations based upon their 

identification by the RUC through code screens that we establish. These codes are not 

specifically identified by CMS through notice and comment rulemaking as potentially misvalued 

codes. We recognize that if stakeholders are not monitoring RUC activities or evaluating 
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Medicare claims data, they may be unaware that these codes are being reviewed and could be 

revalued on an interim final basis in a final rule with comment period for a year. 

In recent years, we have increased our scrutiny of the RUC recommendations and have 

increasingly found cause to modify the values recommended by the RUC in establishing interim 

final values under the PFS. Sometimes we also find it appropriate, on an interim final basis, to 

refine how the CPT codes are to be used for Medicare services or to create G-codes for reporting 

certain services to Medicare. Some stakeholders have objected to such interim final decisions 

because they do not learn of the CMS action until the final rule with comment period is issued. 

They believe they do not have an opportunity to meaningfully comment and for CMS to address 

their comments before the coding or valuation decision takes effect. 

We received comments on the CY 2014 PFS final rule with comment period suggesting 

that the existing process for review and adoption of interim final values for new, revised, and 

misvalued codes violates section 1871(a)(2) of the Act, which prescribes the rulemaking 

requirements for the agency in establishing payment rates. In response to those commenters, we 

note that the process we use to establish interim final rates is in full accordance with the statute 

and we do not find this a persuasive reason to consider modifying the process that we use to 

establish PFS rates. 

Our recent revaluation of the four epidural injection codes provides an example of the 

concerns that have been expressed with the existing process. In the CY 2014 PFS final rule with 

comment period, we established interim final values for four epidural injection codes, which 

resulted in payment reductions for the services when furnished in the office setting of between 

35 percent and 56 percent. (In the facility setting, the reductions range from 17 percent to 33 

percent.) One of these codes had been identified as a potentially misvalued code 2 years earlier. 

The affected specialties had been involved in the RUC process and were generally aware that the 
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family of codes would be revalued on an as interim basis in an upcoming rule. They were also 

aware that the RUC had made significant changes to the direct PE inputs, including removal of 

the radiographic-fluoroscopy room, which explains, in large part, the reduction to values in the 

office setting. The societies representing the affected specialty were also aware of significant 

reductions in the RUC-recommended “time” to furnish the procedures based on the most recent 

survey of practitioners who furnish the services, which resulted in reductions in both the work 

and PE portion of the values. Although the specialties were aware of the changes that the RUC 

was recommending to direct PE inputs, they were not specifically aware of how those changes 

would affect the values and payment rate. In addition, we decreased the work RVUs for these 

procedures because we found the RUC-recommended work RVUs did not adequately reflect the 

RUC-recommended decreases in time. This decision is consistent with our general practice 

when the best available information shows that the time involved in furnishing the service has 

gone down, and in the absence of information suggesting an increase in work intensity. Since 

the interim final values for these codes were issued in the CY 2014 PFS final rule with comment 

period, we have received numerous comments that will be useful to us as we consider finalizing 

values for these codes. If we had followed a process that involved proposing values for these 

codes in a proposed rule, we would have been able to consider the additional information 

contained in these comments prior to making payments for the services based upon revised 

values. (See section II.B.3.b.2 of this proposed rule for a discussion of proposed valuation of 

these epidural injection codes for CY 2015.) 

3. Alternatives to the Current Process 

Although we continue to believe the existing process for new, revised and potentially 

misvalued codes is an appropriate one given the incongruity between our rulemaking schedule 

and the CPT and RUC schedules, given our heightened review of the RUC recommendations and 
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the increased concerns expressed by some stakeholders, we believe that an assessment of our 

process for valuing these codes is warranted. To that end, we have considered potential 

alternatives to address the timing and rulemaking issues associated with establishing values for 

new, revised and potentially misvalued codes (as well as for codes within the same families as 

these codes). Specifically, we have explored three alternatives to our current approach: 

● Propose work and MP RVUs and direct PE inputs for all new, revised and potentially 

misvalued codes in a proposed rule. 

● Propose changes in work and MP RVUs and direct PE inputs in the proposed rule for 

new, revised, and potentially misvalued codes for which we receive RUC recommendations in 

time; continue to establish interim final values in the final rule for other new, revised, and 

potentially misvalued codes. 

● Increase our efforts to make available more information about the specific issues being 

considered in the course of developing values for new, revised and potentially misvalued codes 

to increase transparency, but without making changes to the existing process for establishing 

values. 

A discussion of each of these alternatives follows. 

(a) Propose work and MP RVUs and direct PE inputs for new, revised and potentially 

misvalued codes in the proposed rule: 

Under this approach, we would evaluate the RUC recommendations for all new, revised, 

and potentially misvalued codes, and include proposed work and MP RVUs and direct PE inputs 

for the codes in the first available PFS proposed rule. We would receive and consider public 

comments on those proposals and establish final values in the final rule. The primary obstacle to 

this approach relates to the current timing of the CPT coding changes and RUC activities. Under 
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the current calendar, all CPT coding changes and most RUC recommendations are not available 

to us in time to include proposed values for all codes in the proposed rule for that year. 

Therefore, if we were to adopt this proposal, which would require us to propose changes 

in inputs before we revalue codes based upon those values, we would need a mechanism to pay 

for services for which the existing codes would no longer be available or for which there would 

be changes for a given year. 

As we noted in the CY 2012 PFS final rule with comment period, the RUC 

recommendations are an essential element that we consider when valuing codes. Likewise, we 

recognize the significant contribution that the CPT Editorial Panel makes to the success of the 

potentially misvalued code initiative through its consideration and adoption of coding changes. 

Although we have increased our scrutiny of the RUC recommendations in recent years and 

accepted fewer of the recommendations without making our own refinements, the CPT codes 

and the RUC recommendations continue to play a major role in our valuations. For many codes, 

the surveys conducted by specialty societies as part of the RUC process are the best data that we 

have regarding the time and intensity of work. The RUC determines the criteria and the 

methodology for those surveys. It also reviews the survey results. This process allows for 

development of survey data that are more reliable and comparable across specialties and services 

than would be possible without having the RUC at the center of the survey vetting process. In 

addition, the debate and discussion of the services at the RUC meetings in which CMS staff 

participate provides a good understanding of what the service entails and how it compares to 

other services in the family, and to services furnished by other specialties. The debate among the 

specialties is also an important part of this process. Although we increasingly consider data and 

information from many other sources, and we intend to expand the scope of those data and 

sources, the RUC recommendations remain a vital part of our valuation process. 
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Thus, if we were to adopt this approach, we would need to address how to make payment 

for the services for which new or revised codes take effect for the following year but for which 

we did not receive RUC recommendations in time to include proposed work values and PE 

inputs in the proposed rule. Because the annual coding changes are effective on January 1st of a 

year, we would need a mechanism for practitioners to report services and be paid appropriately 

during the interval between the date the code takes effect and the time that we receive RUC 

recommendations and complete rulemaking to establish values for the new and revised codes. 

One option would be to establish G-codes with identical descriptors to the predecessors of the 

new and revised codes and, to the fullest extent possible, carry over the existing values for those 

codes. This would effectively preserve the status quo for one year. 

The primary advantage of this approach would be that the RVUs for all services under 

the PFS would be established using a full notice and comment procedure, including 

consideration of the RUC recommendations, before they take effect. In addition to having the 

benefit of the RUC recommendations, this would provide the public the opportunity to comment 

on a specific proposal prior to it being implemented. This would be a far more transparent 

process, and would assure that we have the full benefit of stakeholder comments before 

establishing values. 

One drawback to such a process is that the use of G-codes for a significant number of 

codes may create an administrative burden for CMS and for practitioners. Presumably, 

practitioners would need to use the G-codes to report certain services for purposes of Medicare, 

but would use the new or revised CPT codes to report the same services to private insurers. The 

number of G-codes needed each year would depend on the number of CPT code changes for 

which we do not receive the RUC recommendations in time to formulate a proposal to be 

included in the proposed rule for the year. To the extent that we receive the RUC 
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recommendations for all new and revised codes in time to develop proposed values for inclusion 

in the proposed rule, there would be no need to use G-codes for this purpose. 

Another drawback is that we would need to delay for at least one year the revision of 

values for any misvalued codes for which we do not receive RUC recommendations in time to 

include a proposal in the proposed rule. For a select set of codes, we would be continuing to use 

the RVUs for the codes for an additional year even though we know they do not reflect the most 

accurate resources. Since the PFS is a budget neutral system, misvalued services affect 

payments for all services across the fee schedule. On the other hand, if we were to take this 

approach, we would have the full benefit of public comments received on the proposed values 

for potentially misvalued services before implementing any revisions. 

(b) Propose changes in work and MP RVUs and PE inputs in the proposed rule for new, 

revised, and potentially misvalued codes for which we receive RUC recommendations in time; 

continue to establish interim final values in the final rule for other new, revised, and potentially 

misvalued codes: 

This alternative approach would allow for notice and comment rulemaking before we 

adopt values for some new, revised and potentially misvalued codes (those for which we receive 

RUC recommendations in time to include a proposal in the proposed rule), while others would be 

valued on an interim final basis (those for which we do not receive the RUC recommendations in 

time). Under this approach, we would establish values in a year for all new, revised, and 

potentially misvalued codes, and there would be no need to provide for a mechanism to continue 

payment for outdated codes pending receipt of the RUC recommendations and completion of a 

rulemaking cycle. For codes for which we do not receive the RUC recommendations in time to 

include a proposal in the proposed rule for a year, there would be no change from the existing 

valuation process. 
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This would be a balanced approach that recognizes the benefits of a full opportunity for 

notice and comment rulemaking before establishing rates when timing allows, and the 

importance of establishing appropriate values for the current version of CPT codes and for 

potentially misvalued codes when the timing of the RUC recommendations does not allow for a 

full notice and comment procedure. 

However, this alternative would go only part of the way toward addressing concerns 

expressed by some stakeholders. For those codes for which the RUC recommendations are not 

received in time for us to include a proposal in the proposed rule, Medicare payment for one year 

would still be based on inputs established without the benefit of full public notice and comment. 

Another concern with this approach is that it could lead to the valuation of codes within the same 

family at different times depending on when we receive RUC recommendations for each code 

within a family. As discussed previously, we believe it is important to value an entire code 

family together in order to make adjustments to account appropriately for relativity within the 

family and between the family and other families. If we receive RUC recommendations in time 

to propose values for some, but not for all, codes within a family, we would respond to 

comments in the final rule to establish final values for some of the codes while adopting interim 

final values for other codes within the same family. The differences in the treatment of codes 

within the same family could limit our ability to value codes within the same family with 

appropriate relativity. Moreover, under this alternative, the main determinant of how a code 

would be handled would be the timing of our receipt of the RUC recommendation for the code. 

Although this approach would offer stakeholders the opportunity to comment on specific 

proposals in the proposed rule, the adoption of changes for a separate group of codes in the final 

rule could significantly change the proposed values simply due to the budget neutrality 

adjustments due to additional codes being valued in the final rule. 
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(c) Increase our efforts to make available more information about the specific issues 

being considered in the course of developing values for new, revised and potentially misvalued 

codes in order to increase transparency, but without a change to the existing process for 

establishing values: 

The main concern with continuing our current approach is that stakeholders have 

expressed the desire to have adequate and timely information to permit the provision of relevant 

feedback to CMS for our consideration prior to establishing a payment rate for new, revised, and 

potentially misvalued codes. We could address some aspects of this issue by increasing the 

transparency of the current process. Specifically, we could make more information available on 

the CMS website before interim final values are established for codes. Examples of such 

information include an up-to-date list of all codes that have been identified as potentially 

misvalued, a list of all codes for which RUC recommendations have been received, and the RUC 

recommendations for all codes for which we have received them. 

Although the posting of this information would significantly increase transparency for all 

stakeholders, it still would not allow for full notice and comment rulemaking procedures before 

values are established for payment purposes. Nor would it provide the public with advance 

information about whether or how we will make refinements to the RUC recommendations or 

coding decisions in the final rule with comment period. Thus, stakeholders would not have an 

opportunity to provide input on our potential modifications before interim final values are 

adopted. 

4. Proposal to Modify the Process for Establishing Values for New, Revised, and Potentially 

Misvalued Codes. 

After considering the current process, including its strengths and weaknesses, and the 

alternatives to the current process described previously, we are proposing to modify our process 
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to make all changes in the work and MP RVUs and the direct PE inputs for new, revised and 

potentially misvalued services under the PFS by proposing the changes in the proposed rule, 

beginning with the PFS proposed rule for CY 2016. We propose to include proposed values for 

all new, revised and potentially misvalued codes for which we have complete RUC 

recommendations by January 15th of the preceding year. For the CY 2016 rulemaking process, 

we would include in the proposed rule proposed values for all services for which we have RUC 

recommendations by January 15, 2015. 

For those codes for which we do not receive the RUC recommendations by January 15th

of a year, we would delay revaluing the code for one year (or until we receive RUC 

recommendations for the code before January 15th of a year) and include proposed values in the 

following year’s rule. Thus, we would include proposed values prior to using the new code (in 

the case of new or revised codes) or revising the value (in the case of potentially misvalued 

codes). Due to the complexities involved in code changes and rate setting, there could be some 

circumstances where, even when we receive the RUC recommendations by January 15th of a 

year, we are not able to propose values in that year’s proposed rule. For example, we might not 

have recommendations for the whole family or we might need additional information to 

appropriately value these codes. In situations where it would not be appropriate or possible to 

propose values for certain new, revised, or potentially misvalued codes, we would treat them in 

the same way as those for which we did not receive recommendations before January 15th. 

For new, revised, and potentially misvalued codes for which we do not receive RUC 

recommendations before January 15th of a year, we propose to adopt coding policies and 

payment rates that conform, to the extent possible, to the policies and rates in place for the 

previous year. We would adopt these conforming policies on an interim basis pending our 

consideration of the RUC recommendations and the completion of notice and comment 
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rulemaking to establish values for the codes. For codes for which there is no change in the CPT 

code, it is a simple matter to continue the current valuation. For services for which there are 

CPT coding changes, it is more complicated to maintain the current payment rates until the codes 

can be valued through the notice and comment rulemaking process. Since the changes in CPT 

codes are effective on January 1st of a year, and we would not have established values for the 

new or revised codes (or other codes within the code family), it would not be practicable for 

Medicare to use those CPT codes. For codes that were revised or deleted as part of the annual 

CPT coding changes, when the changes could affect the value of a code and we have not had an 

opportunity to consider the relevant RUC recommendations prior to the proposed rule, we 

propose to create G-codes to describe the predecessor codes to these codes. If CPT codes are 

revised in a manner that would not affect the resource inputs used to value the service, (for 

example, a grammatical changes to CPT code descriptors,) we could use these revised codes and 

continue to pay at the rate developed through the use of the same resource inputs. For example, 

if a single CPT code was separated into two codes and we did not receive RUC 

recommendations for the two codes before January 15th of the year, we would assign each of 

those new codes an “I” status indicator (which denotes that the codes are “not valid for Medicare 

purposes”), and those codes could not be used for Medicare payment during the year. Instead we 

would create a G-code with the same description as the single predecessor CPT code and 

continue to use the same inputs as the predecessor CPT code for that G-code during the year. 

For new codes that describe wholly new services, as opposed to new or revised codes that 

describe services which are already on the PFS, we would make every effort to work with the 

RUC to ensure that we receive recommendations in time to include proposed values in the 

proposed rule. However, if we do not receive timely recommendations from the RUC for such a 

code and we determine that it is in the public interest for Medicare to use a new code during the 
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code’s initial year, we would need to establish values for the code’s initial year. As we do under 

our current policy, if we receive the RUC recommendations in time to consider them for the final 

rule, we propose to establish values for the initial year on an interim final basis subject to 

comment in the final rule. In the event we do not receive RUC recommendations in time to 

consider them for the final rule, or in other situations where it would not be appropriate to 

establish interim final values (for example, because of a lack of necessary information about the 

work or the price of the PE inputs involved), we would contractor price the code for the initial 

year. 

We propose to modify the regulation at §414.24 to codify the process described above. 

We recognize that the use of G-codes, especially if there are many of them in a given 

year, may place an administrative burden on those who bill for services under the PFS. We also 

recognize that, to the extent we do not receive RUC recommendations in time to include 

proposed values in the proposed rule, the most updated version of some CPT codes would not be 

used by the Medicare program for the first year. The AMA has been working to develop 

timeframes that would allow a much greater percentage of codes to be addressed in the proposed 

rule and has shared with us some plans to achieve this goal. We appreciate AMA’s efforts and 

are hopeful that if this proposal is adopted the CPT Editorial Panel and the RUC ultimately will 

be able to adjust their timelines and processes so that most, if not all, of the annual coding 

changes and valuation recommendations can be addressed in the proposed rule prior to the 

effective date of the coding changes. 

As discussed previously, the work of the AMA through the CPT Editorial Panel and the 

RUC are critical elements in the appropriate valuation of services under the PFS. We have 

proposed implementation of the revised CMS process for establishing values for new, revised, 

and potentially misvalued codes for CY 2016; but would consider alternative implementation 
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dates to allow time for the CPT Editorial Panel and the RUC to adjust their schedules to avoid 

the necessity to use G-codes. 

With regard to this proposal, we would be specifically interested in comments on the 

following topics: 

● Is this proposal preferable to the present process? Is another one of the alternatives 

better? 

● If we were to implement this proposal, is it better to move forward with the changes, 

or is more time needed to make the transition such that implementation should be delayed 

beyond CY 2016? What factors should we consider in selecting an implementation date? 

● Are there alternatives other than the use of G-codes that would allow us to address the 

annual CPT changes through notice and comment rather than interim final rulemaking? 

5. Refinement Panel. 

As discussed in the 1993 PFS final rule with comment period (57 FR 55938), we adopted 

a refinement panel process to assist us in reviewing the public comments on CPT codes with 

interim final work RVUs for a year and in developing final work values for the subsequent year. 

We decided the panel would be comprised of a multispecialty group of physicians who would 

review and discuss the work involved in each procedure under review, and then each panel 

member would individually rate the work of the procedure. We believed establishing the panel 

with a multispecialty group would balance the interests of the specialty societies who 

commented on the work RVUs with the budgetary and redistributive effects that could occur if 

we accepted extensive increases in work RVUs across a broad range of services. 

Following enactment of section 1848(c)(2)(K) of the Act, which required the Secretary 

periodically to review potentially misvalued codes and make appropriate adjustments to the 

RVUs, we reassessed the refinement panel process. As detailed in the CY 2011 PFS final rule 
 168 

with comment period (75 FR 73306), we continued using the established refinement panel 

process with some modifications. 

As we consider changes to the processes for valuing codes, we are reassessing the role 

that the refinement panel process plays in the code valuation process. As we note in the 

discussion above, the current refinement panel process is tied to interim final values. It provides 

an opportunity for stakeholders to provide new clinical information that was not available at the 

time of the RUC valuation that might affect work RVU values that are adopted in the interim 

final value process. If our proposal to modify the valuation process for new, revised and 

potentially misvalued codes is adopted, there would no longer be interim final values except for a 

very few codes that describe totally new services. Thus, we are proposing to eliminate the 

refinement panel process. By using the proposed process for new, revised, and potentially 

misvalued codes, we believe that the consideration of additional clinical information and any 

other issues associated with the CMS proposed values could be addressed through the notice and 

public comment process. Similarly, prior to CY 2012 when we consolidated the five-year 

valuation, changes made as part of the five-year review process were addressed in the proposed 

rule and those codes were generally not subject to the refinement process. The notice and 

comment process would provide stakeholders with complete information on the basis and 

rationale for our proposed inputs and any relating coding policies. We also note that an 

increasing number of requests for refinement do not include new clinical information that was 

not available at the time of the RUC meeting that would justify a change in the work RVUs, in 

accordance with the current requirements for refinement. Thus, we do not believe the 

elimination of the refinement panel process would negatively affect the code valuation process. 

We believe the proposed process, which includes a full notice and comment procedure before 

values are used for purposes of payment, offers stakeholders a better mechanism for providing 
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any additional data for our consideration and discussing any concerns with our proposed values 

than the current refinement process. 
 170 

G. Chronic Care Management (CCM) 

As we discussed in the CY 2013 PFS final rule with comment period, we are committed 

to supporting primary care and we have increasingly recognized care management as one of the 

critical components of primary care that contributes to better health for individuals and reduced 

expenditure growth (77 FR 68978). Accordingly, we have prioritized the development and 

implementation of a series of initiatives designed to improve payment for, and encourage longterm investment in, care management services. These initiatives include the following programs 

and demonstrations: 

● The Medicare Shared Savings Program (described in ‘‘Medicare Program; Medicare 

Shared Savings Program: Accountable Care Organizations; Final Rule,’’ which appeared in the 

November 2, 2011 Federal Register (76 FR 67802)). 

● The testing of the Pioneer ACO model, designed for experienced health care 

organizations (described on the Center for Medicare and Medicaid Innovation’s (Innovation 

Center’s) website at http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/index.html). 

● The testing of the Advance Payment ACO model, designed to support organizations 

participating in the Medicare Shared Savings Program (described on the Innovation Center’s 

website at http://innovation.cms.gov/initiatives/Advance-Payment-ACO-Model/). 

● The Primary Care Incentive Payment (PCIP) Program (described on the CMS website 

at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf). 

● The patient-centered medical home model in the Multi-payer Advanced Primary Care 

Practice (MAPCP) Demonstration designed to test whether the quality and coordination of health 

care services are improved by making advanced primary care practices more broadly available 

(described on the CMS website at www.cms.gov/Medicare/Demonstration-
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Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf ). 

● The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice 

demonstration (described on the CMS website at http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/Downloads/FQHC_APCP_Demo_FAQsOct2011.pdf and the 

Innovation Center’s website at www.innovations.cms.gov/initiatives/FQHCs/index.html). 

● The Comprehensive Primary Care (CPC) initiative (described on the Innovation 

Center’s website at http://innovations.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html). The CPC initiative is a multi-payer initiative fostering collaboration 

between public and private health care payers to strengthen primary care in certain markets 

across the country. 

In addition, HHS leads a broad initiative focused on optimizing health and quality of life 

for individuals with multiple chronic conditions. HHS’s Strategic Framework on Multiple 

Chronic Conditions outlines specific objectives and strategies for HHS and private sector 

partners centered on strengthening the health care and public health systems; empowering the 

individual to use self-care management with the assistance of a healthcare provider who can 

assess the patient’s health literacy level; equipping care providers with tools, information, and 

other interventions; and supporting targeted research about individuals with multiple chronic 

conditions and effective interventions. Further information on this initiative is available on the 

HHS website at http://www.hhs.gov/ash/initiatives/mcc/index.html. 

In coordination with all of these initiatives, we also have continued to explore potential 

refinements to the PFS that would appropriately value care management within Medicare’s 

statutory structure for fee-for-service physician payment and quality reporting. For example, in 

the CY 2013 PFS final rule with comment period, we adopted a policy to pay separately for care 

management involving the transition of a beneficiary from care furnished by a treating physician 
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during a hospital stay to care furnished by the beneficiary’s primary physician in the community 

(77 FR 68978 through 68993). 

In the CY 2014 PFS final rule with comment period, we finalized a policy to pay 

separately for care management services furnished to Medicare beneficiaries with two or more 

chronic conditions beginning in CY 2015 (78 FR 74414). 

1. Valuation of CCM Services − GXXX1 

CCM is a unique PFS service designed to pay separately for non-face-to-face care 

coordination services furnished to Medicare beneficiaries with two or more chronic conditions. 

(See 78 FR 74414 for a more complete description of the beneficiaries for whom this service 

may be billed.) In the CY 2014 PFS final rule with comment period, we indicated that, to 

recognize the additional resources required to provide CCM services to patients with multiple 

chronic conditions, we were creating the following code to use for reporting this service (78 FR 

74422): 

● GXXX1 Chronic care management services furnished to patients with multiple (two or 

more) chronic conditions expected to last at least 12 months, or until the death of the patient, that 

place the patient at significant risk of death, acute exacerbation/decompensation, or functional 

decline; 20 minutes or more; per 30 days. 

Although this service is unique in that it was created to separately pay for care 

management services, other codes include care management components. To value CCM, we 

compared it to other codes that involve care management. In doing so, we concluded that the 

CCM services were similar in work (time and intensity) to that of the non-face-to-face portion of 

transitional care management (TCM) services (CPT code 99495 (Transitional Care Management 

Services with the following required elements: Communication (direct contact, telephone, 

electronic) with the patient and/or caregiver within 2 business days of discharge Medical 
 173 

decision making of at least moderate complexity during the service period Face-to-face visit, 

within 14 calendar days of discharge)). 

Accordingly, we used the work RVU and work time associated with the non-face-to-face 

portion of CPT code 99495 as a foundation to determine our proposed values for CCM services. 

Specifically, we are proposing a work RVU for GXXX1 of 0.61, which is the portion of the work 

RVU for CPT code 99495 that remains after subtracting the work attributable to the face-to-face 

visit. (CPT code 99214 (office/outpatient visit est) was used to value CPT code 99495), which 

has a work RVU of 1.50.) Similarly, we are proposing a work time of 15 minutes for HCPCS 

code GXXX1 for CY 2015 based on the time attributable to the non-face-to-face portion of CPT 

99495. The work time file associated with this PFS proposed rule is available on the CMS 

website in the Downloads section for the CY 2015 PFS proposed rule at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. 

For direct PE inputs, we are proposing 20 minutes of clinical labor time. As established 

in the CY 2014 PFS final rule with comment period, in order to bill for this code, at least 20 

minutes of CCM services must be furnished during the 30-day billing interval (78 FR 74422). 

Based upon input from stakeholders and the nature of care management services, we believe that 

many aspects of this service will be provided by clinical staff, and thus, clinical staff will be 

involved in the typical service for the full 20 minutes. The proposed CY 2015 direct PE input 

database reflects this input and is available on the CMS website under the supporting data files 

for the CY 2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The proposed PE RVUs 

included in Addendum B to this proposed rule reflect the RVUs that result from using these 

inputs to establish PE RVUs. 
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The proposed MP RVU was calculated using the weighted risk factors for the specialties 

that we believe will furnish this service. We believe this malpractice risk factor appropriately 

reflects the relative malpractice risk associated with furnishing CCM services. The MP RVU 

included in Addendum B of this proposed rule reflects the RVU that results from the application 

of this proposal. 

2. CCM and TCM Services Furnished Incident to a Physician’s Service under General Physician 

Supervision 

In the CY 2014 PFS final rule with comment period (75 FR 74425 through 74427), we 

discussed how the policies relating to services furnished incident to a practitioner’s professional 

services apply to CCM services. (In this discussion, the term practitioner means both physicians 

and NPPs who are permitted to bill for services furnished incident to their own professional 

services.) Specifically, we addressed the policy for counting clinical staff time for services 

furnished incident to the billing practitioner’s services toward the minimum amount of service 

time required to bill for CCM services. 

We established an exception to the usual rules that apply to services furnished incident to 

the services of a billing practitioner. Generally, under the “incident to” rules, practitioners may 

bill for services furnished incident to their own services if the services meet the requirements 

specified in our regulations at §410.26. One of these requirements is that the “incident to” 

services must be furnished under direct supervision, which means that the supervising 

practitioner must be present in the office suite and be immediately available to provide assistance 

and direction throughout the service (but does not mean that the supervising practitioner must be 

present in the room where the service is furnished). We noted in last year’s PFS final rule with 

comment period that because one of the required elements of the CCM service is the availability 

to a beneficiary 24-hours-a-day, 7-days-a-week to address the patient’s chronic care needs (78 
 175 

FR 74426) that we expect the beneficiary to be provided with a means to make timely contact 

with health care providers in the practice whenever necessary to address chronic care needs 

regardless of the time of day or day of the week. In those cases when the need for contact arises 

outside normal business hours, it is likely that the patient’s initial contact would be with clinical 

staff employed by the practice (for example, a nurse) and not necessarily with a practitioner. 

Under these circumstances, it would be unlikely that a practitioner would be available to provide 

direct supervision of the service. 

Therefore, in the CY 2014 PFS final rule with comment period, we created an exception 

to the generally applicable requirement that “incident to” services must be furnished under direct 

supervision. Specifically, we finalized a policy to require only general, rather than direct, 

supervision when CCM services are furnished incident to a practitioner’s services outside of the 

practice’s normal business hours by clinical staff who are direct employees of the practitioner or 

practice. We explained that, given the potential risk to patients that the exception to direct 

supervision could create, we believed that it was appropriate to design the exception as narrowly 

as possible (78 FR 74426). The direct employment requirement was intended to balance the less 

stringent general supervision requirement by ensuring that there is a direct oversight relationship 

between the supervising practitioner and the clinical staff personnel who provide after hours 

services. 

In this rule, we are proposing to revise the policy that we adopted in the CY 2014 PFS 

final rule with comment period, and to amend our regulations to codify the requirements for 

CCM services furnished incident to a practitioner’s services. Specifically, we are proposing to 

remove the requirement that, in order to count the time spent by clinical staff providing aspects 

of CCM services toward the CCM time requirement, the clinical staff person must be a direct 

employee of the practitioner or the practitioner’s practice. (We note that the existing 
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requirement that these services be provided by clinical staff, specifically, rather than by other 

auxiliary personnel is an element of the service for both CCM and TCM services, rather than a 

requirement imposed by the “incident to” rules themselves.) We are also proposing to remove 

the restriction that services provided by clinical staff under general (rather than direct) 

supervision may be counted only if they are provided outside of the practice’s normal business 

hours. Under our proposed revised policy, then, the time spent by clinical staff providing aspects 

of CCM services can be counted toward the CCM time requirement at any time, provided that 

the clinical staff are under the general supervision of a practitioner and all requirements of the 

“incident to” regulations at §410.26 are met. 

We are proposing to revise these aspects of the policy for several reasons. First, one of 

the required elements of the CCM service is the availability of a means for the beneficiary to 

make contact with health care practitioners in the practice to address a patient’s urgent chronic 

care needs (78 FR 74418 through 74419). Other elements within the scope of CCM services are 

similarly required to be furnished by practitioners or clinical staff. We believe that these 

elements of the CCM scope of service require the presence of an organizational infrastructure 

sufficient to adequately support CCM services, irrespective of the nature of the employment or 

contractual relationship between the clinical staff and the practitioner or practice. We also 

believe that the elements of the CCM scope of service, such as the requirement of a care plan, 

ensure a close relationship between a practitioner furnishing ongoing care for a beneficiary and 

clinical staff providing aspects of CCM services under general supervision; and that this close 

working relationship is sufficient to render a requirement of a direct employment relationship or 

direct supervision unnecessary. Under our proposal, CCM services could be furnished “incident 

to” under general supervision if the auxiliary personnel providing the services in conjunction 

with CCM services are clinical staff, and whether or not they are direct employees of the 
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practitioner or practice billing for the service; but the clinical staff must meet the requirements 

for auxiliary personnel contained in §410.26(a)(1). Other than the exception to permit general 

supervision for clinical staff, the same requirements apply to CCM services furnished incident to 

a practitioner’s professional services as apply to other “incident to” services. Furthermore, since 

last year’s final rule, we have had many consultations with physicians and others about the 

organizational structures and other factors that contribute to effective provision of CCM services. 

These consultations have convinced us that, for purposes of clinical staff providing aspects of 

CCM services, it does not matter whether the practitioner is directly available to supervise 

because the nature of the services are such that they can be, and frequently are, provided outside 

of normal business hours or while the physician is away from the office during normal business 

hours. This is because, unlike most other services to which the “incident to” rules apply, the 

CCM services are intrinsically non-face-to-face care coordination services. 

In conjunction with this proposed revision to the requirements for CCM services 

provided by clinical staff incident to the services of a practitioner, we are also proposing to adopt 

the same requirements for equivalent purposes in relation to TCM services. As in the case of 

CCM, TCM explicitly includes separate payment for services that are not necessarily furnished 

face-to-face, such as coordination with other providers and follow-up with patients. It would 

also not be uncommon for auxiliary personnel to provide elements of the TCM services when the 

physician was not in the office. Generally, we believe that it is appropriate to treat separately 

billable care coordination services similarly whether in the form of CCM or TCM. We also 

believe that it would be appropriate to apply the same “incident to” rules that we are proposing 

for CCM services to TCM services. We are not proposing to extend this policy to the E/M 

service that is a required element of TCM. Rather, the required E/M service must still be 

furnished under direct supervision. 
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 Therefore, we are proposing to revise our regulation at §410.26, which sets out the 

applicable requirements for “incident to” services, to permit TCM and CCM services provided 

by clinical staff incident to the services of a practitioner to be furnished under the general 

supervision of a physician or other practitioner. As with other “incident to” services, the 

physician (or other practitioner) supervising the auxiliary personnel need not be the same 

physician (or other practitioner) upon whose professional service the “incident to” service is 

based. We note that all other “incident to” requirements continue to apply and that 

documentation of services provided must be included in the medical record. 

3. Scope of Services and Standards for CCM Services 

In the CY 2014 final rule with comment period (78 FR 74414 through 74428), we 

defined the elements of the scope of service for CCM services required in order for a practitioner 

to bill Medicare for CCM services. In addition, we indicated that we intended to develop 

standards for practices that furnish CCM services to ensure that the practitioners who bill for 

these services have the capability to fully furnish them (78 FR 74415, 74418). At that time, we 

anticipated that we would propose these standards in this proposed rule. We actively sought 

input toward development of these standards by soliciting public comments on the CY 2014 PFS 

final rule with comment period, through outreach to stakeholders in meetings, by convening a 

Technical Expert Panel, and by collaborating with federal partners such as the Office of the 

Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Health, 

the Office of the National Coordinator for Health Information Technology, and the Health 

Resources and Services Administration. Our goal is to recognize the trend toward practice 

transformation and overall improved quality of care, while preventing unwanted and unnecessary 

care. 

As we worked to develop appropriate practice standards that would meet this goal, we 
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consistently found that many of the standards we thought were important overlapped in 

significant ways with the scope of service or with the billing requirements for the CCM services 

that had been finalized in the CY 2014 final rule with comment period. In cases where the 

standards we identified were not unique to CCM requirements, we found that the standards 

overlapped with other Medicare requirements or other federal requirements that apply generally 

to health care practitioners. Based upon the feedback we had received, we sought to avoid 

duplicating other requirements or, worse, imposing conflicting requirements on practitioners that 

would furnish CCM services. Given the standards and requirements already in place for health 

care practitioners and that will apply to those who furnish and bill for CCM services, we have 

decided not to propose an additional set of standards that must be met in order for practitioners to 

furnish and bill for CCM services. Instead of proposing a new set of standards applicable to only 

CCM services, we have decided to emphasize that certain requirements are inherent in the 

elements of the existing scope of service for CCM services, and clarify that these must be met in 

order to bill for CCM services. 

In one area – that of electronic health records – we are concerned that the existing 

elements of the CCM service could leave some gaps in assuring that beneficiaries consistently 

receive care management services that offer the benefits of advanced primary care as it was 

envisioned when this service was created. It is clear that effective care management can be 

accomplished only through regular monitoring of the patient’s health status, needs, and services, 

and through frequent communication and exchange of information with the beneficiary and 

among health care practitioners treating the beneficiary. As a part of the CY 2014 PFS final rule 

with comment period (78 FR 43338 through 43339), we specified that the electronic health 

record for a patient receiving CCM services should include a full list of problems, medications 

and medication allergies in order to inform the care plan, care coordination, and ongoing clinical 
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care. Furthermore, those furnishing CCM services must be able to facilitate communication of 

relevant patient information through electronic exchange of a summary care record with other 

health care providers as a part of managing health care transitions. We believe that if care is to 

be coordinated effectively, all communication must be timely, and it must include the 

information that each team member needs to know to furnish care that is congruent with a 

patient’s needs and preferences. In addition, those furnishing CCM services need to establish 

reliable flows of information from emergency departments, hospitals, and providers of post-acute 

care services to track their CCM patients receiving care in those settings. Reliable information 

flow supports care transitions, and can be used to assess the need for modifications of the care 

plan that will reduce the risk of readmissions, increased morbidity, or mortality. 

After gathering input from stakeholders, we believe that requiring those who furnish 

CCM services to utilize electronic health record technology that has been certified by a certifying 

body authorized by the National Coordinator for Health Information Technology will ensure that 

practitioners have adequate capabilities to allow members of the interdisciplinary care team to 

have immediate access to the most updated information informing the care plan. Furthermore, 

we believe that requiring those that furnish CCM services to maintain and share an electronic 

care plan will alleviate the development of duplicative care plans or updates and the associated 

errors that can occur when care plans are not systematically reconciled. To ensure that practices 

offering CCM services meet these needs, we are proposing a new scope of service requirement 

for electronic care planning capabilities and electronic health records. Specifically, we are 

proposing that CCM services must be furnished with the use of an electronic health record or 

other health IT or health information exchange platform that includes an electronic care plan that 

is accessible to all providers within the practice, including being accessible to those who are 

furnishing care outside of normal business hours, and that is available to be shared electronically 
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with care team members outside of the practice. To ensure all practices have adequate 

capabilities to meet electronic health record requirements, the practitioner must utilize EHR 

technology certified by a certifying body authorized by the National Coordinator for Health 

Information Technology to an edition of the electronic health record certification criteria 

identified in the then-applicable version of 45 CFR part 170. At a minimum, the practice must 

utilize EHR technology that meets the certification criteria adopted at 45 CFR 170.314(a)(3), 

170.314(a)(4), 170.314(a)(5), 170.314(a)(6), 170.314(a)(7) and 170.314(e)(2) pertaining to the 

capture of demographics, problem lists, medications, and other key elements related to the 

ultimate creation of an electronic summary care record. For example, practitioners furnishing 

CCM services beginning in CY 2015 would be required to utilize an electronic health record 

certified to at least those 2014 Edition certification criteria. Given these certification criteria, 

EHR technology would be certified to capture data and ultimately produce summary records 

according to the HL7 Consolidated Clinical Document Architecture standard (see 45 CFR 

170.205(a)(3)). When any of the CCM scope of service requirements include a reference to a 

health or medical record, a system meeting these requirements is required. 

We believe this scope of service element will ensure that practitioners have adequate 

capabilities to fully furnish CCM services, allow practitioners to innovate around the systems 

that they use to furnish these services, and avoid overburdening small practices. We believe that 

allowing flexibility as to how providers capture, update, and share care plan information is 

important at this stage given the maturity of current electronic health record standards and other 

electronic tools in use in the market today for care planning. 

In addition to seeking comment on this new proposed scope of service element, we are 

seeking comment on any changes to the scope of service or billing requirements for CCM 

services that may be necessary to ensure that the practitioners who bill for these services have the 
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capability to furnish them and that we can appropriately monitor billing for these services. 

To assist stakeholders in commenting, we remind you of the elements of the current 

scope of service for CCM services that are required in order for a practitioner to bill Medicare 

for CCM services as finalized in the CY 2014 final rule with comment period. We would note 

that additional explanation of these elements can be found at 78 FR 74414 through 74428. The 

CCM service includes: 

● Access to care management services 24-hours-a-day, 7-days- a-week, which means 

providing beneficiaries with a means to make timely contact with health care providers in the 

practice to address the patient’s urgent chronic care needs regardless of the time of day or day of 

the week. 

● Continuity of care with a designated practitioner or member of the care team with 

whom the patient is able to get successive routine appointments. 

● Care management for chronic conditions including systematic assessment of patient’s 

medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt 

of all recommended preventive care services; medication reconciliation with review of adherence 

and potential interactions; and oversight of patient self-management of medications. 

● Creation of a patient-centered care plan document to assure that care is provided in a 

way that is congruent with patient choices and values. A plan of care is based on a physical, 

mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory 

of resources and supports. It is a comprehensive plan of care for all health issues. 

● Management of care transitions between and among health care providers and settings, 

including referrals to other clinicians, follow-up after a beneficiary visit to an emergency 

department, and follow-up after discharges from hospitals, skilled nursing facilities, or other 

health care facilities. 
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● Coordination with home and community based clinical service providers as 

appropriate to support a beneficiary’s ’s psychosocial needs and functional deficits. 

● Enhanced opportunities for a beneficiary and any relevant caregiver to communicate 

with the practitioner regarding the beneficiary’s care through, not only telephone access, but also 

through the use of secure messaging, internet or other asynchronous non face-to-face 

consultation methods. 

Similarly, we remind stakeholders that in the CY 2014 final rule, we established 

particular billing requirements for CCM services that require the practitioner to: 

● Inform the beneficiary about the availability of the CCM services from the practitioner 

and obtain his or her written agreement to have the services provided, including the beneficiary’s 

authorization for the electronic communication of the patient’s medical information with other 

treating providers as part of care coordination. 

● Document in the patient’s medical record that all of the CCM services were explained 

and offered to the patient, and note the beneficiary’s decision to accept or decline these services. 

● Provide the beneficiary a written or electronic copy of the care plan and document in 

the electronic medical record that the care plan was provided to the beneficiary. 

● Inform the beneficiary of the right to stop the CCM services at any time (effective at 

the end of a 30-day period) and the effect of a revocation of the agreement on CCM services. 

● Inform the beneficiary that only one practitioner can furnish and be paid for these 

services during the 30-day period. 

With the addition of the electronic health record element that we are proposing, we 

believe that these elements of the scope of service for CCM services, when combined with other 

important federal health and safety regulations, provide sufficient assurance that Medicare 

beneficiaries receiving CCM services will receive appropriate services. However, we remain 
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interested in receiving public feedback regarding any meaningful elements of the CCM service 

or beneficiary protections that may be missing from these scope of service elements and billing 

requirements. We encourage commenters, in recommending additional possible elements or 

safeguards, to provide as much specific detail as possible regarding their recommendations and 

how they can be applied to the broad complement of practitioners who may furnish CCM 

services under the PFS. 

4. Payment of CCM Services in CMS Models and Demonstrations 

As discussed above, several CMS models and demonstrations address payment for care 

management services. The Multi-payer Advanced Primary Care Practice Demonstration and the 

Comprehensive Primary Care Initiative both include payments for care management services that 

closely overlap with the scope of service for the new chronic care management services code. In 

these two initiatives, primary care practices are receiving per beneficiary per month payments for 

care management services furnished to Medicare fee-for-service beneficiaries attributed to their 

practices. We propose that practitioners participating in one of these two models may not bill 

Medicare for CCM services furnished to any beneficiary attributed to the practice for purposes of 

participating in one of these initiatives, as we believe the payment for CCM services would be a 

duplicative payment for substantially the same services for which payment is made through the 

per beneficiary per month payment. However, we propose that these practitioners may bill 

Medicare for CCM services furnished to eligible beneficiaries who are not attributed to the 

practice for the purpose of the practice’s participation as part of one of these initiatives. As the 

Innovation Center implements new models or demonstrations that include payments for care 

management services, or as changes take place affecting existing models or demonstrations, we 

will address potential overlaps with CCM and seek to implement appropriate reimbursement 

policies. We welcome comments on this proposal. We also solicit comments on the extent to 
 185 

which these services may not actually be duplicative and, if so, how our reimbursement policy 

could be tailored to address those situations. 
 186 

H. Definition of Colorectal Cancer Screening Tests 

 Section 1861(pp) of the Act defines “colorectal cancer screening tests” and, under section 

1861(pp)(1)(C), a “screening colonoscopy” is one of the recognized procedures. Among other 

things, section 1861(pp)(1)(D) of the Act authorizes the Secretary to modify the tests and 

procedures covered under this subsection, “with such frequency and payment limits, as the 

Secretary determines appropriate,” in consultation with appropriate organizations. The current 

definition of “colorectal cancer screening tests” at §410.37(a)(1) includes “screening 

colonoscopies.” Until recently, the prevailing standard of care for screening colonoscopies has 

been moderate sedation provided intravenously by the endoscopist, without resort to separately 

provided anesthesia.1 Based on this standard of care, payment for moderate sedation has 

accordingly been bundled into the payment for the colorectal cancer screening tests, (for 

example, G0104, G0105). For these procedures, because moderate sedation is bundled into the 

payment, the same physician cannot also report a sedation code. An anesthesia service can be 

billed by a second physician. 

However, a recent study in The Journal of the American Medical Association (JAMA) 

cited an increase in the percentage of colonoscopies and upper endoscopy procedures furnished 

using an anesthesia professional, from 13.5 percent in 2003 to 30.2 percent in 2009 within the 

Medicare population, with a similar increase in the commercially-insured population.2

 A 2010 

study projected that the percentage of this class of procedures involving an anesthesia 

professional would grow to 53.4 percent by 2015.3 These studies suggest that the prevailing 

standard of care for endoscopies in general and screening colonoscopies in particular is 

 

1 Faulx, A. L. et al. (2005). The changing landscape of practice patterns regarding unsedated colonoscopy and propofol use: A 

national web survey. Gastrointestinal Endoscopy, 62. 9-15. 2 Liu H, Waxman DA, Main R, Mattke S. Utilization of Anesthesia Services during Outpatient Endoscopies and Colonoscopies 

and Associated Spending in 2003-2009. (2012). JAMA, 307(11):1178-1184. 3 Inadomi, J. M. et al. (2010). Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and

EGD in the United States: 2009 to 2015. Gastrointestinal Endoscopy, 72, 580-586.
 187 

undergoing a transition, and that anesthesia separately provided by an anesthesia professional is 

becoming the prevalent practice. After reviewing these studies, we analyzed Medicare claims 

data and found that the same trend was observed in screening colonoscopies for Medicare 

beneficiaries. We found that in 53 percent of screening colonoscopies for which Medicare 

claims were submitted in 2013 a separate anesthesia claim was reported. 

In light of these developments, we are concerned that the mere reference to “screening 

colonoscopies” in the definition of “colorectal cancer screening tests” has become inadequate. 

Indeed, we are convinced that the growing prevalence of separately provided anesthesia services 

in conjunction with screening colonoscopies reflects a change in practice patterns. Therefore, 

consistent with the authority delegated by section 1861(pp)(1)(D) of the Act, we believe it is 

appropriate to revise the definition of “colorectal cancer screening tests” to adequately reflect 

these new patterns. Accordingly, we are proposing to revise the definition of “colorectal cancer 

screening tests” at §410.37(a)(1)(iii) to include anesthesia that is separately furnished in 

conjunction with screening colonoscopies. 

Our proposal to revise the definition of “colorectal cancer screening tests” in this manner 

would further reduce our beneficiaries’ cost-sharing obligations under Part B. Screening 

colonoscopies have been recommended with a grade of A by the United States Preventive 

Services Task Force (USPSTF) and §410.152(l)(5) provides that Medicare Part B pays 100 

percent of the Medicare payment amount established under the PFS for colorectal cancer 

screening tests except for barium enemas (which do not have a grade A or B recommendation 

from the USPSTF). This regulation is based on section 4104 of the Affordable Care Act, which 

amended section 1833(a)(1) of the Act to require 100 percent Medicare payment of the fee 

schedule amount for those “preventive services” that are appropriate for the individual and are 

recommended with a grade of A or B by the USPSTF. Section 4104 effectively waives any Part 
 188 

B coinsurance that would otherwise apply under section 1833(a)(1) of the Act for certain 

recommended preventive services, including screening colonoscopies. For additional discussion 

of the impact of section 4104 of the Affordable Care Act, and our prior rulemaking based on this 

provision see the CY 2011 PFS final rule with comment period (75 FR 73412 through 73431). 

We also note that under §410.160(b)(7) colorectal cancer screening tests are not subject to the 

Part B annual deductible and do not count toward meeting that deductible. 

In implementing the amendments made by section 4104 of the Affordable Care Act, we 

did not provide at that time for waiving the Part B deductible and coinsurance for covered 

anesthesia services separately furnished in conjunction with screening colonoscopies. At that 

time, we believed that our payment for the screening colonoscopy, which included payment for 

moderate sedation services, reflected the typical screening colonoscopy. Under the current 

regulations, Medicare beneficiaries who receive anesthesia from a different professional than the 

one furnishing the screening colonoscopy would be incurring costs for the coinsurance and 

deductible under Part B for those separate services. With the changes in the standard of care and 

shifting practice patterns toward increased use of anesthesia in conjunction with screening 

colonoscopy, beneficiaries who receive covered anesthesia services from a different professional 

than the one furnishing the colonoscopy would incur costs for any coinsurance and any unmet 

part of the deductible for this component of the service. However, our proposed revision to the 

definition of “colorectal cancer screening tests” would lead to Medicare paying 100 percent of 

the fee schedule amounts for screening colonoscopies, including any portion attributable to 

anesthesia services furnished by a separate practitioner in conjunction with such tests, under 

§410.152(l)(5). Similarly, this revision would also mean that expenses incurred for a screening 

colonoscopy, and the anesthesia services furnished in conjunction with such tests, will not be 

subject to the Part B deductible and will not count toward meeting that deductible under 
 189 

§410.160(b)(7). If adopted, we believe this proposal will encourage more beneficiaries to obtain 

a screening colonoscopy, which is consistent with the intent of the statutory provision to waive 

Medicare cost-sharing for certain recommended preventive services, and is consistent with the 

authority delegated to the Secretary in section 1861(pp)(1)(D) of the Act. 

In light of the changing practice patterns for screening colonoscopies, continuing to 

require Medicare beneficiaries to bear the deductible and coinsurance expenses for separately 

billed anesthesia services furnished and covered by Medicare in conjunction with screening 

colonoscopies could become a significant barrier to these essential preventive services. As we 

noted when we implemented the provisions of the Affordable Care Act waiving the Part B 

deductible and coinsurance for these preventive services, the goal of these provisions was to 

eliminate financial barriers so that beneficiaries would not be deterred from receiving them 

(75 FR 73412). Therefore, we are exercising our authority under section 1861(pp)(1)(D) of the 

Act to propose a revision to the definition of colorectal cancer screening tests to encourage 

beneficiaries to seek these services by extending the waiver of coinsurance and deductible to 

anesthesia or sedation services furnished in conjunction with a screening colonoscopy. 

We note that, in implementing these proposed revisions to the regulations, it will be 

necessary to establish a modifier for use when billing the relevant anesthesia codes for services 

that are furnished in conjunction with a screening colonoscopy and, thus, qualify for the waiver 

of the Part B deductible and coinsurance. If we adopt this proposal in the final rule, we will 

provide appropriate and timely information on this new modifier and its proper use so that 

physicians will be able to bill correctly for these services when the revised regulations become 

effective. We also note that the valuation of colonoscopy codes, which include moderate 

sedation, will be subject to the same proposed review as other codes that include moderate 

sedation, as discussed in section II.B.6 of this proposed rule. 
 190 
 191 

I. Payment of Secondary Interpretation of Images 

In general, Medicare makes one payment for the professional component of an imaging 

service for each technical component service that is furnished. Section 100.1, Chapter 13, of the 

Medicare Claims Processing Manual (Pub. 100-04) explains this policy in the context of EKGs 

and X-rays furnished in an Emergency Room. The manual section discusses the distinction 

between a “review” of an X-ray or EKG for which payment is included in the payment for the 

emergency department E/M payment, and the “interpretation and report” of an X-ray or EKG 

which can be billed separately and includes a written report addressing “the findings, relevant 

clinical issues, and comparative data (when available).” The section makes clear that a 

“professional component” interpretation service should only be billed for a full interpretation and 

report. The manual section goes on to explain that, in general, Medicare pays for only one 

interpretation of an EKG or X-ray service furnished to an emergency room patient. However, 

Medicare can pay for a second interpretation (which is billed using modifier -77) under “unusual 

circumstances (for which documentation is provided).” For instance, if an emergency room 

physician conducts an interpretation, identifies a questionable finding, and believes another 

physician’s expertise is needed, then a second claim for an interpretation can be paid when 

furnished, for example, by a radiologist. The second interpretation must directly contribute to 

the diagnosis and treatment of the individual patient (rather than serving as a quality control 

measure), and the second interpretation must also be accompanied by a written report.

While a separate payment for the professional component for a radiology service is 

contingent upon meeting the conditions described in this section, practitioners bill Medicare and 

are paid for reviews of radiology images in other ways. For instance, review of a patient’s 

previous radiology images is included and paid as part of the review of previous documentation 

in conjunction with E/M services. Reviews of extensive documentation and efforts to obtain 
 192 

previous documentation including existing imaging studies are considerations in deciding the 

appropriate level of complexity for evaluation and management services.4

In recent years, technological advances such as the integration of picture and archiving 

communications systems across health systems, growth in image sharing networks and health 

information exchange platforms through which providers can share images, and consumermediated exchange of images, have greatly increased physicians’ access to existing diagnosticquality radiology images. These advances offer new opportunities for physicians to reduce 

duplicative imaging, particularly with respect to high cost advanced diagnostic imaging 

modalities. For instance, a trauma patient transferred from a community hospital to a tertiary 

care center may arrive with high quality CT images sufficient to support an additional 

professional interpretation service. By accessing and utilizing these images to inform the 

diagnosis and record an interpretation in the medical record at the tertiary care facility, the 

provider and physicians may be able to avoid ordering substantially duplicative tests. 

Questions have arisen as to whether and under what circumstances it would be 

appropriate for Medicare to permit payment under the PFS when physicians furnish subsequent 

interpretations of existing images, and whether uncertainty associated with payment for 

secondary interpretations inhibits physicians from seeking out, accessing, and utilizing existing 

images in cases where avoidance of a new study would result in savings to Medicare. We are 

seeking comment to assess whether there is an expanded set of circumstances under which it 

would be appropriate to allow more routine Medicare payment for a second professional 

component for radiology services, and whether such a policy would be likely to reduce the 

incidence of duplicative advanced imaging studies. 

Specifically we are seeking comment on the following questions: 

 

4

 See, for example, 1997 Documentation Guidelines for Evaluation and Management Service, p. 45. 
 193 

● For which radiology services are physicians currently conducting secondary 

interpretations, and what, if any, institutional policies are in place to determine when existing 

images are utilized? To what extent are physicians seeking payment for these secondary 

interpretations from Medicare or other payers? 

● Should routine payment for secondary interpretations be restricted to certain high-cost 

advanced diagnostic imaging services, such as those defined as such under section 1834(e)(1)(B) 

of the Act, for example, diagnostic magnetic resonance imaging, computed tomography, and 

nuclear medicine (including positron emission tomography)? 

● How should the value of routine secondary interpretations be determined? Is it 

appropriate to apply a modifier to current codes or are new HCPCS codes for secondary 

interpretations necessary? 

● We believe most secondary interpretations would be likely to take place in the hospital 

setting. Are there other settings in which claims for secondary interpretations would be likely to 

reduce duplicative imaging services? 

● Is there a limited time period within which an existing image should be considered 

adequate to support a secondary interpretation? 

● Would allowing for more routine payment for secondary interpretations be likely to 

generate cost savings to Medicare by avoiding potentially duplicative imaging studies? 

● What operational steps could Medicare take to ensure that any routine payment for 

secondary interpretations is limited to cases where a new imaging study has been averted while 

minimizing undue burden on providers or Part B contractors? For instance, steps might include 

restricting physicians’ ability to refer multiple interpretations to another physician that is part of 

their network or group practice, requiring that physicians attach a physician’s order for an 
 194 

averted imaging study to a claim for a secondary interpretation, or requiring physicians to 

identify the technical component of the existing image supporting the claim. 

We seek comments on these questions, and welcome input on any additional 

considerations not mentioned here regarding the potential impact of allowing payment for 

secondary interpretation of images under other circumstances. Upon reviewing the comments 

received, we will consider whether any further action is appropriate, for instance, proposing 

under a future rulemaking to allow for payment of subsequent interpretations of advanced 

diagnostic images in lieu of duplicative studies. 
 195 

J. Conditions Regarding Permissible Practice Types for Therapists in Private Practice 

Section 1861(p) of the Act defines outpatient therapy services to include physical 

therapy, occupational therapy, and speech-language pathology services furnished by qualified 

occupational therapists, physical therapists, and speech-language pathologists in their offices and 

in the homes of beneficiaries. The regulations at §§410.59(c), 410.60(c), and 410.62(c) set forth 

special provisions for services furnished by therapists in private practice, including basic 

qualifications necessary to qualify as a supplier of occupational therapy (OT), physical therapy 

(PT), and speech-language pathology (SLP), respectively. As part of these basic qualifications, 

the current regulatory language includes descriptions of the various practice types for therapists’ 

private practices. Based on our recent review of these three sections of our regulations, we are 

concerned that the language is not as clear as it could be – especially with regard to the relevance 

of whether a practice is incorporated. The regulations appear to make distinctions between 

unincorporated and incorporated practices, and some practice types are listed twice. 

Accordingly, we are proposing changes to the regulatory language to remove unnecessary 

distinctions and redundancies within the regulations for OT, PT, and SLP. We note that these 

proposed changes are for clarification only, and do not reflect any proposed change in our 

current policy. 

To consistently specify the permissible practice types (a solo practice, partnership, or 

group practice; or as an employee of one of these) for suppliers of outpatient therapy services in 

private practice (for occupational therapists, physical therapists and speech-language 

pathologists), we propose to replace the regulatory text at §410.59(c)(1)(ii)(A) through (E), 

§410.60(c)(1)(ii)(A) though (E), and §410.62(c)(1)(ii)(A) through (E). 
 196 

K. Payments for Physicians and Practitioners Managing Patients on Home Dialysis 

In the CY 2005 PFS final rule with comment period (69 FR 66357 through 66359), we 

established criteria for furnishing outpatient per diem ESRD-related services in partial month 

scenarios. We specified that use of per diem ESRD-related services is intended to accommodate 

unusual circumstances when the outpatient ESRD-related services would not be paid for under 

the monthly capitation payment (MCP), and that use of the per diem services are limited to the 

circumstances listed below. 

• Transient patients – Patients traveling away from home (less than full month); 

• Home dialysis patients (less than full month); 

• Partial month where there were one or more face-to-face visits without the 

comprehensive visit and either the patient was hospitalized before a complete assessment was 

furnished, dialysis stopped due to death, or the patient received a kidney transplant. 

• Patients who have a permanent change in their MCP physician during the month. 

Additionally, we provided billing guidelines for partial month scenarios in the Medicare 

claims processing manual, publication 100-04, chapter 8, section 140.2.1. For center-based 

patients, we specified that if the MCP physician or practitioner furnishes a complete assessment 

of the ESRD beneficiary, the MCP physician or practitioner should bill for the full MCP service 

that reflects the number of visits furnished during the month. However, we did not extend this 

policy to home dialysis (less than a full month) because the home dialysis MCP service did not 

include a specific frequency of required patient visits. In other words, unlike the ESRD MCP 

service for center-based patients, a visit was not required for the home dialysis MCP service as a 

condition of payment. 

In the CY 2011 PFS final rule with comment period (75 FR 73295 through 73296), we 

changed our policy for the home dialysis MCP service to require the MCP physician or 
 197 

practitioner to furnish at least one face-to-face patient visit per month as a condition of payment. 

However, we inadvertently did not modify our billing guidelines for home dialysis (less than a 

full month) to be consistent with partial month scenarios for center-based dialysis patients. 

Stakeholders have recently brought this inconsistency to our attention. After reviewing this 

issue, we are proposing to allow the MCP physician or practitioner to bill for the age appropriate 

home dialysis MCP service (as described by HCPCS codes 90963 through 90966) for the home 

dialysis (less than a full month) scenario if the MCP physician or practitioner furnishes a 

complete monthly assessment of the ESRD beneficiary and at least one face-to-face patient visit. 

For example, if a home dialysis patient was hospitalized during the month and at least one faceto-face outpatient visit and complete monthly assessment was furnished, the MCP physician or 

practitioner should bill for the full home dialysis MCP service. We believe that this proposed 

change to home dialysis (less than a full month) provides consistency with our policy for partial 

month scenarios pertaining to patients dialyzing in a dialysis center. If this proposal is adopted, 

we would modify the Medicare Claims Processing Manual to reflect the revised billing 

guidelines for home dialysis in the less than a full month scenario. 
 198 

III. Other Provisions of the Proposed Regulations 

A. Ambulance Extender Provisions 

1. Amendment to Section 1834(l)(13) of the Act 

Section 146(a) of the MIPPA amended section 1834(l)(13)(A) of the Act to specify that, 

effective for ground ambulance services furnished on or after July 1, 2008 and before January 1, 

2010, the ambulance fee schedule amounts for ground ambulance services shall be increased as 

follows: 

● For covered ground ambulance transports that originate in a rural area or in a rural 

census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 

3 percent. 

● For covered ground ambulance transports that do not originate in a rural area or in a 

rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased 

by 2 percent. 

The payment add-ons under section 1834(l)(13) of the Act have been extended several 

times. Recently, section 1104(a) of the Pathway for SGR Reform Act of 2013, enacted on 

December 26, 2013, as Division B (Medicare and Other Health Provisions) of Pub L. 113-67, 

amended section 1834(l)(13)(A) of the Act to extend the payment add-ons described above 

through March 31, 2014. Subsequently, section 104(a) of the Protecting Access to Medicare Act 

of 2014 (Pub. L. 113-93, enacted on April 1, 2014) amended section 1834(l)(13)(A) of the Act to 

extend the payment add-ons again through March 31, 2015. Thus, these payment add-ons also 

apply to covered ground ambulance transports furnished before April 1, 2015. We are proposing 

to revise §414.610(c)(1)(ii) to conform the regulations to these statutory requirements. (For a 

discussion of past legislation extending section 1834(l)(13) of the Act, please see the CY 2014 

PFS final rule (78 FR 74438 through 74439)). 
 199 

These statutory requirements are self-implementing. A plain reading of the statute 

requires only a ministerial application of the mandated rate increase, and does not require any 

substantive exercise of discretion on the part of the Secretary. 

2. Amendment to Section 1834(l)(12) of the Act 

 Section 414(c) of the Medicare Prescription Drug, Improvement and Modernization Act 

of 2003 (Pub. L. 108-173, enacted on December 8, 2003) (MMA) added section 1834(l)(12) to 

the Act, which specified that in the case of ground ambulance services furnished on or after July 

1, 2004, and before January 1, 2010, for which transportation originates in a qualified rural area 

(as described in the statute), the Secretary shall provide for a percent increase in the base rate of 

the fee schedule for such transports. The statute requires this percent increase to be based on the 

Secretary’s estimate of the average cost per trip for such services (not taking into account 

mileage) in the lowest quartile of all rural county populations as compared to the average cost 

per trip for such services (not taking into account mileage) in the highest quartile of rural county 

populations. Using the methodology specified in the July 1, 2004 interim final rule (69 FR 

40288), we determined that this percent increase was equal to 22.6 percent. As required by the 

MMA, this payment increase was applied to ground ambulance transports that originated in a 

“qualified rural area”; that is, to transports that originated in a rural area included in those areas 

comprising the lowest 25th percentile of all rural populations arrayed by population density. For 

this purpose, rural areas included Goldsmith areas (a type of rural census tract). This rural bonus 

is sometimes referred to as the “Super Rural Bonus” and the qualified rural areas (also known as 

“super rural” areas) are identified during the claims adjudicative process via the use of a data 

field included on the CMS-supplied ZIP code File. 

The Super Rural Bonus under section 1834(l)(12) of the Act has been extended several 

times. Recently, section 1104(b) of the Pathway for SGR Reform Act of 2013, enacted on 
 200 

December 26, 2013, as Division B (Medicare and Other Health Provisions) of Pub. L. 113-67, 

amended section 1834(l)(12)(A) of the Act to extend this rural bonus through March 31, 2014. 

Subsequently, section 104(b) of the Protecting Access to Medicare Act of 2014 (Pub. L. 113-93, 

enacted on April 1, 2014) amended section 1834(l)(12)(A) of the Act to extend this rural bonus 

again through March 31, 2015. Therefore, we are continuing to apply the 22.6 percent rural 

bonus described above (in the same manner as in previous years), to ground ambulance services 

with dates of service before April 1, 2015 where transportation originates in a qualified rural 

area. Accordingly, we are proposing to revise §414.610(c)(5)(ii) to conform the regulations to 

these statutory requirements. (For a discussion of past legislation extending section 1834(l)(12) 

of the Act, please see the CY 2014 PFS final rule (78 FR 74439 through 74440)).

 These statutory provisions are self-implementing. Together, these statutory provisions 

require a 15-month extension of this rural bonus (which was previously established by the 

Secretary) through March 31, 2015, and do not require any substantive exercise of discretion on 

the part of the Secretary. 

B. Proposed Changes in Geographic Area Delineations for Ambulance Payment 

1. Background

Under the ambulance fee schedule, the Medicare program pays for ambulance 

transportation services for Medicare beneficiaries when other means of transportation are 

contraindicated by the beneficiary’s medical condition, and all other coverage requirements are 

met. Ambulance services are classified into different levels of ground (including water) and air 

ambulance services based on the medically necessary treatment provided during transport. 

 These services include the following levels of service: 

● For Ground-- 

 ++ Basic Life Support (BLS) (emergency and non-emergency) 
 201 

 ++ Advanced Life Support, Level 1 (ALS1) (emergency and non-emergency) 

 ++ Advanced Life Support, Level 2 (ALS2) 

 ++ Paramedic ALS Intercept (PI) 

++ Specialty Care Transport (SCT) 

● For Air-- 

 ++ Fixed Wing Air Ambulance (FW) 

 ++ Rotary Wing Air Ambulance (RW) 

a. Statutory Coverage of Ambulance Services 

 Under sections 1834(l) and 1861(s)(7) of the Act, Medicare Part B (Supplemental 

Medical Insurance) covers and pays for ambulance services, to the extent prescribed in 

regulations, when the use of other methods of transportation would be contraindicated by the 

beneficiary’s medical condition. 

The House Ways and Means Committee and Senate Finance Committee Reports that 

accompanied the 1965 Social Security Amendments suggest that the Congress intended that-- 

● The ambulance benefit cover transportation services only if other means of 

transportation are contraindicated by the beneficiary’s medical condition; and 

● Only ambulance service to local facilities be covered unless necessary services are not 

available locally, in which case, transportation to the nearest facility furnishing those services is 

covered (H.R. Rep. No. 213, 89th Cong., 1st Sess. 37 and Rep. No. 404, 89th Cong., 1st Sess. Pt 1, 

43 (1965)). 

 The reports indicate that transportation may also be provided from one hospital to 

another, to the beneficiary’s home, or to an extended care facility. 

b. Medicare Regulations for Ambulance Services 

 Our regulations relating to ambulance services are set forth at 42 CFR part 410, subpart B 
 202 

and 42 CFR part 414, subpart H. Section 410.10(i) lists ambulance services as one of the 

covered medical and other health services under Medicare Part B. Therefore, ambulance 

services are subject to basic conditions and limitations set forth at §410.12 and to specific 

conditions and limitations included at §410.40 and §410.41. Part 414, subpart H, describes how 

payment is made for ambulance services covered by Medicare. 

2. Provisions of the Proposed Rule 

Historically, the Medicare ambulance fee schedule has used the same geographic area 

designations as the acute care hospital inpatient prospective payment system (IPPS) and other 

Medicare payment systems to take into account appropriate urban and rural differences. This 

promotes consistency across the Medicare program, and it provides for use of consistent 

geographic standards for Medicare payment purposes. 

The current geographic areas used under the ambulance fee schedule are based on OMB 

standards published on December 27, 2000 (65 FR 82228 through 82238) and Census 2000 data 

and Census Bureau population estimates for 2007 and 2008 (OMB Bulletin No. 10-02). For a 

discussion of OMB’s delineation of Core-Based Statistical Areas (CBSAs) and our 

implementation of the CBSA definitions under the ambulance fee schedule, we refer readers to 

the preamble of the CY 2007 Ambulance Fee Schedule proposed rule (71 FR 30358 through 

30361) and the CY 2007 PFS final rule (71 FR 69712 through 69716). On February 28, 2013, 

OMB issued OMB Bulletin No. 13-01, which established revised delineations for Metropolitan 

Statistical Areas (MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas, and 

provided guidance on the use of the delineations of these statistical areas. A copy of this bulletin 

may be obtained at http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-

01.pdf. According to OMB, “[t]his bulletin provides the delineations of all Metropolitan 

Statistical Areas, Metropolitan Divisions, Micropolitan Statistical Areas, Combined Statistical 
 203 

Areas, and New England City and Town Areas in the United States and Puerto Rico based on the 

standards published on June 28, 2010, in the Federal Register (75 FR 37246 - 37252) and 

Census Bureau data.” OMB defines an MSA as a CBSA associated with at least one urbanized 

area that has a population of at least 50,000, and a Micropolitan Statistical Area (referred to in 

this discussion as a Micropolitan Area) as a CBSA associated with at least one urban cluster that 

has a population of at least 10,000 but less than 50,000 (75 FR 37252). Counties that do not 

qualify for inclusion in a CBSA are deemed “Outside CBSAs.” We note that, when referencing 

the new OMB geographic boundaries of statistical areas, we are using the term “delineations” 

consistent with OMB’s use of the term (75 FR 37249). 

While the revisions OMB published on February 28, 2013 are not as sweeping as the 

changes made when we adopted the CBSA geographic designations for CY 2007, the February 

28, 2013 OMB bulletin does contain a number of significant changes. For example, if we adopt 

the revised OMB delineations, there would be new CBSAs, urban counties that would become 

rural, rural counties that would become urban, and existing CBSAs that would be split apart. 

Because the bulletin was not issued until February 28, 2013, with supporting data not available 

until later, and because the changes made by the bulletin and their ramifications needed to be 

extensively reviewed and verified, we were unable to undertake such a lengthy process before 

publication of the CY 2014 PFS proposed rule, and thus, did not implement the changes to the 

OMB delineations under the ambulance fee schedule for CY 2014. We have reviewed our 

findings and impacts relating to the new OMB delineations, and find no compelling reason to 

further delay implementation. We believe it is important for the ambulance fee schedule to use 

the latest labor market area delineations available as soon as reasonably possible in order to 

maintain a more accurate and up-to-date payment system that reflects the reality of population 

shifts. 
 204 

Additionally, in the FY 2015 IPPS proposed rule (79 FR 28055), we also proposed to 

adopt OMB’s revised delineations to identify urban areas and rural areas for purposes of the 

IPPS wage index. For the reasons discussed above, we believe it would be appropriate to adopt 

the same geographic area delineations for use under the ambulance fee schedule as are used 

under the IPPS and other Medicare payment systems. Thus, we are proposing to implement the 

new OMB delineations as described in the February 28, 2013 OMB Bulletin No. 13-01 

beginning in CY 2015 to more accurately identify urban and rural areas for ambulance fee 

schedule payment purposes. We believe that the updated OMB delineations more realistically 

reflect rural and urban populations, and that the use of such delineations under the ambulance fee 

schedule would result in more accurate payment. Under the ambulance fee schedule, consistent 

with our current definitions of urban and rural areas (§414.605), MSAs would continue to be 

recognized as urban areas, while Micropolitan and other areas outside MSAs, and rural census 

tracts within MSAs (as discussed below), would be recognized as rural areas. 

In addition to the OMB’s statistical area delineations, the current geographic areas used 

in the ambulance fee schedule also are based on the most recent version of the Goldsmith 

Modification. Section 1834(l) of the Act requires that we use the most recent version of the 

Goldsmith Modification to determine rural census tracts within MSAs. These rural census tracts 

are considered rural areas under the ambulance fee schedule (see § 414.605). In the CY 2007 

PFS final rule (71 FR 69714 through 69716), we adopted the most recent (at that time) version of 

the Goldsmith Modification, designated as Rural-Urban Commuting Area (RUCA) codes. 

RUCA codes use urbanization, population density, and daily commuting data to categorize every 

census tract in the country. For a discussion about RUCA codes, we refer the reader to the CY 

2007 PFS final rule (71 FR 69714 through 69716). As stated previously, on February 28, 2013, 

OMB issued OMB Bulletin No. 13-01, which established revised delineations for Metropolitan 
 205 

Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and provided 

guidance on the use of the delineations of these statistical areas. Several modifications of the 

RUCA codes were necessary to take into account updated commuting data and the revised OMB 

delineations. We refer readers to the U.S. Department of Agriculture’s Economic Research 

Service website for a detailed listing of updated RUCA codes found at 

http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. The updated 

RUCA code definitions were introduced in late 2013 and are based on data from the 2010 

decennial census and the 2006-10 American Community Survey. We are proposing to adopt the 

most recent modifications of the RUCA codes beginning in CY 2015, to recognize levels of 

rurality in census tracts located in every county across the nation, for purposes of payment under 

the ambulance fee schedule. If we adopt the most recent RUCA codes, many counties that are 

designated as urban at the county level based on population would have rural census tracts within 

them that would be recognized as rural areas through our use of RUCA codes. 

The 2010 Primary RUCA codes are as follows: 

(1) Metropolitan area core: primary flow with an urbanized area (UA). 

(2) Metropolitan area high commuting: primary flow 30 percent or more to a UA. 

(3) Metropolitan area low commuting: primary flow 10 to 30 percent to a UA. 

(4) Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 

(large UC). 

(5) Micropolitan high commuting: primary flow 30 percent or more to a large UC. 

(6) Micropolitan low commuting: primary flow 10 to 30 percent to a large UC. 

(7) Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small 

UC). 

(8) Small town high commuting: primary flow 30 percent or more to a small UC. 
 206 

(9) Small town low commuting: primary flow 10 to 30 percent to a small UC. 

(10) Rural areas: primary flow to a tract outside a UA or UC. 

Based on this classification, and consistent with our current policy (71 FR 69715), we 

would continue to designate any census tracts falling at or above RUCA level 4.0 as rural areas 

for purposes of payment for ambulance services under the ambulance fee schedule. As discussed 

in the CY 2007 PFS final rule (71 FR 69715), the Office of Rural Health Policy within the 

Health Resources and Services Administration (HRSA) determines eligibility for its rural grant 

programs through the use of the RUCA code methodology. Under this methodology, HRSA 

designates any census tract that falls in RUCA level 4.0 or higher as a rural census tract. In 

addition to designating any census tracts falling at or above RUCA level 4.0 as rural areas, under 

the updated RUCA code definitions, HRSA has also designated as rural census tracts, those 

census tracts with RUCA codes 2 or 3 that are at least 400 square miles in area with a population 

density of no more than 35 people. We refer readers to HRSA’s website: 

ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf for additional information. Consistent with the 

HRSA guidelines discussed above, we are proposing, beginning in CY 2015, to designate as 

rural areas (1) those census tracts that fall at or above RUCA level 4.0, and (2) those census 

tracts that fall within RUCA levels 2 or 3 that are at least 400 square miles in area with a 

population density of no more than 35 people. As discussed in the CY 2007 PFS final rule (71 

FR 69715), we continue to believe that HRSA’s guidelines accurately identify rural census tracts 

throughout the country, and thus would be appropriate to apply for ambulance payment 

purposes. We invite comments on this proposal. 

The adoption of the most current OMB delineations and the updated RUCA codes would 

affect whether certain areas are recognized as rural or urban. The distinction between urban and 

rural is important for ambulance payment purposes because urban and rural transports are paid 
 207 

differently. The determination of whether a transport is urban or rural is based on the point of 

pick-up for the transport, and thus a transport is paid differently depending on whether the point 

of pick-up is in an urban or a rural area. During claims processing, geographic designation of 

urban, rural, or super rural is assigned to each claim for an ambulance transport based on the 

point of pick-up ZIP code that is indicated on the claim. 

Currently, section 1834(l)(12) of the Act (as amended by section 104(b) of the PAMA) 

specifies that, for services furnished during the period July 1, 2004 through March 31, 2015, the 

payment amount for the ground ambulance base rate is increased by a “percent increase” (Super 

Rural Bonus) where the ambulance transport originates in a “qualified rural area,” which is a 

rural area that we determine to be in the lowest 25th percentile of all rural populations arrayed by 

population density (also known as a “super rural area”). We implement this Super Rural Bonus 

in §414.610(c)(5)(ii). Adoption of the revised OMB delineations and the updated RUCA codes 

would have no negative impact on ambulance transports in super rural areas, as none of the 

current super rural areas would lose their status due to the revised OMB delineations and the 

updated RUCA codes. 

The adoption of the new OMB delineations and the updated RUCA codes would affect 

whether or not transports would be eligible for other rural adjustments under the ambulance fee 

schedule statute and regulations. For ground ambulance transports where the point of pick-up is 

in a rural area, the mileage rate is increased by 50 percent for each of the first 17 miles 

(§414.610(c)(5)(i)). For air ambulance services where the point of pick-up is in a rural area, the 

total payment (base rate and mileage rate) is increased by 50 percent (§414.610(c)(5)(i)). 

Furthermore, under section 1834(l)(13) of the Act (as amended by section 104(a) of the PAMA), 

for ground ambulance transports furnished through March 31, 2015, transports originating in 
 208 

rural areas are paid based on a rate (both base rate and mileage rate) that is 3 percent higher than 

otherwise is applicable. (See also §414.610(c)(1)(ii)). 

 If we adopt OMB’s revised delineations and the updated RUCA codes, ambulance 

providers and suppliers that pick up Medicare beneficiaries in areas that would be Micropolitan 

or otherwise outside of MSAs based on OMB’s revised delineations or in a rural census tract of 

an MSA based on the updated RUCA codes (but are currently within urban areas) may 

experience increases in payment for such transports because they may be eligible for the rural 

adjustment factors discussed above, while those ambulance providers and suppliers that pick up 

Medicare beneficiaries in areas that would be urban based on OMB’s revised delineations and 

the updated RUCA codes (but are currently in Micropolitan Areas or otherwise outside of MSAs, 

or in a rural census tract of an MSA) may experience decreases in payment for such transports 

because they would no longer be eligible for the rural adjustment factors discussed above. 

 The use of the revised OMB delineations and the updated RUCA codes would mean the 

recognition of new urban and rural boundaries based on the population migration that occurred 

over a 10-year period, between 2000 and 2010. Based on the latest United States Postal Service 

(USPS) ZIP code file, there are a total of 42,914 ZIP codes in the U.S. The geographic 

designations for approximately 99.48 percent of ZIP codes would be unchanged by OMB’s 

revised delineations and the updated RUCA codes. There are a similar number of ZIP codes that 

would change from rural to urban (122, or 0.28 percent) and from urban to rural (100, or 0.23 

percent). In general, it is expected that ambulance providers and suppliers in 100 ZIP codes 

within 11 states may experience payment increases if we adopt the revised OMB delineations 

and the updated RUCA codes, as these areas would be redesignated from urban to rural. The 

state of Ohio would have the most ZIP codes changing from urban to rural with a total of 40, or 

2.69 percent. Ambulance providers and suppliers in 122 ZIP codes within 22 states may 
 209 

experience payment decreases if we adopt the revised OMB delineations and the updated RUCA 

codes, as these areas would be redesignated from rural to urban. The state of West Virginia 

would have the most ZIP codes changing from rural to urban (17, or 1.82 percent), while 

Connecticut would have the greatest percentage of ZIP codes changing from rural to urban (15 

ZIP codes, or 3.37 percent). Our findings are illustrated in Table 17. 

TABLE 17: ZIP Codes Analysis Based on OMB’s Revised Delineations and Updated 

RUCA Codes 

State 

Total 

ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Rural to 

Urban 

Percentage 

Of Total 

ZIP Codes 

Total 

ZIP 

Codes 

Changed 

Urban 

To Rural 

Percentage 

Of Total ZIP 

Codes 

Total 

ZIP 

Codes 

Not 

Changed 

Percentage 

Of Total ZIP 

Codes Not 

Changed 

AK 276 0 0.00% 0 0.00% 276 100.00% 

AL 854 0 0.00% 0 0.00% 854 100.00% 

AR 725 0 0.00% 3 0.41% 722 99.59% 

AS 1 0 0.00% 0 0.00% 1 100.00% 

AZ 569 0 0.00% 0 0.00% 569 100.00% 

CA 2723 0 0.00% 0 0.00% 2723 100.00% 

CO 677 0 0.00% 0 0.00% 677 100.00% 

CT 445 15 3.37% 0 0.00% 430 96.63% 

DC 301 0 0.00% 0 0.00% 301 100.00% 

DE 99 1 1.01% 0 0.00% 98 98.99% 

EK 63 0 0.00% 0 0.00% 63 100.00% 

EM 856 0 0.00% 3 0.35% 853 99.65% 

FL 1513 5 0.33% 0 0.00% 1508 99.67% 

FM 4 0 0.00% 0 0.00% 4 100.00% 

GA 1032 4 0.39% 0 0.00% 1028 99.61% 

GU 21 0 0.00% 0 0.00% 21 100.00% 

HI 143 0 0.00% 0 0.00% 143 100.00% 

IA 1080 5 0.46% 0 0.00% 1075 99.54% 

ID 335 0 0.00% 0 0.00% 335 100.00% 

IL 1628 0 0.00% 0 0.00% 1628 100.00% 

IN 1000 1 0.10% 14 1.40% 985 98.50% 

KY 1030 0 0.00% 0 0.00% 1030 100.00% 

LA 739 2 0.27% 0 0.00% 737 99.73% 

MA 751 0 0.00% 4 0.53% 747 99.47% 

MD 630 9 1.43% 0 0.00% 621 98.57% 

ME 505 0 0.00% 0 0.00% 505 100.00% 
 210 

State 

Total 

ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Rural to 

Urban 

Percentage 

Of Total 

ZIP Codes 

Total 

ZIP 

Codes 

Changed 

Urban 

To Rural 

Percentage 

Of Total ZIP 

Codes 

Total 

ZIP 

Codes 

Not 

Changed 

Percentage 

Of Total ZIP 

Codes Not 

Changed 

MH 2 0 0.00% 0 0.00% 2 100.00% 

MI 1185 4 0.34% 8 0.68% 1173 98.99% 

MN 1043 1 0.10% 0 0.00% 1042 99.90% 

MP 3 0 0.00% 0 0.00% 3 100.00% 

MS 541 0 0.00% 0 0.00% 541 100.00% 

MT 411 0 0.00% 0 0.00% 411 100.00% 

NC 1101 12 1.09% 5 0.45% 1084 98.46% 

ND 418 0 0.00% 0 0.00% 418 100.00% 

NE 632 0 0.00% 0 0.00% 632 100.00% 

NH 292 0 0.00% 0 0.00% 292 100.00% 

NJ 747 0 0.00% 0 0.00% 747 100.00% 

NM 438 0 0.00% 0 0.00% 438 100.00% 

NV 257 0 0.00% 0 0.00% 257 100.00% 

NY 2246 4 0.18% 0 0.00% 2242 99.82% 

OH 1487 6 0.40% 40 2.69% 1441 96.91% 

OK 791 0 0.00% 0 0.00% 791 100.00% 

OR 494 6 1.21% 0 0.00% 488 98.79% 

PA 2244 8 0.36% 0 0.00% 2236 99.64% 

PR 177 0 0.00% 0 0.00% 177 100.00% 

PW 2 0 0.00% 0 0.00% 2 100.00% 

RI 91 0 0.00% 0 0.00% 91 100.00% 

SC 543 7 1.29% 0 0.00% 536 98.71% 

SD 418 0 0.00% 0 0.00% 418 100.00% 

TN 814 2 0.25% 0 0.00% 812 99.75% 

TX 2726 0 0.00% 1 0.04% 2725 99.96% 

UT 359 0 0.00% 0 0.00% 359 100.00% 

VA 1277 8 0.63% 17 1.33% 1252 98.04% 

VI 16 0 0.00% 0 0.00% 16 100.00% 

VT 309 0 0.00% 0 0.00% 309 100.00% 

WA 744 2 0.27% 0 0.00% 742 99.73% 

WI 919 3 0.33% 0 0.00% 916 99.67% 

WK 711 0 0.00% 2 0.28% 709 99.72% 

WM 342 0 0.00% 0 0.00% 342 100.00% 

WV 936 17 1.82% 3 0.32% 916 97.86% 

WY 198 0 0.00% 0 0.00% 198 100.00% 
 211 

State 

Total 

ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Rural to 

Urban 

Percentage 

Of Total 

ZIP Codes 

Total 

ZIP 

Codes 

Changed 

Urban 

To Rural 

Percentage 

Of Total ZIP 

Codes 

Total 

ZIP 

Codes 

Not 

Changed 

Percentage 

Of Total ZIP 

Codes Not 

Changed 

Totals 42914 122 0.28% 100 0.23% 42692 99.48% 

 We believe that the most current OMB statistical area delineations, coupled with the 

updated RUCA codes, more accurately reflect the contemporary urban and rural nature of areas 

across the country, and thus we believe that use of the most current OMB delineations and 

RUCA codes under the ambulance fee schedule would enhance the accuracy of ambulance fee 

schedule payments. We invite comments on our proposal to implement the new OMB 

delineations and the updated RUCA codes as discussed above beginning in CY 2015, for 

purposes of payment under the Medicare ambulance fee schedule. 

C. Clinical Laboratory Fee Schedule 

In the CY 2014 PFS final rule with comment period (78 FR 74440-74445, 74820), we 

finalized a process under which we would reexamine the payment amounts for test codes on the 

Clinical Laboratory Fee Schedule (CLFS) for possible payment revision based on technological 

changes beginning with the CY 2015 proposed rule, and we codified this process at §414.511. 

After we finalized this process, Congress enacted the PAMA. Section 216 of the PAMA creates 

new section 1834A of the Act, which requires us to implement a new Medicare payment system 

for clinical diagnostic laboratory tests based on private payor rates. Section 216 of the PAMA 

also rescinds the statutory authority in section 1833(h)(2)(A)(i) of the Act for adjustments based 

on technological changes for tests furnished on or after April 1, 2014 (PAMA’s enactment date). 

As a result of these provisions, we are not proposing any revisions to payment amounts for test 

codes on the CLFS based on technological changes and are proposing to remove §414.511. 

Instead, we will establish through rulemaking the parameters for the collection of private payor 

rate information and other requirements to implement section 216 of the PAMA. 
 212 

D. Removal of Employment Requirements for Services Furnished “Incident to” Rural Health 

Clinics (RHC) and Federally Qualified Health Center (FQHC) Visits 

1. Background 

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) furnish 

physicians’ services; services and supplies incident to the services of physicians; nurse 

practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist 

(CP), and clinical social worker (CSW) services; and services and supplies incident to the 

services of NPs, PAs, CNMs, CPs, and CSWs. They may also furnish diabetes self-management 

training and medical nutrition therapy (DSMT/MNT), transitional care management services, 

and in some cases, visiting nurse services furnished by a registered professional nurse or a 

licensed practical nurse. (For additional information on requirements for furnishing services in 

RHCs and FQHCs, see Chapter 13 of the CMS Benefit Policy Manual.) 

In the May 2, 2014 final rule with comment period (79 FR 25436) entitled “Prospective 

Payment System for Federally Qualified Health Centers; Changes to Contracting Policies for 

Rural Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988 

Enforcement Actions for Proficiency Testing Referral,” we removed the regulatory requirements 

that NPs, PAs, CNMs, CSWs, and CPs furnishing services in a RHC must be employees of the 

RHC. RHCs are now allowed to contract with NPs, PAs, CNMs, CSWs, and CPs, as long as at 

least one NP or PA is employed by the RHC, as required under section 1861(aa)(2)(iii) of the 

Act. 

Services furnished in RHCs and FQHCs by nurses, medical assistants, and other auxiliary 

personnel are considered “incident to” a RHC or FQHC visit furnished by a RHC or FQHC 

practitioner. The regulations at §405.2413(a)(6), §405.2415(a)(6), and §405.2452(a)(6) state that 

services furnished incident to an RHC or FQHC visit must be furnished by an employee of the 
 213 

RHC or FQHC. Since there is no separate benefit under Medicare law that specifically 

authorizes payment to nurses, medical assistants, and other auxiliary personnel for their 

professional services, they cannot bill the program directly and receive payment for their 

services, and can only be remunerated when furnishing services to Medicare patients in an 

“incident to” capacity. 

2. Provisions of Proposed Rule 

To provide RHCs and FQHCs with as much flexibility as possible to meet their staffing 

needs, we are proposing to revise §405.2413(a)(5), §405.2415(a)(5) and §405.2452(a)(5) and 

delete §405.2413(a)(6), §405.2415(a)(6) and §405.2452(a)(6) to remove the requirement that 

services furnished incident to an RHC or FQHC visit must be furnished by an employee of the 

RHC or FQHC to allow nurses, medical assistants, and other auxiliary personnel to furnish 

incident to services under contract in RHCs and FQHCs. We believe that removing the 

requirements will provide RHCs and FQHCs with additional flexibility without adversely 

impacting the quality or continuity of care. 
 214 

E. Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models 

1. Background and Statutory Authority 

 Section 3021 of the Affordable Care Act amended the Social Security Act to include a 

new section 1115A, which established the Center for Medicare and Medicaid Innovation 

(Innovation Center). Section 1115A tasks the Innovation Center with testing innovative payment 

and service delivery models that could reduce program expenditures while preserving and/or 

enhancing the quality of care furnished to individuals under titles XVIII, XIX, and XX of the 

Act. The Secretary is also required to conduct an evaluation of each model tested. 

Evaluations will typically include quantitative and qualitative methods to assess the 

impact of the model on quality of care and health care expenditures. To comply with the 

statutory requirement to evaluate all models conducted under section 1115A of the Act, we will 

conduct rigorous quantitative analyses of the impact of the model test on health care 

expenditures, as well as an assessment of measures of the quality of care furnished under the 

model test. Evaluations will also include qualitative analyses to capture the qualitative 

differences between model participants, and to form the context within which to interpret the 

quantitative findings. Through the qualitative analyses, we will assess the experiences and 

perceptions of model participants, providers, and individuals affected by the model. 

In the evaluations we use advanced statistical methods to measure effectiveness. Our 

methods are intended to provide results that meet a high standard of evidence, even when 

randomization is not feasible. To successfully carry out evaluations of Innovation Center 

models, we must be able to determine specifically which individuals are receiving services from 

or are the subject of the intervention being tested by the entity participating in the model test. 

Identification of such individuals is necessary for a variety of purposes, including the 

construction of control groups against which model performance can be compared. In addition, 
 215 

to determine whether the observed impacts are due to the model being tested and not due to 

differences between the intervention and comparison groups, our evaluations will have to 

account for potential confounding factors at the individual level, which will require the ability to 

identify every individual associated with the model test, control or comparison groups, and the 

details of the intervention at the individual level. 

Evaluations will need to consider such factors as outcomes, clinical quality, adverse 

effects, access, utilization, patient and provider satisfaction, sustainability, potential for the 

model to be applied on a broader scale, and total cost of care. Individuals receiving services 

from or who are the subjects of the intervention will be compared to clinically, sociodemographically, and geographically similar matched individuals along various process, 

outcome, and patient-reported measures. Research questions in a typical evaluation will include, 

but are not limited to, the following: 

● Clinical Quality: 

++ Did the model improve or have a negative impact on clinical process measures, such 

as adherence to evidence-based guidelines? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on clinical outcome measures, such 

as mortality rates, and the incidence and prevalence of chronic conditions? If so, how, how 

much, and for which individuals? 

++ Did the model improve or have a negative impact on access to care? If so, how, how 

much, and for which individuals? 

++ Did the model improve or have a negative impact on care coordination among 

providers? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on medication management? If so, 

how, how much, and for which individuals? 
 216 

● Patient Experience: 

++ Did the model improve or have a negative impact on patient-provider 

communication? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on patient experiences of care, 

quality of life, or functional status? If so, how, how much, and for which individuals? 

● Utilization/Expenditures: 

++ Did the model result in decreased utilization of emergency department visits, 

hospitalizations, and readmissions? If so how, how much, and for which individuals? 

++ Did the model result in increased utilization of physician or pharmacy services? If so 

how, how much, and for which individuals? 

++ Did the model result in decreased total cost of care? Were changes in total costs of 

care driven by changes in utilization for specific types of settings or health care services? What 

specific aspects of the model led to these changes? Were any savings due to improper costshifting to the Medicaid program? 

To carry out this research we must have access to patient records not generally available 

to us. As such, we propose to exercise our authority in section 1115A(b)(4)(B) of the Act to 

establish requirements for states and other entities participating in the testing of past, present, and 

future models under section 1115A of the Act to collect and report information that we have 

determined is necessary to monitor and evaluate such models. Thus, we propose to require 

model participants, and providers and suppliers working under the models operated by such 

participants to produce such individually identifiable health information and such other 

information as the Secretary identifies as being necessary to conduct the statutorily mandated 

research described above. Such research will include the monitoring and evaluation of such 

models. Further, we view engagement with other payers, both public and private, as a critical 
 217 

driver of the success of these models. CMS programs constitute only a share of any provider’s 

revenue. Therefore, efforts to improve quality and reduce cost are more likely to be successful if 

signals are aligned across payers. Section 1115A of the Act specifically allows the Secretary of 

Health and Human Services to consider, in selecting which models to choose for testing, 

“whether the model demonstrates effective linkage with other public sector or private sector 

payers.” Multi-payer models, such as but not limited to the Comprehensive Primary Care model, 

will conduct quality measurement across all patients regardless of payer in order to maximize 

alignment and increase efficiency. Construction of multi-payer quality measures requires the 

ability to identify all individuals subject to the model test regardless of payer. In addition, 

section 1115A also permits the Secretary to consider models that allow states to test and evaluate 

systems of all-payer payment reform for the medical care of residents of the state, including dual 

eligible individuals. Under the State Innovation Model (SIM), the Innovation Center is testing 

the ability for state governments to accelerate transformation. The premise of the SIM initiative 

is to support Governor-sponsored, multi-payer models that are focused on public and private 

sector collaboration to transform the state’s delivery system. States have policy and regulatory 

authorities, as well as ongoing relationships with private payers, health plans, and providers that 

can accelerate delivery system reform. SIM models must impact the preponderance of care in 

the state and are expected to work with public and private payers to create multi-payer 

alignment. The evaluation of SIM will include all populations and payers involved in the state 

initiative, which in many cases includes private payers. The absence of identifiable data from 

private payers would result in considerable limitations on the level of evaluation conducted. 

Therefore, under this authority, we also propose to require the submission of identifiable health 

and utilization information for patients of private payers treated by providers/suppliers 

participating in the testing of a model under section 1115A of the Act when an explicit purpose 
 218 

of the model test is to engage private sector payers. If finalized, this regulation will provide clear 

legal authority for HIPAA Covered Entities to disclose any required protected health 

information. Identifiable data submitted by entities participating in the testing of models under 

section 1115A of the Act will meet CMS Acceptable Risks Safe Guards (ARS) guidelines. 

When data is expected to be exchanged over the internet such exchange will also meet all E-Gov 

requirements. In accordance with the requirements of the Privacy Act of 1974, these data will be 

covered under a CMS established system of records (System No. 09–70–0591), which serves as 

the Master system for all demonstrations, evaluations, and research studies administered by the 

Innovation Center. These data will be stored until the evaluation is complete and all necessary 

policy deliberations have been finalized. 

2. Provisions of the Proposed Regulations 

 Wherever possible, evaluations will make use of claims, assessment, and enrollment data 

available through CMS’ existing administrative systems. However, evaluations will generally 

also need to include additional data not available through existing CMS administrative systems. 

As such, depending on the particular project, CMS or its contractor will require the production of 

the minimum data necessary to carry out the statutorily mandated research work described in 

section E.1. of this proposed rule. Such data may include the identities of the patients served 

under the model, relevant clinical details about the services furnished and outcomes achieved, 

and any confounding factors that might influence the evaluation results achieved through the 

delivery of such services. For illustrative purposes, below are examples of some of the types of 

information that could be required to carry out an evaluation, and for which the evaluator would 

need patient level identifiers. 

● Utilization data not otherwise available through existing Center for Medicare & 

Medicaid Services (CMS) systems. 
 219 

● Beneficiary, patient, participant, family, and provider experiences. 

● Beneficiary, patient, participant, and provider rosters with identifiers that allow 

linkages across time and datasets. 

● Beneficiary, patient, participant, and family socio-demographic and ethnic 

characteristics. 

● Care management details, such as details regarding the provision of services, payments 

or goods to beneficiaries, patients, participants, families, or other providers. 

● Beneficiary, patient, and participant functional status and assessment data. 

● Beneficiary, patient, and participant health behaviors. 

● Clinical data, such as, but not limited to lab values and information from EHRs. 

● Beneficiary, patient, participant quality data not otherwise available through claims.

● Other data relevant to identified outcomes—for example, participant employment 

status, participant educational degrees pursued/achieved, and income. 

 We invite public comment on this proposal to mandate the production of the individually 

identifiable information necessary to conduct the statutorily mandated research under section 

1115A of the Act. 

 In addition, we are proposing a new subpart K in part 403 to implement section 1115A 

of the Act. 
 220 

F. Local Coverage Determination Process for Clinical Diagnostic Laboratory Testing 

1. Background 

On April 1, 2014, the PAMA was enacted and section 216 addresses Medicare payment 

and coverage policies for clinical diagnostic laboratory testing. In regard to coverage policies, 

section 216 amended the statute by adding section 1834A(g) of the Act, which establishes 

mandates related to issuance of local coverage policies by the Medicare Administrative 

Contractors (MACs) for clinical diagnostic laboratory tests. The law states: “A medicare 

administrative contractor shall only issue a coverage policy with respect to a clinical diagnostic 

laboratory test in accordance with the process for making a local coverage determination (as 

defined in section 1869(f)(2)(B)), including the appeals and review process for local coverage 

determinations under part 426 of title 42, Code of Federal Regulations (or successor 

regulations).” 

Section 1869(f)(2)(B) of the Act defines a local coverage determination (LCD) as “a 

determination by a fiscal intermediary or a carrier under Part A or Part B, as applicable, 

respecting whether or not a particular item or service is covered on an intermediary– or carrier–

wide basis under such parts, in accordance with section 1862(a)(1)(A) of the Act.” 

Since the new law requires that the process for making local coverage determinations be 

used as the vehicle for local coverage policies for clinical diagnostic laboratory tests, it is 

important that we carefully consider the LCD process that is used today and determine if there 

are certain, limited aspects of the LCD process that may provide an opportunity to better fit the 

needs of this particular area of medicine. In addition to the current LCD process, we will 

examine how the LCD process was applied to a pilot project for molecular diagnostic tests as we 

are learning important lessons from this ongoing pilot. We believe lessons learned from this 

project can be applied to all clinical diagnostic laboratory testing and not just molecular 
 221 

diagnostic tests (which are encompassed under the PAMA requirement for local coverage 

policies). In this proposed process, we will review the current LCD process, as well as the pilot 

in support of a proposal to create, consistent with the requirements set forth under the PAMA, an 

expedited LCD process for clinical diagnostic laboratory testing. 

The current LCD process (Table 18) requires that a draft LCD be published in the 

Medicare Coverage Database (MCD). This serves as a public announcement that an LCD is 

being developed. Once a draft LCD is published, at least 45 calendar days are provided for 

public comment. We note that the National Coverage Determination (NCD) process only 

requires a 30-day public comment period after a proposed NCD is published. This timeframe is 

based on the NCD statutory requirements under 1862(l) of the Act and in our experience at the 

national policy level, 30 days is generally adequate to allow for robust public comment. 

After the draft LCD is made public, MACs are required to hold an open meeting to 

discuss the draft LCD with stakeholders. In addition to the open meeting, the MACs present the 

draft policy to the Carrier Advisory Committee (CAC). These two aspects of LCD development 

can be time-consuming and may involve logistical complications that extend the length of time it 

takes to reach a final policy. We note that unlike the national advisory committee, the Medicare 

Evidence Development and Coverage Advisory Committee (MEDCAC), the CAC meetings and 

open stakeholder meetings are scheduled to discuss many LCD policies at a time as opposed to 

narrowly focusing on one policy. Due to the resources required, the constant development of 

LCDs and scheduling considerations, MACs do not hold ad hoc meetings. Both the open 

stakeholder meetings and the CAC meetings are scheduled far in advance, generally at the start 

of the calendar year before MACs know which policies will be presented in these forums. The 

timing of the open stakeholder meeting, CAC meeting, and public release of the draft LCD are 

all factors in determining which LCDs are on the agendas. Because of these scheduling issues, 
 222 

some LCDs may not have to wait as long for a CAC meeting or an open stakeholder meeting 

while others could have lengthy delays. In contrast, at the national level, MEDCACs are not 

convened for every NCD and separate open meetings are also not a part of the NCD process. 

Based on our experience with the NCD process over the past decade, we believe that public input 

is now readily available through more technologically advanced mechanisms of collecting public 

comment. For example, the information gathered and knowledge gained from the LCD open 

stakeholder meetings may now be acquired more broadly through the collection of public 

comments via web-based applications. CMS and its contractors are receiving more input on 

their policies because of these technology advances, which were not as available to the public 

when the LCD manual was originally written approximately 25 years ago. Medical literature, 

clinical practice guidelines, complicated charts and graphs can now be easily submitted 

electronically through the public comment process. Questions or follow- up information from a 

specific commenter can be addressed through conference calls or email. In addition, through 

these processes, all public comments are available to everyone rather than to the few people who 

attend meetings in person. In addition to publishing a draft LCD, MACs publish a document that 

provides a summary of all of the comments received and responses to those comments. This 

allows the public to understand the reasoning behind the final LCD and to know that all of the 

public comments were taken under consideration as the MAC developed the final policy. Since 

this information is made readily available in writing, an open meeting is no longer necessary for 

the public to be heard. There are more efficient methods available to the public to submit 

comments and additional evidence that supports or rejects the application of a draft LCD. 

 Somewhat different considerations apply to CACs, which are state-specific bodies 

representing the clinical expertise of a geographic area. CACs allow a unique opportunity for 

CAC members to provide practical information regarding a draft policy since they are the entities 
 223 

actually delivering services in the community. However, like MEDCACs, a CAC may not be 

needed in all instances for the creation or revision of an LCD. CAC meeting agendas can 

quickly fill up with draft LCDs since the CAC meetings are scheduled far in advance. We 

believe CACs may be a better resource and used more efficiently in the development of LCDs if 

the MAC is able to select which draft LCDs are presented to a CAC for discussion, as opposed to 

taking all LCDs to the CAC. Of note, NCDs that go before the MEDCAC are selected by the 

agency and it is not part of the process for every NCD. 

Under the current LCD process, after the close of the comment period and the required 

meetings, the MAC publishes a final LCD. As stated earlier, the MAC must also respond to any 

comments received, via a comment/response document. A notice period of at least 45 calendar 

days is then required before the LCD can take effect. While it takes time for the provider 

community and the claims processing systems to adapt to changes in coverage, a notice period 

delays the date of when coverage may be become effective. 

In addition to evaluating the effectiveness of certain aspects of the LCD implementation 

process, we are also examining a pilot project that CMS launched with a single MAC, Palmetto 

GBA, on November 1, 2011. While the pilot discussed in this section only includes molecular 

diagnostic (genetic) laboratory tests, a subset of all clinical diagnostic lab tests, we believe the 

pilot’s design and some of the lessons learned from the pilot can be applied to all clinical 

diagnostic laboratory tests 

For background, the universe of molecular diagnostic laboratory tests is vast and the 

current LCD process can be lengthy for some of these innovative tests, which are technically 

complex. For example, multiple molecular diagnostic tests designated to diagnose the same 

disease may rely on different underlying technologies and, therefore, have significantly different 

performance characteristics. It would not be appropriate to assume that all tests for a particular 
 224 

condition behave the same. Because of these complexities, we have an obligation to consider the 

evidence at a granular level; that is, to ensure coverage of the appropriate test for the appropriate 

Medicare beneficiary. 

The pilot project’s long-term goal was to assist clinicians by determining whether the 

molecular diagnostic tests they order actually perform as expected and, thus, ultimately improve 

clinical care. This goal stemmed from concerns that some tests were being marketed directly to 

physicians without information regarding the test’s performance. The pilot project sought to 

achieve this goal by identifying all of the molecular diagnostic tests that Medicare was covering 

in the Palmetto MAC jurisdiction. This required the ability to uniquely identify tests through test 

registration and assignment of an identifier. In addition, the MAC reviewed clinical statements 

made by the manufacturer for each molecular diagnostic test to ensure the test was delivering 

what was being claimed. Essentially, the pilot project facilitated claims processing, tracked 

utilization, and determined clinical validity, utility and coverage through technical assessments 

of published test data. 

As part of the pilot project, Palmetto wrote a single molecular diagnostic laboratory 

testing LCD that outlined the framework they would follow in determining coverage of all 

molecular diagnostic tests in their jurisdiction. Additionally, that LCD included a list of covered 

molecular diagnostic tests. Moreover, Palmetto issued several articles addressing various other 

aspects of the LCD implementation process, including coding guidelines, billing and medical 

review procedures. There is much information that is not contained in the body of an LCD that 

is necessary for consistent and predictable claims processing and payment. 

 We believe a process that ensures transparency and stakeholder participation can be 

achieved without utilizing the current LCD process in its entirety. Some key aspects of the 

process should be maintained such as allowing public comment on draft LCDs and requiring 
 225 

MAC responses to public comments. However, we believe other aspects could be streamlined to 

allow more timely decisions and a more efficient process. 

2. Proposed New LCD Process for Clinical Diagnostic Laboratory Tests 

After assessment of the current LCD process, the Palmetto pilot project, the requirements 

of the PAMA, and the vast field of clinical diagnostic laboratory tests, including molecular 

diagnostic tests, we are proposing a revised LCD process for all new draft clinical diagnostic 

laboratory test LCDs published on or after January 1, 2015. This process would carefully 

balance the need for an expedited process to handle the vast number of clinical diagnostic 

laboratory tests, including the rapidly growing universe of molecular diagnostic tests. The 

National Institutes of Health (NIH)-sponsored Genetic Testing Registry (GTR) currently 

includes 16,000 registered genetic tests for over 4,000 conditions (www.ncbi.nlm.nih.gov/gtr/). 

We have a responsibility to ensure that appropriate tests are covered by Medicare and that 

coverage is limited to tests for which the test results are used by the ordering physician in the 

management of the beneficiary’s specific medical problem (as required in §410.32(a)). 

Coverage for diagnostic laboratory tests may be achieved through various policy vehicles, 

including an NCD, LCD, or claim-by-claim adjudication at the local contractor level. For most 

molecular diagnostic tests, coverage has been determined by the MACs, through LCDs or claimby-claim adjudication. Few such tests have been the subject of an NCD, to date. This 

concentration of coverage decisions at the local level, and the responsibility of the agency to 

allow coverage of appropriate tests provide additional reasons to provide MACs with a more 

streamlined LCD process. 

Based on these considerations, we are proposing a new LCD process that would apply 

only to clinical diagnostic laboratory tests. Specifically, we are proposing to establish a process 

MACs must follow when developing clinical diagnostic laboratory test LCDs and encouraging 
 226 

MACs to collaborate on such policies across jurisdictions. We propose that the process apply to 

all new clinical diagnostic laboratory testing draft LCDs published on or after January 1, 2015. 

Consistent with Chapter 13, section 13.7.3 of the Medicare Program Integrity Manual (PIM), 

however, we further propose that this process will not apply to clinical diagnostic laboratory 

testing LCDs that are being revised for the following reasons: to liberalize an existing LCD; 

being issued for a compelling reason; making a non-substantive correction; providing a 

clarification; making a non-discretionary coverage or diagnosis coding update; making a 

discretionary diagnosis coding update that does not restrict; or revising to effectuate an 

Administrative Law Judge’s decision on a Benefits Improvement and Protection Act (BIPA) 522 

challenge. 

The proposed new process would allow any person or entity to request an LCD or the 

MAC to initiate an LCD regarding clinical diagnostic laboratory testing. After this external 

request or internal initiation, the MAC would publish a draft LCD in the Medicare Coverage 

Database (http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx), 

thereby making the draft LCD publicly available. Next, a minimum of 30 calendar days for 

public comment would be required. We note that in the event that stakeholders and/or members 

of the public are not able to submit comments within the 30 calendar day window, the MAC 

would have discretion to extend the comment period. We would expect the draft LCDs to 

outline the criteria the MAC would use when determining whether a specific clinical diagnostic 

laboratory test or a group of tests are covered or non-covered. The MAC would review, analyze, 

and take under consideration all public comments on the draft LCD. For draft LCDs where the 

MAC determines that a CAC meeting would contribute to the quality of the final policy, the 

MAC has discretion to take draft LCDs to the CAC. In the event the MAC involves the CAC in 

the development of an LCD, we would require that the public comment period be extended to 
 227 

allow for the CAC to be held before the final policy is issued. The MAC would be required to 

respond to all public comments in writing and post their responses on a public website. As a 

final step, the MAC would publish the final LCD in the Medicare Coverage Database no later 

than 45 calendar days after the close of the comment period. We believe 45 days to be an 

adequate time for the MAC to take all comments under consideration, prepare responses to those 

comments, and develop a final policy. 

The final LCD would be effective immediately upon publication. This effective date 

would be different than under the current LCD process (which includes a notice period of at least 

45 calendar days before a final LCD is effective); however, based on our experience with NCDs, 

which are also effective upon publication, we believe this is an efficient mechanism to make tests 

available to beneficiaries more quickly. 

3. Reconsideration Process 

The proposed process for developing clinical diagnostic laboratory testing LCDs would 

not change the LCD reconsideration process as outlined in the PIM in Chapter 13. This section 

of the manual allows interested parties the opportunity to request reconsideration of an LCD. 

Under the proposed process, the MACs would continue to implement all sections of the PIM that 

relate to the LCD reconsideration process. 

4. LCD Challenge Process 

The proposed process for clinical diagnostic laboratory testing LCDs would also not 

change any of the current review processes available to an aggrieved party. An aggrieved party 

would continue to be able to challenge an LCD according to the requirements set out in 42 CFR 

part 426. 

As discussed previously, we believe an administratively more efficient process is needed 

for local coverage determinations for clinical diagnostic laboratory testing. If we continue to 
 228 

require that MACs follow all steps in the current LCD process, we fear that LCDs will not be 

able to be finalized quickly enough for even a fraction of the thousands of new clinical 

diagnostic (particularly molecular) tests developed each year. 

We believe this proposed new process for clinical diagnostic laboratory tests will allow 

for public dialogue, notification of stakeholders, and expedited beneficiary access to covered 

tests. Table 18 summarizes the differences between the current LCD process and the proposed 

new LCD process for the development of clinical diagnostic laboratory testing policies. 

TABLE 18: Comparison of Current LCD Process versus Proposed LCD Process for 

Clinical Diagnostic Laboratory Tests 

Current LCD Process Proposed LCD Process for Clinical Diagnostic 

Laboratory Tests 

Issue Draft LCD in Medicare Coverage Database, 

which identifies criteria used for determining 

coverage under statutory “reasonable and 

necessary” standard 

Issue Draft LCD in Medicare Coverage Database, 

which identifies criteria used for determining 

coverage under statutory “reasonable and 

necessary” standard 

Public comment period of 45 calendar days Public comment period of 30 calendar days with 

option to extend 

Present LCD at CAC & discussion at open 

stakeholder meetings 

Optional CAC meeting. No requirement for open 

stakeholder meeting 

Publication of Comment/Response Document and 

final LCD (no specified time of publication after 

the close of the comment period) 

Publication of Comment/Response Document and 

final LCD within 45 calendar days of the close of 

the draft LCD comment period 

Notice period of 45 calendar days with the final 

LCD effective the 46th calendar day 

Final LCD effective on the date of publication 

Interested parties may request reconsideration of an 

LCD 

Interested parties may request reconsideration of an 

LCD 

An aggrieved party may further challenge an LCD An aggrieved party may further challenge an LCD 

 In summary, we believe this proposed process would meet all the requirements of the 

PAMA, would be open and transparent, would allow for public input, and would be 

administratively efficient. We are proposing this process only for clinical diagnostic laboratory 

testing when coverage policies are developed by a MAC through an LCD; it would not apply to 

the NCD process or other vehicles of coverage including claim-by-claim adjudication. We 

believe the proposed process would balance stakeholders’ concerns about ensuring an open and 
 229 

transparent process with the ability to efficiently review clinical laboratory tests for coverage. 

We encourage public comment on all aspects of this proposed process.
 230 

G. Private Contracting/Opt-out 

1. Background 

Effective January 1, 1998, section 1802(b) of the Act permits certain physicians and 

practitioners to opt-out of Medicare if certain conditions are met, and to furnish through private 

contracts services that would otherwise be covered by Medicare. For those physicians and 

practitioners who opt-out of Medicare in accordance with section 1802(b) of the Act, the 

mandatory claims submission and limiting charge rules of section 1848(g) of the Act would not 

apply. As a result, if the conditions necessary for an effective opt-out are met, physicians and 

practitioners are permitted to privately contract with Medicare beneficiaries and to charge them 

without regard to Medicare’s limiting charge rules. Regulations governing the requirements and 

procedures for private contracts appear at 42 CFR part 405, subpart D. 

a. Opt-out Determinations (§405.450) 

 The private contracting regulation at §405.450 describes certain opt-out determinations 

made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to 

appeal those determinations. Section 405.450(a) describes the process available for physicians 

or practitioners to appeal Medicare enrollment determinations related to opting out of the 

program, and §405.450(b) describes the process available to challenge payment determinations 

related to claims for services furnished by physicians who have opted out. Both provisions refer 

to §405.803, the Part B claims appeals process that was in place at the time the opt-out 

regulations were issued (November 2, 1998). When those regulations were issued, a process for 

a physician or practitioner to appeal enrollment related decisions had not been implemented in 

regulation. Thus, to ensure an appeals process was available to physicians and practitioners for 

opt-out related issues, we chose to utilize the existing claims appeals process in §405.803 for 

both enrollment and claims related appeals. 
 231 

In May 16, 2012 Federal Register (77 FR 29002), we published a final rule entitled 

“Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, 

Transparency and Burden Reduction.” In that final rule, we deleted the provisions relating to 

initial determinations, appeals, and reopenings of Medicare Part A and Part B claims, and 

relating to determinations and appeals regarding an individual’s entitlement to benefits under 

Medicare Part A and Part B, which were contained in part 405, subparts G and H (including 

§405.803) because these provisions were obsolete and had been replaced by the regulations at 

part 405, subpart I. We inadvertently neglected to revise the cross-reference in §405.450(a) and 

(b) of the private contracting regulations to direct appeals of opt-out determinations through the 

current appeal process. However, it is important to note that our policy regarding the appeal of 

opt-out determinations did not change when the appeal regulations at part 405, subpart I were 

finalized. 

The procedures set forth in current part 498 establish the appeals procedures regarding 

decisions made by Medicare that affect enrollment in the program. We believe this process, and 

not the appeal process in part 405, subpart I, is the appropriate channel for physicians and 

practitioners to challenge an enrollment related opt-out decision made by Medicare. There are 

now two different sets of appeal regulations for initial determinations; and the appeal of 

enrollment related opt-out determinations is more like the types of determinations now addressed 

under part 498 than those under part 405, subpart I. Specifically, the appeal process under part 

405, subpart I focus on reviews of determinations regarding beneficiary entitlement to Medicare 

and claims for benefits for particular services. The appeal process under part 498 is focused on 

the review of determinations regarding the participation or enrollment status of providers and 

suppliers. Enrollment related opt-out determinations involve only the status of particular 

physician or practitioners under Medicare, and do not involve beneficiary eligibility or claims for 
 232 

specific services. As such, the appeal process under part 498 is better suited for the review of 

enrollment related opt-out determinations. 

However, we do not believe the enrollment appeals process established in part 498 is the 

appropriate mechanism for challenging payment decisions on claims for services furnished by a 

physician and practitioner who has opted out of the program. Appeals for such claims should 

continue to follow the appeals procedures now set forth in part 405 subpart I. 

b. Definitions, Requirements of the Opt Out Affidavit, Effects of Opting Out of Medicare, 

Application to Medicare Advantage Contracts (§§405.400, 405.420(e), 405.425(a), and 405.455) 

Section 405.400 sets forth certain definitions for purposes of the private contracting 

regulations. Among the defined terms is “Emergency care services” which means services 

furnished to an individual for treatment of an “emergency medical condition” as that term is 

defined in §422.2. The cross-referenced regulation at §422.2 included within the definition of 

emergency care services was deleted on June 29, 2000 (65 FR 40314) and at that time we 

inadvertently neglected to revise that cross-reference. The cross-reference within the definition 

of emergency care services should have been amended at that time to cite the definition of 

“emergency services” in §424.101. 

 The private contracting regulations at §405.420(e), §405.425(a) and §405.455 all use the 

term Medicare+Choice when referring to Part C plans. However, we no longer use the term 

Medicare+Choice when referring to Part C plans; instead the plans are referred to as Medicare 

Advantage plans. When part 422 of the regulations was updated on January 28, 2005 

(70 FR 4741), we inadvertently neglected to revise §405.420(e), §405.425(a) and §405.455 to 

replace the term Medicare+Choice with Medicare Advantage plan. 

2. Provisions of the Proposed Regulation 
 233 

For the reasons discussed above, we propose that a determination described in 

§405.450(a) (relating to the status of opt-out or private contracts) is an initial determination for 

purposes of §498.3(b), and a physician or practitioner who is dissatisfied with a Medicare 

determination under §405.450(a) may utilize the enrollment appeals process currently available 

for providers and suppliers in part 498. In addition, we propose that a determination described in 

§405.450(b) (that payment cannot be made to a beneficiary for services furnished by a physician 

or practitioner who has opted out) is an initial determination for the purposes of §405.924 and 

may be challenged through the existing claims appeals procedures in part 405 subpart I. 

Accordingly, we propose that the cross reference to §405.803 in §405.450(a) be replaced with a 

cross reference to §498.3(b). We also propose that the cross reference to §405.803 in 

§405.450(b) be replaced with a cross reference to §405.924. We also propose corresponding 

edits to §498.3(b) and §405.924 to note that the determinations under §405.450(a) and (b), 

respectively, are initial determinations. 

 For the reasons discussed above, we also propose that the definition of Emergency care 

services at §405.400 be revised to cite the definition of Emergency services in §424.101 and that 

all references to Medicare+Choice in §405.420(e), §405.425(a) and §405.455 be replaced with 

the term “Medicare Advantage.” 

 
 234 

H. Solicitation of Comments on the Payment Policy for Substitute Physician Billing 

Arrangements 

1. Background 

In accordance with section 1842(b)(6) of the Act, no payment under Medicare Part B 

may be made to anyone other than to the beneficiary to whom a service was furnished or to the 

physician or other person who furnished the service. However, there are certain limited 

exceptions to this general prohibition. For example, section 1842(b)(6)(D) of the Act describes 

an exception for substitute physician billing arrangements, which states that “payment may be 

made to a physician for physicians’ services (and services furnished incident to such services) 

furnished by a second physician to patients of the first physician if (i) the first physician is 

unavailable to provide the services; (ii) the services are furnished pursuant to an arrangement 

between the two physicians that (I) is informal and reciprocal, or (II) involves per diem or other 

fee-for-time compensation for such services; (iii) the services are not provided by the second 

physician over a continuous period of more than 60 days or are provided over a longer 

continuous period during all of which the first physician has been called or ordered to active duty 

as a member of a reserve component of the Armed Forces; and (iv) the claim form submitted to 

the [contractor] for such services includes the second physician’s unique identifier . . . and 

indicates that the claim meets the requirements of this subparagraph for payment to the first 

physician.” Section 1842(b)(6) of the Act is self-implementing and we have not interpreted the 

statutory provisions through regulations. 

In practice, section 1842(b)(6)(D) of the Act generally allows for two types of substitute 

physician billing arrangements: (1) an informal reciprocal arrangement where doctor A 

substitutes for doctor B on an occasional basis and doctor B substitutes for doctor A on an 

occasional basis; and (2) an arrangement where the services of the substitute physician are paid 
 235 

for on a per diem basis or according to the amount of time worked. Substitute physicians in the 

second type of arrangement are sometimes referred to as “locum tenens” physicians. It is our 

understanding that locum tenens physicians are substitute physicians who often do not have a 

practice of their own, are geographically mobile, and work on an as-needed basis as independent 

contractors. They are utilized by physician practices, hospitals, and health care entities enrolled 

in Part B as Medicare suppliers to cover for physicians who are absent for reasons such as 

illness, pregnancy, vacation, or continuing medical education. Also, we have heard anecdotally 

that locum tenens physicians are used to fill staffing needs (for example, in physician shortage 

areas) or, on a temporary basis, to replace physicians who have permanently left a medical group 

or employer. 

We are concerned about the operational and program integrity issues that result from the 

use of substitute physicians to fill staffing needs or to replace a physician who has permanently 

left a medical group or employer. For example, although our Medicare enrollment rules require 

physicians and physician groups or organizations to notify us promptly of any enrollment 

changes (including reassignment changes) (see §424.516(d)), processing delays or 

miscommunication between the departing physician and his or her former medical group or 

employer regarding which party would report the change to Medicare could result in the Provider 

Transaction Access Number (PTAN) that links the departed physician and his or her former 

medical group remaining “open” or “attached” for a period of time. During such period, both the 

departed physician and the departed physician’s former medical group might bill Medicare under 

the departed physician’s National Provider Identifier (NPI) for furnished services. This could 

occur where a substitute physician is providing services in place of the departed physician in the 

departed physician’s former medical group, while the departed physician is also providing 

services to beneficiaries following departure from the former group. Operationally, either or 
 236 

both types of claims could be rejected or denied, even though the claims filed by the departed 

physician were billed appropriately. Moreover, the continued use of a departed physician’s NPI 

to bill for services furnished to beneficiaries by a substitute physician raises program integrity 

issues, particularly if the departed physician is unaware of his or her former medical group or 

employer’s actions. 

Finally, as noted above, section 1842(b)(6)(D)(iv) of the Act requires that the claim form 

submitted to the contractor include the substitute physician’s unique identifier. Currently, the 

unique identifier used to identify a physician is the physician’s NPI. Prior to the implementation 

of the NPI, the Unique Physician Identification Number (UPIN) was used. Because a substitute 

physician’s NPI is not captured on the CMS-1500 claim form or on the appropriate electronic 

claim, physicians and other entities that furnish services to beneficiaries through the use of a 

substitute physician are required to enter a modifier on the CMS-1500 claim form or on the 

appropriate electronic claim indicating that the services were furnished by a substitute physician; 

and to keep a record of each service provided by the substitute physician, associated with the 

substitute physician’s UPIN or NPI; and to make this record available to the contractor upon 

request. (See Medicare Claims Processing Manual (Pub. 100-4), Chapter 1, Sections 30.2.10 and 

30.2.11) However, having a NPI or UPIN does not necessarily mean that the substitute 

physician is enrolled in the Medicare program. Without being enrolled in Medicare, we do not 

know whether the substitute physician has the proper credentials to furnish the services being 

billed under section 1842(b)(6)(D) of the Act or if the substitute physician is sanctioned or 

excluded from Medicare. The importance of enrollment and the resulting transparency afforded 

the Medicare program and its beneficiaries was recognized by the Congress when it included in 

the Affordable Care Act a requirement that physicians and other eligible NPPs enroll in the 

Medicare program if they wish to order or refer certain items or services for Medicare 
 237 

beneficiaries. This includes those physicians and other eligible NPPs who do not and will not 

submit claims to a Medicare contractor for the services they furnish. We are seeking comments 

regarding how to achieve similar transparency in the context of substitute physician billing 

arrangements for the identity of the individual actually furnishing the service to a beneficiary. 

2. Solicitation of Comments 

To help inform our decision whether and, if so, how to address the issues discussed in 

section III.H.1., and whether to adopt regulations interpreting section 1842(b)(6)(D) of the Act, 

we are soliciting comments on the policy for substitute physician billing arrangements. We note 

that any regulations would be proposed in a future rulemaking with opportunity for public 

comment. Through this solicitation, we hope to understand better current industry practices with 

respect to the use of substitute physicians and the impact that policy changes limiting the use of 

substitute physicians might have on beneficiary access to physician services. Therefore, we are 

soliciting comments on the following: 

(1) How physicians and other entities are currently utilizing the services of substitute 

physicians and billing for such services. We are interested in specific examples, including the 

circumstances that give rise to the need for the substitute physician, the types of services 

furnished by the substitute physician, the billing for the services of the substitute physician, the 

length of time that the substitute physician’s services are needed or used, and any other 

information relevant to the substitute physician billing arrangement. 

(2) When a physician is “unavailable” to provide services for purposes of section 

1842(b)(6)(D) of the Act. We are particularly interested in comments from physicians, medical 

groups and other entities that utilize the services of substitute physicians regarding when a 

regular physician is “unavailable.” 
 238 

(3) Whether we should limit substitute physician billing arrangements to those “between 

the two physicians” (rather than between a medical group, employer or other entity and the 

substitute physician) as stated in section 1842(b)(6)(D)(ii) of the Act. 

(4) Whether we should permit the sequential use of multiple substitute physicians 

provided that each substitute physician furnishes services for the unavailable physician for no 

more than 60 continuous days. 

(5) Whether we should have identical or different criteria for substitute physician billing 

arrangements under sections 1842(b)(6)(D)(ii)(I) and (II) of the Act; that is, whether we should 

treat reciprocal substitute physician billing arrangements differently than paid (or locum tenens) 

substitute physician billing arrangements. 

(6) Whether substitute physicians furnishing services to Medicare beneficiaries should 

be required to enroll in the Medicare program. 

(7) Whether entities submitting claims for services furnished by substitute physicians 

should include on the CMS-1500 claim form or on the appropriate electronic claim the identity 

of the substitute physician and, if so, whether the CMS-1500 claim form or the appropriate 

electronic claim should be revised to accommodate such a requirement. 

(8) Whether we should place limitations on the use of the substitute physician and billing 

for his or her services (for example, limits on the length of time that an individual substitute 

physician may provide services to replace a particular departed physician; limits on the overall 

length of time that substitute physicians may provide services to replace a particular departed 

physician; a requirement that the departing physician be a party to the substitute physician billing 

arrangement; or permitting the use of a substitute physician only where a demonstrated staffing 

need can be shown). We are also seeking comments regarding whether these limitations should 
 239 

be different depending on the circumstances underlying or requiring the use of the substitute 

physician. 

(9) Whether we should limit or prohibit the use of substitute physician billing 

arrangements in certain programs or for certain purposes (for example, the Medicare Shared 

Savings Program or determining whether a physician is a member of a group practice for 

purposes of the physician self-referral law). 

(10) The impact of substitute physician billing arrangements on CMS programs that rely 

on the Provider Enrollment, Chain and Ownership System (PECOS) (for example, the Medicare 

Shared Savings Program), enforcement of the physician self-referral law, and program integrity 

oversight. 

(11) Additional program integrity safeguards that should be included in our substitute 

physician billing policy to protect against program and patient abuse. These could include, but 

are not limited to, qualifications for substitute physicians related to exclusion status, quality of 

care, or licensure and certifications. 

(12) Any other issues that we should consider in determining whether to propose regulations 

interpreting section 1842(b)(6)(D) of the Act. 
 240 

I. Reports of Payments or Other Transfers of Value to Covered Recipients 

1. Background 

 In the February 8, 2013 Federal Register (78 FR 9458), we published the “Transparency 

Reports and Reporting of Physician Ownership or Investment Interests” final rule which 

implemented section 1128G to the Act, as added by section 6002 of the Affordable Care Act. 

Under section 1128G(a)(1) of the Act, manufacturers of covered drugs, devices, biologicals, and 

medical supplies (applicable manufacturers) are required to submit on an annual basis 

information about certain payments or other transfers of value made to physicians and teaching 

hospitals (collectively called covered recipients) during the course of the preceding calendar 

year. Section 1128G(a)(2) of the Act requires applicable manufacturers and applicable group 

purchasing organizations (GPOs) to disclose any ownership or investment interests in such 

entities held by physicians or their immediate family members, as well as information on any 

payments or other transfers of value provided to such physician owners or investors. The 

implementing regulations are at 42 CFR Part 402, subpart A, and Part 403, subpart I. We have 

organized these reporting requirements under the “Open Payments (Sunshine Act)” program. 

 The Open Payments program creates transparency around the nature and extent of 

relationships that exist between drug, device, biologicals and medical supply manufacturers, and 

physicians and teaching hospitals (covered recipients and physician owner or investors). The 

implementing regulations describe procedures for applicable manufacturers and applicable GPOs 

to submit electronic reports detailing payments or other transfers of value and ownership or 

investment interests provided to covered recipients and physician owners or investors are 

codified at §403.908. 

Since the publication and implementation of the February 8, 2013 final rule, various 

stakeholders have provided feedback to CMS regarding certain aspects of these reporting 
 241 

requirements. Specifically, §403.904(g)(1) excludes the reporting of payments associated with 

certain continuing education events, and §403.904(c)(8) requires reporting of the marketed name 

for drugs and biologicals but makes reporting the marketed name of devices or medical supplies 

optional. We are proposing a change to §403.904(g) to correct an unintended consequence of the 

current regulatory text. Additionally, at §403.904(c)(8), we are proposing to make the reporting 

requirements consistent by requiring the reporting of the marketed name for drugs, devices, 

biologicals, or medical supplies which are associated with a payment or other transfer of value. 

Additionally, at §403.902, we propose to remove the definition of a “covered device” 

because we believe it is duplicative of the definition of “covered drug, device, biological or 

medical supply” which is codified in the same section. We also propose to require the reporting 

of the following distinct forms of payment: stock; stock option; or any other ownership interests 

specified in §403.904(d)(3) to collect more specific data regarding the forms of payment. 

2. Continuing Education Exclusion (§403.904(g)(1)) 

In the February 8, 2013 final rule, many commenters recommended that accredited or 

certified continuing education payments to speakers should not be reported because there are 

safeguards already in place, and they are not direct payments to a covered recipient. In the final 

rule preamble, we noted that “industry support for accredited or certified continuing education is 

a unique relationship” (78 FR 9492). Section 403.904(g)(1) states that payments or other 

transfers of value provided as compensation for speaking at a continuing education program need 

not be reported if the following three conditions are met: 

● The event at which the covered recipient is speaking must meet the accreditation or 

certification requirements and standards for continuing education for one of the following 

organizations: the Accreditation Council for Continuing Medical Education (ACCME); the 

American Academy of Family Physicians (AAFP); the American Dental Association’s 
 242 

Continuing Education Recognition Program (ADA CERP); the American Medical Association 

(AMA); or the American Osteopathic Association (AOA). 

● The applicable manufacturer does not pay the covered recipient speaker directly. 

● The applicable manufacturer does not select the covered recipient speaker or provide 

the third party (such as a continuing education vendor) with a distinct, identifiable set of 

individuals to be considered as speakers for the continuing education program. 

Since the implementation of §403.904(g)(1), other accrediting organizations have 

requested that payments made to speakers at their events also be exempted from reporting. 

These organizations have stated that they follow the same accreditation standards as the 

organizations specified in §403.904(g)(1)(i). Other stakeholders have recommended that the 

exemption be removed in its entirety stating removal of the exclusion will allow for consistent 

reporting for compensation provided to physician speakers at all continuing education events, as 

well as transparency regarding compensation paid to physician speakers. Many stakeholders 

raised concerns that the reporting requirements are inconsistent because certain continuing 

education payments are reportable, while others are not. CMS’ apparent endorsement or support 

to organizations sponsoring continuing education events was an unintended consequence of the 

final rule. 

After consideration of these comments, we propose to remove the language in 

§403.904(g) in its entirety, in part because it is redundant with the exclusion in §403.904(i)(1). 

That provision excludes indirect payments or other transfers of value where the applicable 

manufacturer is “unaware” of, that is, “does not know,” the identity of the covered recipient 

during the reporting year or by the end of the second quarter of the following reporting year. 

When an applicable manufacturer or applicable GPO provides funding to a continuing education 

provider, but does not either select or pay the covered recipient speaker directly, or provide the 
 243 

continuing education provider with a distinct, identifiable set of covered recipients to be 

considered as speakers for the continuing education program, CMS will consider those payments 

to be excluded from reporting under §403.904(i)(1). This approach is consistent with our 

discussion in the preamble to the final rule, in which we explained that if an applicable 

manufacturer conveys “full discretion” to the continuing education provider, those payments are 

outside the scope of the rule (78 FR 9492). In contrast, when an applicable manufacturer 

conditions its financial sponsorship of a continuing education event on the participation of 

particular covered recipients, or pays a covered recipient directly for speaking at such an event, 

those payments are subject to disclosure. 

We considered two alternative approaches to address this issue. First, we explored 

expanding the list of organizations in §403.904(g)(1)(i) by name, however, we believe that this 

approach might imply CMS’s endorsement of the named continuing education providers over 

others. Second, we considered expansion of the organizations in §403.904(g)(1)(i) by 

articulating accreditation or certification standards that would allow a CME program to qualify 

for the exclusion. This approach is not easily implemented because it would require evaluating 

both the language of the standards, as well as the enforcement of the standards of any 

organization professing to meet the criteria. We seek comments on both alternatives presented, 

including commenters’ suggestions about what standards, if any, CMS should incorporate. 

3. Reporting of Marketed Name (§403.904(c)(8)) 

Section 1128G(a)(1)(A)(vii) of the Act requires applicable manufacturers to report the 

name of the covered drug, device, biological or medical supply associated with that payment, if 

the payment is related to ‘‘marketing, education, or research’’ of a particular covered drug, 

device, biological, or medical supply. Section 403.904(c)(8)(i) requires applicable 

manufacturers to report the marketed name for each drug or biological related to a payment or 
 244 

other transfer of value. At §403.904(c)(8)(ii), we require an applicable manufacturer of devices 

or medical supplies to report one of the following: the marketed name; product category; or 

therapeutic area. In the February 8, 2013, final rule, we provided applicable manufactures with 

flexibility when it was determined that the marketed name for all devices and medical supplies 

may not be useful for the general audience. We did not define product categories or therapeutic 

areas in §403.904(c). However, since implementation of the February 8, 2013 final rule and the 

development of the Open Payments system, we have determined that making the reporting 

requirements for marketed name across drugs, biologics, devices and medical supplies will make 

the data fields consistent within the system, and also enhance consumer’s use of the data. 

 Accordingly, we propose to revise §403.904(c)(8) to require applicable manufacturers to 

report the marketed name for all covered and non-covered drugs, devices, biologicals or medical 

supplies. We believe this would facilitate consistent reporting for the consumers and researchers 

using the data displayed publicly on the Open Payments. Manufacturers would still have the 

option to report product category or therapeutic area, in addition to reporting the market name, 

for devices and medical supplies. 

 Section 403.904(d)(3) requires the reporting of stock, stock option or any other 

ownership interest. We are proposing to require applicable manufacturers to report such 

payments as distinct categories. This will enable us to collect more specific data regarding the 

forms of payment made by applicable manufacturers. After issuing the February 8, 2013 final 

rule and the development of the Open Payments system, we determined that this specificity will 

increase the ease of data aggregation within the system, and also enhance consumer’s use of the 

data. We seek comments on the extent to which users of this data set find this disaggregation to 

be useful, and whether this change presents operational or other issues on the part of applicable 

manufacturers. 
 245 

4. Summary of Proposed Changes 

 As noted above in this section, we propose the following changes to Part 403, subpart I: 

● Deleting the definition of “covered device” at §403.902. 

● Deleting §403.904(g) and redesignating the remaining paragraphs in that section. 

● Revising §403.904(c)(8) to require the reporting of the marketed name of the related 

covered and non-covered drugs, devices, biologicals, or medical supplies, unless the payment or 

other transfer of value is not related to a particular covered or non-covered drug, device, 

biological or medical supply. 

● Revising §403.904(d) to require the reporting of the reporting of stock, stock option or 

any other options as distinct categories. 

Data collection requirements would begin January 1, 2015 according to this proposed 

rule for applicable manufacturers and applicable group purchasing organizations. 
 246 

J. Physician Compare Website

1. Background and Statutory Authority 

 Section 10331(a)(1) of the Affordable Care Act, required that, by no later than 

January 1, 2011, we develop a Physician Compare Internet website with information on 

physicians enrolled in the Medicare program under section 1866(j) of the Act, as well as 

information on other eligible professionals (EPs) who participate in the Physician Quality 

Reporting System (PQRS) under section 1848 of the Act. 

 CMS launched the first phase of Physician Compare on December 30, 2010 

(http://www.medicare.gov/physiciancompare). In the initial phase, we posted the names of EPs 

that satisfactorily submitted quality data for the 2009 PQRS, as required by section 

1848(m)(5)(G) of the Act. 

 Section 10331(a)(2) of the Affordable Care Act also required that, no later than 

January 1, 2013, and for reporting periods that began no earlier than January 1, 2012, we 

implement a plan for making publicly available through Physician Compare information on 

physician performance that provides comparable information on quality and patient experience 

measures. We met this requirement in advance of January 1, 2013, as outlined below, and plan 

to continue addressing elements of the plan through rulemaking. 

 To the extent that scientifically sound measures are developed and are available, we are 

required to include, to the extent practicable, the following types of measures for public 

reporting: 

● Measures collected under the Physician Quality Reporting System (PQRS). 

● An assessment of patient health outcomes and functional status of patients. 

● An assessment of the continuity and coordination of care and care transitions, 

including episodes of care and risk-adjusted resource use. 
 247 

● An assessment of efficiency. 

● An assessment of patient experience and patient, caregiver, and family engagement. 

● An assessment of the safety, effectiveness, and timeliness of care. 

● Other information as determined appropriate by the Secretary. 

As required under section 10331(b) of the Affordable Care Act, in developing and implementing 

the plan, we must include, to the extent practicable, the following: 

● Processes to ensure that data made public are statistically valid, reliable, and accurate, 

including risk adjustment mechanisms used by the Secretary. 

● Processes for physicians and eligible professionals whose information is being 

publicly reported to have a reasonable opportunity, as determined by the Secretary, to review 

their results before posting to Physician Compare. We have established a 30-day preview period 

for all measurement performance data that will allow physicians and other EPs to view their data 

as it will appear on the website in advance of publication on Physician Compare (77 FR 69166 

and 78 FR 74450). Details of the preview process will be communicated directly to those with 

measures to preview and will also be published on the Physician Compare Initiative page 

(http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physiciancompare-initiative/) in advance of the preview period. 

● Processes to ensure the data published on Physician Compare provides a robust and 

accurate portrayal of a physician’s performance. 

● Data that reflects the care provided to all patients seen by physicians, under both the 

Medicare program and, to the extent applicable, other payers, to the extent such information 

would provide a more accurate portrayal of physician performance. 

● Processes to ensure appropriate attribution of care when multiple physicians and other 

providers are involved in the care of the patient. 
 248 

● Processes to ensure timely statistical performance feedback is provided to physicians 

concerning the data published on Physician Compare. 

● Implementation of computer and data infrastructure and systems used to support valid, 

reliable and accurate reporting activities. 

 Section 10331(d) of the Affordable Care Act requires us to consider input from 

multi-stakeholder groups when selecting quality measures for Physician Compare. We also 

continue to get input from stakeholders through a variety of means including rulemaking and 

different forms of stakeholder outreach (Town Hall meetings, Open Door Forums, webinars, 

education and outreach, Technical Expert Panels, etc.). In developing the plan for making 

information on physician performance publicly available through Physician Compare, section 

10331(e) of the Affordable Care Act requires the Secretary, as the Secretary determines 

appropriate, to consider the plan to transition to value-based purchasing for physicians and other 

practitioners that was developed under section 131(d) of the MIPPA. 

 Under section 10331(f) of the Affordable Care Act, we are required to submit a report to 

the Congress by January 1, 2015, on Physician Compare development, and include information 

on the efforts and plans to collect and publish data on physician quality and efficiency and on 

patient experience of care in support of value-based purchasing and consumer choice. Section 

10331(g) of the Affordable Care Act provides that any time before that date, we may continue to 

expand the information made available on Physician Compare. 

 We believe section 10331 of the Affordable Care Act supports our overarching goals of 

providing consumers with quality of care information that will help them make informed 

decisions about their health care, while encouraging clinicians to improve the quality of care they 

provide to their patients. In accordance with section 10331 of the Affordable Care Act, we plan 

to publicly report physician performance information on Physician Compare. 
 249 

2. Public Reporting of Performance and Other Data 

 Since the initial launch of the website, we have continued to build on and improve 

Physician Compare. On June 27, 2013, we launched a full redesign of Physician Compare 

bringing significant improvements including a complete overhaul of the underlying database and 

a new Intelligent Search feature, addressing two of our stakeholders’ primary critiques of the site 

– the accuracy and currency of the database and the limitations of the search function – and 

considerably improving website functionality and usability. PECOS, as the sole source of 

verified Medicare professional information, is the primary source of administrative information 

on Physician Compare. With the redesign, however, we incorporated the use of Medicare FeeFor-Service claims information to verify the information in PECOS to help ensure only the most 

current and accurate information is included on the site. 

Currently, website users can view information about approved Medicare professionals 

such as name, primary and secondary specialties, practice locations, group affiliations, hospital 

affiliations that link to the hospital’s profile on Hospital Compare as available, Medicare 

Assignment status, education, languages spoken, and American Board of Medical Specialties 

(ABMS) board certification information. In addition, for group practices, users can also view 

group practice names, specialties, practice locations, Medicare assignment status, and affiliated 

professionals. 

We post on the website the names of individual EPs who satisfactorily report under the 

PQRS, as well as those EPs who are successful electronic prescribers under the Medicare 

Electronic Prescribing (eRx) Incentive Program. Physician Compare contains a link to a 

downloadable database of all information on Physician Compare 

(https://data.medicare.gov/data/physician-compare), including information on this quality 

program participation. In addition, there is a section on each Medicare professional’s profile 
 250 

page indicating with a green check mark the quality programs under which the EP satisfactorily 

or successfully reported. We propose to continue to include this information annually in the year 

following the year it is reported (for example, 2015 PQRS reporting will be included on the 

website in 2016). 

With the Physician Compare redesign, we added a quality programs section to each group 

practice profile page in order to indicate which group practices are satisfactorily participating in 

the Group Practice Reporting Option (GPRO) under the PQRS or are successful electronic 

prescribers under the eRx Incentive Program. We have also included a notation and check mark 

for individuals that successfully participate in the Medicare EHR Incentive Program, as 

authorized by section 1848(o)(3)(D) of the Act. We propose to continue to include this 

information annually in the year following the year it is reported (for example, 2015 data will be 

included on the website in 2016). 

As we finalized in the 2014 PFS final rule with comment period (78 FR 74450), we will 

publicly report the names of those EPs who report the 2014 PQRS Cardiovascular Prevention 

measures group in support of the Million Hearts Initiative on Physician Compare in 2015 by 

including a check mark in the quality programs section of the profile page. We propose to also 

continue to include this information annually in the year following the year it is reported (for 

example, 2015 data will be included on Physician Compare in 2016). Finally, we will also 

indicate with a green check mark those individuals who have earned the 2014 PQRS 

Maintenance of Certification Incentive (Additional Incentive) on the website in 2015 (78 FR 

74450). 

We continue to implement our plan for a phased approach to public reporting 

performance information on Physician Compare. The first phase of this plan was finalized with 

the CY 2012 PFS final rule with comment period (76 FR 73419-73420), where we established 
 251 

that PQRS GPRO measures collected through the GPRO web interface for 2012 would be 

publicly reported on Physician Compare. The plan was expanded with the CY 2013 PFS final 

rule with comment period (77 FR 69166), where we established that the specific GPRO web 

interface measures that would be posted on Physician Compare would include the PQRS GPRO 

measures for Diabetes Mellitus (DM) and Coronary Artery Disease (CAD), and we noted that we 

would report composite measures for these measure groups in 2014, if technically feasible.5 The 

2012 PQRS GPRO measures were publicly reported on Physician Compare in February 2014. 

Data reported in 2013 on the GPRO DM and GPRO CAD measures and composites collected via 

the GPRO web interface that meet the minimum sample size of 20 patients and prove to be 

statistically valid and reliable will be publicly reported on Physician Compare in late CY 2014, if 

technically feasible. If the minimum threshold is not met for a particular measure, or the 

measure is otherwise deemed not to be suitable for public reporting, the group’s performance 

rate on that measure will not be publicly reported. We will only publish on Physician Compare 

those measures that are statistically valid and reliable and therefore most likely to help 

consumers make informed decisions about the Medicare professionals they choose to meet their 

health care needs. 

Measures must be based on reliable and valid data elements to be useful to consumers 

and thus included on Physician Compare. A reliable data element is consistently measuring the 

same thing regardless of when or where it is collected, while a valid data element is measuring 

what it is meant to measure. To address the reliability of performance scores, CMS will measure 

the extent to which differences in each quality measure are due to actual differences in clinician 

performance versus variation that arises from measurement error. Statistically, reliability 

 

5

 By “technically feasible” we mean that there are no operational constraints inhibiting us from moving forward on a 

given public reporting objective. Operational constraints include delays and/or issues related to data collection 

which render a set of quality data unavailable in the timeframe necessary for public reporting. 
 252 

depends on performance variation for a measure across clinicians (“signal”), the random 

variation in performance for a measure within a clinician’s panel of attributed beneficiaries 

(“noise”), and the number of beneficiaries attributed to the clinician. High reliability for a 

measure suggests that comparisons of relative performance across clinicians are likely to be 

stable over different performance periods and that the performance of one clinician on the quality 

measure can confidently be distinguished from another. Potential reliability values range from 

zero to one, where one (highest possible reliability) means that all variation in the measure’s 

rates is the result of variation in differences in performance, while zero (lowest possible 

reliability) means that all variation is a result of measurement error. Reliability testing methods 

included in the CMS Measures Management System Blueprint include test-retest reliability and 

analysis of variance (ANOVA). Reliability tests endorsed by the NQF include the beta-binomial 

model test. 

The validity of a measure refers to the ability to record or quantify what it claims to 

measure. To analyze validity, CMS can investigate the extent to which each quality measure is 

correlated with related, previously validated, measures. CMS can assess both concurrent and 

predictive validity. Predictive validity is most appropriate for process measures or intermediate 

outcome measures, in which a cause-and-effect relationship is hypothesized between the measure 

in question and a validated outcome measure. Therefore, the measure in question is computed 

first, and the validated measure is computed using data from a later period. To examine 

concurrent validity, the measure in question and a previously validated measure are computed 

using contemporaneous data. In this context, the previously validated measure should measure a 

health outcome related to the outcome of interest. 

In the November 2011 Medicare Shared Savings Program final rule (76 FR 67948), we 

noted that because Accountable Care Organization (ACO) providers/suppliers that are EPs are 
 253 

considered to be a group practice for purposes of qualifying for a PQRS incentive under the 

Shared Savings Program, we would publicly report ACO performance on quality measures on 

Physician Compare in the same way as we report performance on quality measures for PQRS 

GPRO group practices. Public reporting of performance on these measures is presented at the 

ACO level only. The first sub-set of ACO measures was also published on the website in 

February 2014. ACO measures can be viewed by following the link for Accountable Care 

Organization (ACO) Quality Data on the homepage of the Physician Compare website 

(http://medicare.gov/physiciancompare/aco/search.html). 

As part of our public reporting plan for Physician Compare, in the CY 2013 PFS final 

rule with comment period (77 FR 69166-69167), we also finalized the decision to publicly report 

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) 

data for group practices of 100 or more eligible professionals reporting data in 2013 under the 

GPRO and for ACOs participating in the Shared Savings Program, if technically feasible. We 

anticipate posting these data on Physician Compare in late 2014, if available. 

We continued to expand our plan for public reporting data on Physician Compare in the 

CY 2014 PFS final rule with comment period (78 FR 74449). In that final rule we finalized a 

decision that all measures collected through the GPRO web interface for groups of two or more 

EPs participating in 2014 under the PQRS GPRO and for ACOs participating in the Medicare 

Shared Savings Program are available for public reporting in CY 2015. As with all measures we 

finalized with regard to Physician Compare, these data would include measure performance rates 

for measures reported that meet the minimum sample size of 20 patients and prove to be 

statistically valid and reliable. We also finalized a 30-day preview period prior to publication of 

quality data on Physician Compare. This will allow group practices to view their data as it will 

appear on Physician Compare before it is publicly reported. We decided that we will detail the 
 254 

process for the 30-day preview and provide a detailed timeline and instructions for preview in 

advance of the start of the preview period. ACOs will be able to view their quality data that will 

be publicly reported on Physician Compare through the ACO Quality Reports, which will be 

made available to ACOs for review at least 30 days prior to the start of public reporting on 

Physician Compare. 

We also finalized a decision to publicly report in CY 2015 on Physician Compare 

performance on certain measures that group practices report via registries and EHRs in 2014 for 

the PQRS GPRO (78 FR 74451). Specifically, we finalized making available for public 

reporting performance on 16 registry measures and 13 EHR measures (78 FR 74451). These 

measures are consistent with the measures available for public reporting via the web interface. 

We will indicate the mechanism by which these data were collected and only those data deemed 

statistically comparable, valid, and reliable would be published on the site. 7 

We also finalized publicly reporting patient experience survey-based measures from the CGCAHPS measures for groups of 100 or more eligible professionals who participate in PQRS 

GPRO, regardless of GPRO submission method, and for Shared Savings Program ACOs 

reporting through the GPRO web interface or other CMS-approved tool or interface (78 FR 

74452). For 2014 data, we finalized publicly reporting data for the 12 summary survey measures 

also finalized for groups of 25 to 99 for PQRS reporting requirements (78 FR 74452). These 

summary survey measures would be available for public reporting 100 or more EPs participating 

in PQRS GPRO as well as group practices of 25 to 99 EPs when collected via any certified 

CAHPS vendor regardless of PQRS participation, as technically feasible. For ACOs 

participating in the Shared Savings Program, the patient experience measures that are included in 

the Patient/Caregiver Experience domain of the Quality Performance Standard under the Shared 

Savings Program (78 FR 74452) are available for public reporting in 2015. 
 255 

For 2014, we also finalized publicly reporting 2014 PQRS measure data reported by 

individual EPs in late CY 2015 for individual PQRS quality measures specifically identified in 

the final rule with comment period, if technically feasible. Specifically, we finalized to make 

available for public reporting 20 individual measures collected through a registry, EHR, or 

claims (78 FR 74453 through 74454). These are measures that are in line with those measures 

reported by groups via the GPRO web interface. 

Finally, in support of the HHS-wide Million Hearts Initiative, we finalized a decision to 

publicly report, no earlier than CY 2015, performance rates on measures in the PQRS 

Cardiovascular Prevention measures group at the individual EP level for data collected in 2014 

for the PQRS (78 FR 74454). See Table 19 for a summary of our final policies for public 

reporting data on Physician Compare. 

TABLE 19: Summary of Previously Finalized Policies for Public Reporting on Physician 

Compare 

Data 

Collection 

Year 

Public 

Reporting 

Year 

Reporting 

Mechanism(s) Quality Measures and Data for Public Reporting 

2012 2013 Web Interface 

(WI), EHR, 

Registry, 

Claims 

Include an indicator for satisfactory reporters under 

PQRS and PQRS GPRO, successful e-prescribers under 

eRx, and participants in EHR for groups and individuals 

as applicable. 

2012 2014 WI 5 Diabetes Mellitus (DM) and Coronary Artery Disease 

(CAD) measures collected via the WI for group 

practices with a minimum sample size of 25 patients and 

Shared Savings Program ACOs. 

2013 2014 WI, EHR, 

Registry, 

Claims 

Include an indicator for satisfactory reporters under 

PQRS and PQRS GPRO, successful e-prescribers under 

eRx, and participants in EHR, as well as for EPs who 

earn a Maintenance of Certification (MOC) Incentive 

and EPs who report the PQRS Cardiovascular 

Prevention measures group in support of Million Hearts. 

2013 Expected 

to be 

December 

2014 

WI Up to 6 DM and 2 CAD measures collected via the WI 

for groups of 25 or more EPs with a minimum sample 

size of 20 patients. 

Will include composites for DM and CAD, if feasible. 

2013 Expected 

to be 

December 

WI 5 CG-CAHPS summary measures for groups of 100 or 

more EPs reporting via the WI and 6 ACO CAHPS 

summary measures for Shared Savings Program ACOs. 
 256 

Data 

Collection 

Year 

Public 

Reporting 

Year 

Reporting 

Mechanism(s) Quality Measures and Data for Public Reporting 

2014 

2014 Expected 

to be 2015 

WI, EHR, 

Registry, 

Claims 

Include an indicator for satisfactory reporters under 

PQRS and PQRS GPRO, participants in EHR, as well as 

for EPs who earn a Maintenance of Certification (MOC) 

Incentive and EPs who report the PQRS Cardiovascular 

Prevention measures group in support of Million Hearts. 

2014 Expected 

to be late 

2015 

WI, EHR, 

Registry 

All measures reported via the GPRO WI, 13 EHR, and 

16 Registry GPRO measures are also available for group 

practices of 2 or more EPs and Shared Savings Program 

ACOs with a minimum sample size of 20 patients. 

Include composites for DM and CAD, if feasible. 

2014 Expected 

to be late 

2015 

WI, Certified 

Survey Vendor 

Up to 12 CG-CAHPS summary measures for groups of 

100 or more EPs reporting via the WI and group 

practices of 25 to 99 EPs reporting via a CMS-approved 

certified survey vendor, as well as 6 ACO CAHPS 

summary measures for Shared Savings Program ACOs 

reporting through the GPRO web interface or other 

CMS-approved tool or interface. 

2014 Expected 

to be late 

2015 

Registry, EHR, 

or Claims 

A sub-set of 20 PQRS measures submitted by individual 

EPs that align with those available for group reporting 

via the WI that are collected through a Registry, EHR, 

or claims with a minimum sample size of 20 patients. 

2014 Expected 

to be late 

2015 

Registry, EHR, 

or Claims 

Measures from the Cardiovascular Prevention measures 

group reported by individual EPs in support of the 

Million Hearts Initiative with a minimum sample size of 

20 patients. 

3. Proposals for Public Data Disclosure on Physician Compare in 2015 and 2016 

 We are continuing the expansion of public reporting on Physician Compare by proposing 

to make an even broader set of quality measures available for publication on the website. We 

started the phased approach with a small number of possible PQRS GPRO web interface 

measures for 2012, and have been steadily building on this to provide Medicare consumers with 

more information to help them make informed health care decisions. As a result, we are now 

proposing to increase the measures available for public reporting. 

We previously finalized in the CY 2014 PFS final rule with comment period (78 FR 74450) to 

make available for public reporting all PQRS GPRO measures collected in 2014 via the web 
 257 

interface. We now propose to expand public reporting of group-level measures by making all 

2015 PQRS GPRO measure sets across group reporting mechanisms – GPRO web interface, 

registry, and EHR – available for public reporting on Physician Compare in CY 2016 for groups 

of 2 or more EPs, as appropriate by reporting mechanism.6

 Similarly, all measures reported by 

Shared Savings Program ACOs would be available for public reporting on Physician Compare. 

As with all quality measures proposed for inclusion on Physician Compare, only measures that 

prove to be valid, reliable, and accurate upon analysis and review at the conclusion of data 

collection will be included on the website. Also, we propose that measures must meet the public 

reporting criteria of a minimum sample size of 20 patients. We propose to include an indicator 

of which reporting mechanism was used and only measures deemed statistically comparable 

would be included on the site.7

 We propose to publicly report all measures submitted and 

reviewed and found to be statistically valid and reliable in the Physician Compare downloadable 

file. However, we propose that not all of these measures necessarily would be included on the 

Physician Compare profile pages. Consumer testing has shown including too much information 

and/or measures that are not well understood by consumers on these pages can negatively impact 

a consumer’s ability to make informed decisions. Our analysis of the measure data once 

collected, consumer testing, and stakeholder feedback would determine specifically which 

measures are published on profile pages on the website. Statistical analyses will ensure the 

measures included are statistically valid and reliable and comparable across data collection 

mechanisms. And, stakeholder feedback will ensure all measures meet current clinical 

standards. CMS will continue to reach out to stakeholders in the professional community, such 

 

6

 Tables Q1-Q27 detail proposed changes to available PQRS measures. Additional information on PQRS measures 

can be found on the CMS.gov PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 7

 By statistically comparable, CMS means that the quality measures are analyzed and proven to measure the same 

phenomena in the same way regardless of the mechanism through which they were collected. 
 258 

as specialty societies, to ensure that the measures under consideration for public reporting remain 

clinically relevant and accurate. As measures are finalized significantly in advance of moment 

they are collected, it is possible that clinical guidelines can change rendering a measure no longer 

relevant. Publishing that measure can lead to consumer confusion regarding what best practices 

their health care professional should be subscribing to. 

The primary goal of Physician Compare is to help consumers make informed health care 

decisions. If a consumer does not properly interpret a quality measure and thus misunderstands 

what the quality score represents, the consumer cannot use this information to make an informed 

decision. Through concept testing, CMS will test with consumers how well they understand 

each measure under consideration for public reporting. If a measure is not consistently 

understood and/or if consumers do not understand the relevance of the measure to their health 

care decision making process, CMS will not include the measure on the Physician Compare 

profile page as inclusion will not aid informed decision making. Finally, consumer testing will 

help ensure the measures included on the profile pages are accurately understood and relevant to 

consumers, thus helping them make informed decisions. This will be done to ensure that the 

information included on Physician Compare is consumer friendly and consumer focused. 

As is the case for all measures published on Physician Compare, group practices will be 

given a 30-day preview period to view their measures as they will appear on Physician Compare 

prior to the measures being published. As in previous years, we will detail the process for the 

30-day preview and provide a detailed timeline and instructions for preview in advance of the 

start of the preview period. ACOs will be able to view their quality data that will be publicly 

reported on Physician Compare through the ACO Quality Reports, which will be made available 

to ACOs for review at least 30 days prior to the start of public reporting on Physician Compare. 
 259 

 In addition to making all 2015 PQRS GPRO measures available for public reporting, we 

seek comment on creating composites using 2015 data and publishing composite scores in 2016 

by grouping measures based on the PQRS GPRO measure groups, if technically feasible. We 

will analyze the data collected in 2015 and conduct psychometric and statistical analyses, 

looking at how the measures best fit together and how accurately they are measuring the 

composite concept, to create composites for certain PQRS GPRO measure groups, including but 

not limited to: 

● Care Coordination/Patient Safety (CARE) Measures 

● Coronary Artery Disease (CAD) Disease Module 

● Diabetes Mellitus (DM) Disease Module 

● Preventive (PREV) Care Measures 

We would analyze the component measures that make up each of these measure groups 

to see if a statistically viable composite can be constructed with the data reported for 2015. We 

have received ample feedback from stakeholders indicating such scores are strongly desired. 

Composite scores, generally, have also proven to be critical for providing consumers a better 

way to understand quality measure data as composites provide a more concise, easy to 

understand picture of physician quality. Therefore, we plan to analyze the data once collected to 

establish the best possible composite, which would help consumers use these quality data to 

make informed health care decisions. 

 Similar to composite scores, benchmarks are also important to ensuring that the quality 

data published on Physician Compare are accurately interpreted and appropriately understood. A 

benchmark will allow consumers to more easily evaluate the information published by providing 

a point of comparison between groups. We continue to receive requests from all stakeholders, 

but especially consumers, to add this information to Physician Compare. As a result, we propose 
 260 

to publicly report on Physician Compare in 2016 benchmarks for 2015 PQRS GPRO data using 

the same methodology currently used under the Shared Savings Program. This ACO benchmark 

methodology was previously finalized in the November 2011 Shared Savings Program final rule 

(76 FR 67898), as amended in the CY 2014 PFS final rule with comment period (78 FR 74759). 

Details on this methodology can be found on CMS.gov at http://cms.gov/Medicare/MedicareFee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks.pdf. We 

propose to follow this methodology using the 2014 PQRS GPRO data, however. 

As outlined for the Shared Savings Program, we propose to calculate benchmarks using 

data at the group practice TIN level for all EPs who have at least 20 cases in the denominator. A 

benchmark per this methodology is the performance rate a group practice must achieve to earn 

the corresponding quality points for each measure. Benchmarks would be established for each 

percentile, starting with the 30th percentile (corresponding to the minimum attainment level) and 

ending with the 90th percentile (corresponding to the maximum attainment level). A quality 

scoring points systems would then be determined. Quality scoring would be based on the group 

practice’s actual level of performance on each measure. A group practice would earn quality 

points on a sliding scale based on level of performance: performance below the minimum 

attainment level (the 30th percentile) for a measure would receive zero points for that measure; 

performance at or above the 90th percentile of the performance benchmark would earn the 

maximum points available for the measure. The total points earned for measures in each 

measure group would be summed and divided by the total points available for that measure 

group to produce an overall measure group score of the percentage of points earned versus points 

available. The percentage score for each measure group would be averaged together to generate 

a final overall quality score for each group practice. The goal of including such benchmarks 
 261 

would be to help consumers see how each group practice performs on each measure, measure 

group, and overall in relation to other group practices. 

 Understanding the value consumers place on patient experience data and the commitment 

to reporting these data on Physician Compare, we propose publicly reporting in CY 2016 patient 

experience data from 2015 for all group practices of 2 or more EPs, who meet the specified 

sample size requirements and collect data via a CMS-specified certified CAHPS vendor. The 

patient experience data available are specifically the CAHPS for PQRS and CAHPS for ACO 

measures, which include the CG-CAHPS core measures. For group practices, we propose to 

publicly report for 2015 data on Physician Compare in 2016 the 12 summary survey measures 

previously finalized for 2014 data: 

● Getting Timely Care, Appointments, and Information. 

● How Well Providers Communicate. 

● Patient’s Rating of Provider. 

● Access to Specialists. 

● Health Promotion & Education. 

● Shared Decision Making. 

● Health Status/Functional Status. 

● Courteous and Helpful Office Staff. 

● Care Coordination. 

● Between Visit Communication. 

● Helping You to Take Medication as Directed. 

● Stewardship of Patient Resources. 

We propose that these 12 summary survey measures would be available for public 

reporting for all group practices. For ACOs participating in the Shared Savings Program, we 
 262 

propose that the patient experience measures that are included in the Patient/Caregiver 

Experience domain of the Quality Performance Standard under the Shared Savings Program in 

2015 would be available for public reporting in 2016. We would review all quality measures 

after they are collected to ensure that only those measures deemed valid and reliable are included 

on the website. 

 We previously finalized in the 2014 PFS final rule with comment period (78 FR 74454) 

that 20 2014 PQRS measures for individual EPs collected via registry, EHR, or claims would be 

available for public reporting in late 2015, if technically feasible. We propose to expand on this 

in two ways. First, we propose to publicly report these same 20 measures for 2013 PQRS data in 

early 2015. Publicly reporting these 2013 individual measures will help ensure individual level 

measures are made available as soon as possible. Consumers are looking for measures about 

individual doctors and other health care professionals, and this would make these quality data 

available to the public sooner. 

 Second, we propose to make all individual EP-level PQRS measures collected via 

registry, EHR, or claims available for public reporting on Physician Compare for data collected 

in 2015 to be publicly reported in late CY 2016, if technically feasible.8 This will provide the 

opportunity for more EPs to have measures included on Physician Compare, and it will provide 

more information to consumers to make informed decisions about their health care. As with 

group-level measures, we propose to publicly report all measures submitted and reviewed and 

deemed valid and reliable in the Physician Compare downloadable file. However, not all of 

these measures necessarily would be included on the Physician Compare profile pages. Our 

analysis of the measure data once collected, consumer testing, and stakeholder feedback would 

 

8

 Tables Q1-Q27 detail proposed changes to available PQRS measures. Additional information on PQRS measures 

can be found on the CMS.gov PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 
 263 

determine specifically which measures are published on profile pages on the website. In this 

way, quality information at the individual practitioner level would be available, as has been 

regularly requested by Medicare consumers, but consumers will not be overwhelmed with too 

much information on each EPs profile page. 

 As noted above for group-level reporting, composite scores and benchmarks are critical 

in helping consumers best understand the quality measure information presented. For that 

reason, in addition to making all 2015 PQRS measures available for public reporting, we seek 

comment to create composites and publish composite scores by grouping measures based on the 

PQRS measure groups, if technically feasible. We will analyze the data collected in 2015 and 

conduct psychometric and statistical analyses to create composites for PQRS measure groups to 

be published in 2016, including: 

● Coronary Artery Disease (CAD) (see Table 30) 

● Diabetes Mellitus (DM) (see Table 32) 

● General Surgery (see Table 33) 

● Oncology (see Table 38) 

● Preventive Care (see Table 41) 

● Rheumatoid Arthritis (RA) (see Table 42) 

● Total Knee Replacement (TKR) (see Table 45) 

We would analyze the component measures that make up each of these measure groups 

to see if a statistically viable composite can be constructed with the data reported for 2015. In 

addition, we propose to use the same methodology outlined above for group practices to develop 

benchmarks for individual practitioners. As noted for group practices, we believe that providing 

composite scores and benchmarks will give consumers the tools needed to most accurately 

interpret the quality data published on Physician Compare. 
 264 

 Previously, we indicated an interest in including specialty society measures on Physician 

Compare. We now seek comment on posting these measures on the website. We also seek 

comment on the option of linking from Physician Compare to specialty society websites that 

publish non-PQRS measures. Including specialty society measures on the site or linking to 

specific specialty society measures would provide the opportunity for more eligible professionals 

to have measures included on Physician Compare and thus help Medicare consumers make more 

informed choices. The quality measures developed by specialty societies that would be 

considered for future posting on Physician Compare are those that have been comprehensively 

vetted and tested, and are trusted by the physician community. These measures would provide 

access to available specialty specific quality measures that are often highly regarded and trusted 

by the stakeholder community and, most importantly, by the specialties they represent. We are 

working to identify possible societies to reach out to, and seek comment on the concept, as well 

as potential specific society measures of interest. 

 Finally, we propose to make available on Physician Compare, 2015 Qualified Clinical 

Data Registry (QCDR) measure data collected at the individual level or aggregated to a higher 

level of the QCDR’s choosing – such as the group practice level, if technically feasible. QCDRs 

are able to collect both PQRS measures and non-PQRS measures.9

 We believe that making 

QCDR data available on Physician Compare further supports the expansion of quality measure 

data available for EPs and group practices regardless of specialty therefore providing more 

quality data to consumers to help them make informed decisions. The QCDR would be required 

to declare during their self-nomination if they plan to post data on their own website and allow 

Physician Compare to link to it or if they will provide data to us for public reporting on 

 

9

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaimsRegistry_MeasureSpecs

_SupportingDocs_12132013.zip 
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Physician Compare. We propose that measures collected via QCDRs must also meet the 

established public reporting criteria, including a 20 patient minimum sample size. As with 

PQRS data, we propose to publicly report all measures submitted and reviewed and deemed 

valid and reliable in the Physician Compare downloadable file. However, not all of these 

measures necessarily would be included on the Physician Compare profile pages. Our analysis 

of the measure data once collected, consumer testing, and stakeholder feedback would determine 

specifically which measures are published on profile pages on the website. 

 Table 20 summarizes the Physician Compare proposals detailed in this section. We 

solicit comments on all proposals. Increasing the measures available for public reporting on 

Physician Compare at both the individual and group level will help accomplish the website’s 

twofold purpose: 

● Provide more information for consumers to encourage informed patient choice. 

● Create explicit incentives for physicians to maximize performance. 

TABLE 20: Summary of Proposed Data for Public Reporting 

Data 

Collection 

Year 

Publication 

Year Data Type Reporting 

Mechanism 

Proposed Quality Measures and Data for Public 

Reporting 

2013 2015 PQRS Registry, 

EHR, or 

Claims 

Twenty 2013 PQRS individual measures collected 

through a Registry, EHR, or claims mirroring the 

measures finalized for 2014 (78 FR 74454). 

2015 2016 Multiple Web 

Interface, 

EHR, 

Registry, 

Claims 

Include an indicator for satisfactory reporters under 

PQRS and PQRS GPRO, participants in EHR, and 

EPs who report the PQRS Cardiovascular 

Prevention measures group in support of Million 

Hearts. 

2015 2016 PQRS GPRO 

& ACO 

GPRO 

Web 

Interface, 

EHR, & 

Registry 

All 2015 PQRS GPRO measures reported via the 

Web Interface, EHR, and Registry are available for 

public reporting for group practices of 2 or more 

EPs and all measures reported by ACOs with a 

minimum sample size of 20 patients. 

2015 2016 CAHPS for 

PQRS& 

CAHPS for 

ACOs 

CMSSpecified 

Certified 

CAHPS 

Vendor 

2015 CAHPS for PQRS for groups of 2 or more EPs 

and CAHPS for ACOs for those who meet the 

specified sample size requirements and collect data 

via a CMS-specified certified CAHPS vendor. 
 266 

Data 

Collection 

Year 

Publication 

Year Data Type Reporting Mechanism 

Proposed Quality Measures and Data for Public 

Reporting 

2015 2016 PQRS Registry, 

EHR, or 

Claims 

All 2015 PQRS measures for individual EPs 

collected through a Registry, EHR, or claims. 

2015 2016 QCDR data QCDR All 2015 QCDR data available for public report on 

Physician Compare at the individual level or 

aggregated to a higher level of the QCDR’s 

choosing. 
 267 

K. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting 

System 

This section contains the proposed requirements for the Physician Quality Reporting 

System (PQRS). The PQRS, as set forth in sections 1848(a), (k), and (m) of the Act, is a quality 

reporting program that provides incentive payments (ending with 2014) and payment 

adjustments (beginning in 2015) to eligible professionals and group practices based on whether 

they satisfactorily report data on quality measures for covered professional services furnished 

during a specified reporting period or to individual eligible professionals that satisfactorily 

participate in a qualified clinical data registry (QCDR). 

The proposed requirements will primarily focus on our proposals related to the 2017 

PQRS payment adjustment, which will be based on an eligible professional’s or a group 

practice’s reporting of quality measures data during the 12-month calendar year reporting period 

occurring in 2015 (that is, January 1 through December 31, 2015). Please note that, in 

developing these proposals, we focused on aligning our requirements with other quality reporting 

programs, such as the Medicare EHR Incentive Program for Eligible Professionals, the Physician 

Value-Based Payment Modifier (VM), and the Medicare Shared Savings Program, where and to 

the extent appropriate and feasible. In previous years, we have made various strides in our 

ongoing efforts to align the reporting requirements in CMS’ various quality reporting programs 

to reduce burden on the eligible professionals and group practices that participate in these 

programs. Particularly through the QCDR option, we are exploring opportunities to align with 

quality reporting programs that exist outside of CMS where and to the extent appropriate and 

feasible. We continued to focus on alignment as we developed our proposals for the 2017 PQRS 

payment adjustment below. 
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The PQRS regulation is located at 42 CFR 414.90. The program requirements for the 

2007 through 2014 PQRS incentives and the 2015 and 2016 PQRS payment adjustment that 

were previously established, as well as information on the PQRS, including related laws and 

established requirements, are available at http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/index.html. In addition, the 2012 PQRS and eRx 

Experience Report, which provides information about eligible professional participation in 

PQRS, is available for download at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip. 

We note that eligible professionals in critical access hospitals (CAHs) were previously 

not able to participate in the PQRS. Due to a change we made in the manner in which eligible 

professionals in CAHs are reimbursed by Medicare, it is now feasible for eligible professionals 

in CAHs to participate in the PQRS. Although eligible professionals in CAHs are not able to use 

the claims-based reporting mechanism to report PQRS quality measures data in 2014, beginning 

in 2015, these eligible professionals in CAHs may participate in the PQRS using ALL reporting 

mechanisms available, including the claims-based reporting mechanism. Finally, please note 

that in accordance with section 1848(a)(8) of the Act, all eligible professionals who do not meet 

the criteria for satisfactory reporting or satisfactory participation for the 2017 PQRS payment 

adjustment will be subject to the 2017 PQRS payment adjustment with no exceptions. 

In addition, in the CY 2013 PFS final rule with comment period, we introduced the 

reporting of the Agency for Healthcare Research and Quality’s (AHRQ’s) Clinician & Group 

(CG) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures, 

referenced at https://cahps.ahrq.gov/Surveys-Guidance/CG/index.html. AHRQ's CAHPS 

Clinician & Group Survey Version 2.0 (CG-CAHPS) includes 34 core CG-CAHPS survey 

questions. In addition to these 34 core questions, the CAHPS survey measures that are used in 
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the PQRS include supplemental questions from CAHPS Patient-Centered Medical Home Survey, 

Core CAHPS Health Plan Survey Version 5.0, other CAHPS supplemental items, and some 

additional questions. Since the CAHPS survey used in the PQRS covers more than just the 34 

core CG-CAHPS survey measures, we will refer to the CG-CAHPS survey measures used in the 

PQRS as “CAHPS for PQRS.” We propose to make this revision throughout §414.90. 

1. Requirements for the PQRS Reporting Mechanisms 

The PQRS includes the following reporting mechanisms: claims; qualified registry; EHR 

(including direct EHR products and EHR data submission vendor products); the Group Practice 

Reporting Option (GPRO) web interface; certified survey vendors, for CG-CAHPS survey 

measures; and the QCDR. Under the existing PQRS regulation, §414.90(h) through (k) govern 

which reporting mechanisms are available for use by individuals and group practices for the 

PQRS incentive and payment adjustment. This section III.K.1 contains our proposals to change 

the qualified registry, direct EHR and EHR data submission vendor products, QCDR, and GPRO 

web interface reporting mechanisms. Please note that we are not proposing to make changes to 

the claims-based reporting mechanism. 

a. Proposed Changes to the Requirements for the Qualified Registry 

In the CY 2013 and 2014 PFS final rules with comment period, we established certain 

requirements for entities to become qualified registries for the purpose of verifying that a 

qualified registry is prepared to submit data on PQRS quality measures for the reporting period 

in which the qualified registry seeks to be qualified (77 FR 69179 through 69180 and 78 FR 

74456). Specifically, in the CY 2014 PFS final rule with comment period, in accordance with 

the satisfactory reporting criterion we finalized for individual eligible professionals or group 

practices reporting PQRS quality measures via qualified registry, we finalized the following 

requirement that a qualified registry must be able to collect all needed data elements and transmit 
 270 

to CMS the data at the TIN/NPI level for at least 9 measures covering at least 3 of the National 

Quality Strategy (NQS) domains (78 FR 74456). 

As we explain in further detail in this section III.K, we are proposing that – in addition to 

proposing to require that an eligible professional or group practice report on at least 9 measures 

covering 3 NQS domains –an eligible professional or group practice who sees at least 1 

Medicare patient in a face-to-face encounter, as we propose to define that term in section 

III.K.2.a., and wishes to meet the proposed criterion for satisfactory reporting of PQRS quality 

measures via a qualified registry for the 2017 PQRS payment adjustment would be required to 

report on at least 2 cross-cutting PQRS measures specified in Table 21. In accordance with this 

proposal, we are proposing to require that, in addition to being required to be able to collect all 

needed data elements and transmit to CMS the data at the TIN/NPI level for at least 9 measures 

covering at least 3 of the NQS domains for which a qualified registry transmits data, a qualified 

registry would be required to be able to collect all needed data elements and transmit to CMS the 

data at the TIN/NPI level for ALL cross-cutting measures specified in Table 21 for which the 

registry’s participating eligible professionals are able to report. We are proposing to require that 

qualified registries be able to report on all cross-cutting measures specified in Table 21 for which 

the registry’s participating eligible professionals are able to report, rather than proposing to 

require a minimum of 2, so that eligible professionals and group practices using qualified 

registries to report PQRS measures would have the flexibility in choosing which cross-cutting 

measures to report, and to report on as many cross-cutting measures specified in Table 21 as they 

are able. 

Furthermore, in the CY 2013 PFS final rule, we noted that qualified registries have until 

the last Friday of February following the applicable reporting period (for example, February 28, 

2014, for reporting periods ending in 2013) to submit quality measures data on behalf of its 
 271 

eligible professionals (77 FR 69182). We continue to receive stakeholder feedback, particularly 

from qualified registries currently participating in the PQRS, urging us to extend this submission 

deadline due to the time it takes for these qualified registries to collect and analyze the quality 

measures data received after the end of the reporting period. While, at the time, we emphasized 

the need to have quality measures data received by CMS no later than the last Friday of the 

February occurring after the end of the applicable reporting period, we believe it is now feasible 

to extend this deadline. Therefore, we propose to extend the deadline for qualified registries to 

submit quality measures data, including, but not limited to, calculations and results, to March 31 

following the end of the applicable reporting period (for example, March 31, 2016, for reporting 

periods ending in 2015). 

In addition, we seek comment on whether to propose in future rulemaking to allow more 

frequent submissions of data, such as quarterly or year-round submissions, rather than having 

only one opportunity to submit quality measures data as is our current process. 

We invite public comment on these proposals. 

b. Proposed Changes to the Requirements for the Direct EHR and EHR Data Submission 

Vendor Products That Are CEHRT 

In the CY 2013 PFS final rule with comment period, we finalized requirements that 

although EHR vendors and their products would no longer be required to undergo the previously 

existing qualification process, we would only accept the data if the data are: (1) transmitted in a 

CMS-approved XML format utilizing a Clinical Document Architecture (CDA) standard such as 

Quality Reporting Data Architecture (QRDA) level 1 (and for EHR data submission vendor 

products that intend to report for purposes of the proposed PQRS-Medicare EHR Incentive 

Program Pilot, if the aggregate data are transmitted in a CMS-approved XML format); and (2) in 

compliance with a CMS-specified secure method for data submission (77 FR 69183 through 
 272 

69187). To further clarify, EHR vendors and their products must be able to submit data in the 

form and manner specified by CMS. Accordingly, direct EHRs and EHR data submission 

vendors must comply with CMS Implementation Guides for both the QRDA-I and QRDA-III 

data file formats. The Implementation Guides for 2014 are available at 

http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Guide_QRDA_2014eCQM.pdf. 

Updated guides for 2015, when available, will be posted on the CMS EHR Incentive Program 

website at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms. 

These implementation guides further describe the technical requirements for data submission to 

ensure the data elements required for measure calculation and verification are provided. We 

propose to continue applying these requirements to direct EHR products and EHR data 

submission vendor products for 2015 and beyond. For 2015 and beyond, we also propose to 

have the eligible professional or group practice provide the CMS EHR Certification Number of 

the product used by the eligible professional or group practice for direct EHRs and EHR data 

submission vendors. 

We believe this requirement is necessary to ensure that the eligible professionals and 

group practices that are using EHR technology are using a product that is certified EHR 

technology (CEHRT) and will allow CMS to ensure that the eligible professional or group 

practice’s data is derived from a product that is CEHRT. 

Additionally, we seek comment on whether to propose in future rulemaking to allow 

more frequent submissions of data, such as quarterly or year-round submissions, rather than 

having only one opportunity to submit quality measures data as is our current process. 

We invite public comment on these proposals. 

c. Proposed Changes to the Requirements for the QCDR 
 273 

In the CY 2014 PFS final rule with comment period, we established certain requirements 

for entities to become QCDRs for the purpose of having their participating eligible professionals 

meet the criteria for satisfactory participation in a QCDR for purposes of the PQRS incentives 

and payment adjustments (78 FR 74465 through 74474). 

Specifically, in accordance with the final criterion that required eligible professionals to 

report on at least 1 outcome measure, we required that an entity possess at least 1 outcome 

measure for which its participating eligible professionals may report (78 FR 74470). As we 

explain in further detail in section III.K. of this proposed rule, we are proposing that an eligible 

professional wishing to meet the proposed criterion for satisfactory participation in a QCDR for 

the 2017 PQRS payment adjustment report on at least 3 outcome measures (or if less than 3 

outcome measures are available for reporting, report on at least 2 outcome measures and at least 

1 of the following types of measures: resource use; patient experience of care; or 

efficiency/appropriate use). Accordingly, we are proposing to amend the requirement for the 

2017 PQRS payment adjustment to require a QCDR to possess at least 3 outcome measures (or, 

in lieu of 3 outcome measures, at least 2 outcome measures and at least 1 of the following other 

types of measures - resource use, patient experience of care, or efficiency/appropriate use). 

To establish the minimum number of measures (9 measures covering at least 3 NQS 

domains) a QCDR may report for the PQRS, we placed a limit on the number of non-PQRS 

measures (20) that a QCDR may submit on behalf of an eligible professional at this time (78 FR 

74476). Although we believe such a limit is still necessary because the QCDR option is still new 

and we are still gaining familiarity with the measures available for reporting under the QCDRs, 

we believe it is appropriate to increase the number of non-PQRS that may be reported by 

QCDRs. We have received comments from entities currently undergoing the QCDR 

qualification process who wish to submit data on additional measures and we believe that 
 274 

accepting additional quality measures data is important, as it provides a better and more 

complete picture of the quality of care provided by eligible professionals. Therefore, we are 

proposing to change this limit from 20 measures to 30. In other words, beginning with the 

criteria for satisfactory participation for the 2017 PQRS payment adjustment, a QCDR may 

submit quality measures data for a maximum of 30 non-PQRS measures. Please note that this 

proposed limit does not apply to measures contained in the PQRS measure set, as QCDRs can 

report on as many measures in the PQRS measure set as they wish. 

Additionally, CMS’ experience during the 2014 self-nomination process shed light on 

clarifications needed on what is considered a non-PQRS measure. Therefore, to clarify the 

definition of non-PQRS measures, we propose the following parameters for a measure to be 

considered a non-PQRS measure: 

● A measure that is not contained in the PQRS measure set for the applicable reporting 

period. 

● A measure that may be in the PQRS measure set but has substantive differences in the 

manner it is reported by the QCDR. For example, PQRS measure 319 is reportable only via the 

GPRO web interface. A QCDR wishes to report this measure on behalf of its eligible 

professionals. However, as CMS has only extracted the data collected from this quality measure 

using the GPRO web interface, in which CMS utilizes a claims-based assignment and sampling 

methodology to inform the groups on which patients they are to report, the reporting of this 

measure would require changes to the way that the measure is calculated and reported to CMS 

via a QCDR instead of through the GPRO web interface. Therefore, due to the substantive 

changes needed to report this measure via a QCDR, PQRS measure 319 would be considered a 

non-PQRS measure. In addition, CAHPS for PQRS is currently reportable only via a CMScertified survey vendor. However, although CAHPS for PQRS is technically contained in the 
 275 

PQRS measure set, we consider the changes that will need to be made to be available for 

reporting by individual eligible professionals (and not as a part of a group practice) significant 

enough as to treat CAHPS for PQRS as a non-PQRS measure for purposes of reporting CAHPS 

for PQRS via a QCDR. 

Furthermore, under our authority to establish the requirements for an entity to be 

considered a QCDR under section 1848(m)(3)(E)(i) of the Act, we established certain 

requirements for an entity to be considered a QCDR in the CY 2014 PFS final rule with 

comment period (78 FR 74467 through 74473). Under this same authority, we are proposing 

here to add the following requirement that an entity must meet to serve as a QCDR under the 

PQRS for reporting periods beginning in 2015: 

● Require that the entity make available to the public the quality measures data for 

which its eligible professionals report. 

In the CY 2014 PFS proposed rule, we proposed that, to be considered a QCDR, an entity 

would be required to demonstrate that it has a plan to publicly report its quality data through a 

mechanism where the public and registry participants can view data about individual eligible 

professionals, as well as view regional and national benchmarks (78 FR 43363). Due to 

stakeholder feedback against this proposal, as well as comments requesting more details 

surrounding this proposal, we did not finalize this proposed requirement in the CY 2014 PFS 

final rule with comment period. However, we noted that we would revisit this proposal in future 

years (78 FR 74471). Because of our ongoing interest in providing transparency to the public for 

quality measures data that is reported under the PQRS, we again propose the requirement that an 

entity make available to the public the quality measures data for which its eligible professionals 

report. To clarify this proposal, we propose that, at a minimum, the QCDR publicly report the 
 276 

following quality measures data information that we believe will give patients adequate 

information on the care provided by an eligible professional: 

● The title and description of the measures that a QCDR reports for purposes of the 

PQRS, as well as the performance results for each measure the QCDR reports. 

With respect to when the quality measures data must be publicly reported, we propose 

that the QCDR must have the quality measures data by April 31 of the year following the 

applicable reporting period (that is, April 31, 2016, for reporting periods occurring in 2015). The 

proposed deadline of April 31 will provide QCDRs with one month to post quality measures data 

and information following the March 31 deadline for the QCDRs to transmit quality measures 

data for purposes of the PQRS payment adjustments. We also propose that this data be available 

on a continuous basis and be continuously updated as the measures undergo changes in measure 

title and description, as well as when new performance results are calculated. 

Please note that, in making this proposal, we defer to the entity in terms of the method it 

will use to publicly report the quality measures data it collects for the PQRS. For example, to 

meet this proposed requirement, it would be sufficient for a QCDR to publicly report 

performance rates of eligible professionals through means such as, but not excluding, board or 

specialty websites, performance or feedback reports, or listserv dashboards or announcements. 

We also note that a QCDR would meet this public reporting requirement if the QCDR’s 

measures data were posted on Physician Compare. In addition, we defer to the QCDR to 

determine whether to report performance results at the individual eligible professional level or 

aggregate the results for certain sets of eligible professionals who are in the same practice 

together (but we are not registered as a group practice for the purposes of PQRS reporting). We 

believe it is appropriate to allow a QCDR to publicly report performance results at an aggregate 
 277 

level for certain eligible professionals when those who are in the same practice contribute to the 

overall care provided to a patient. 

Based on CMS experience with the qualifying entities wishing to become QCDRs for 

reporting periods occurring in 2014, we received feedback from many organizations who 

expressed concern that the entity wishing to become a QCDR may not meet the requirements of 

a QCDR solely on its own. Therefore, we provide the following proposals beginning in 2015 on 

situations where an entity may not meet the requirements of a QCDR solely on its own but, in 

conjunction with another entity, may be able to meet the requirements of a QCDR and therefore 

be eligible for qualification: 

● We propose to allow that an entity that uses an external organization for purposes of 

data collection, calculation or transmission may meet the definition of a QCDR so long as the 

entity has a signed, written agreement that specifically details the relationship and 

responsibilities of the entity with the external organizations effective as of January 1 the year 

prior to the year for which the entity seeks to become a QCDR (for example, January 1, 2014, to 

be eligible to participate for purposes of data collected in 2015). We are adding this proposal 

because we received questions from entities wishing to become QCDRs who are engaged in 

quality improvement activities but use an external organization for purposes of quality measures 

data collection, calculation, and transmission. We believe that it may be appropriate to classify 

the entity as a QCDR so long as the entity meets the definition of a QCDR by the date for which 

we require that a QCDR must be in existence (that is, January 1 the year prior to the year for 

which the entity seeks to become a QCDR (78 FR 74467)). Entities that have a mere verbal, 

non-written agreement to work together to become a QCDR by January 1 the year prior to the 

year for which the entity seeks to become a QCDR would not fulfill this proposed requirement. 
 278 

● In addition, we propose that an entity that has broken off from a larger organization 

may be considered to be in existence for the purposes of QCDR qualification as of the earliest 

date the larger organization begins continual existence. We received questions from entities who 

used to be part of a larger organization but have recently become independent from the larger 

organization as to whether the entities would meet the requirement established in the CY 2014 

PFS final rule with comment period that the entity be in existence as of January 1 the year prior 

to the year for which the entity seeks to become a QCDR (78 FR 74467). For example, a 

registry that was previously a part of a larger medical society as of January 1, 2013, could have 

broken off from the medical society and become an independent registry in 2014. Likewise, a 

member of a medical society could create a registry separate from the medical society. As such, 

there would be concern as to whether that entity would meet the requirement of being in 

existence prior to January 1, 2013, to be considered for qualification for reporting periods 

occurring in 2014. In these examples, for purposes of meeting the requirement that the entity be 

in existence as of January 1 the year prior to the year for which the entity seeks to become a 

QCDR, we may consider this entity as being in existence as of the date the larger medical society 

was in existence. 

 In the CY 2014 PFS final rule with comment period, in accordance with the submission 

deadline of quality measures data for qualified registries, we noted a deadline of the last Friday 

in February occurring after the end of the applicable reporting period to submit quality measures 

data to CMS (78 FR 74471). In accordance with our proposal to extend this deadline for 

qualified registries, we propose to extend the deadline for QCDRs to submit quality measures 

data calculations and results by March 31 following the end of the applicable reporting period 

(that is, March 31, 2016, for reporting periods occurring in 2015). 
 279 

Additionally, we seek comment on whether to propose in future rulemaking to allow 

more frequent submissions of data, such as quarterly or year-round submissions, rather than 

having only one opportunity to submit quality measures data as is our current process. 

We seek public comment on these proposed changes to the requirements for the QCDR. 

d. Proposed Changes to the GPRO Web Interface 

In the CY 2014 PFS final rule with comment period (78 FR 74456), we finalized our 

proposal to require “that group practices register to participate in the GPRO by September 30 of 

the year in which the reporting period occurs (that is September 30, 2014 for reporting periods 

occurring in 2014), as proposed.” However, we noted that, in order “to respond to the 

commenters concerns to provide timelier feedback on performance on CG CAHPS in the future, 

we anticipate proposing an earlier deadline for group practices to register to participate in the 

GPRO in future years” (78 FR 74456). Indeed, to provide timelier feedback on performance on 

CAHPS for PQRS, we propose to modify the deadline that a group practice must register to 

participate in the GPRO to June 30 of the year in which the reporting period occurs (that is, June 

30, 2015, for reporting periods occurring in 2015). Although this proposed GPRO registration 

deadline would provide less time for a group practice to decide whether to participate in the 

GPRO, we believe the benefit of providing timelier feedback reports outweighs this concern. 

Furthermore, we seek comment on whether to allow more frequent submissions of data, 

such as quarterly or year-round submissions, rather than having only one opportunity to submit 

quality measures data as is our current process. 

We seek public comment on these proposals. 

2. Proposed Criteria for the Satisfactory Reporting for Individual Eligible Professionals for the 

2017 PQRS Payment Adjustment 
 280 

Section 1848(a)(8) of the Act, as added by section 3002(b) of the Affordable Care Act, 

provides that for covered professional services furnished by an eligible professional during 2015 

or any subsequent year, if the eligible professional does not satisfactorily report data on quality 

measures for covered professional services for the quality reporting period for the year, the fee 

schedule amount for services furnished by such professional during the year (including the fee 

schedule amount for purposes of determining a payment based on such amount) shall be equal to 

the applicable percent of the fee schedule amount that would otherwise apply to such services. 

For 2016 and subsequent years, the applicable percent is 98.0 percent. 

a. Proposed Criterion for the Satisfactory Reporting of Individual Quality Measures via Claims 

and Registry for Individual Eligible Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2014 PFS final rule with comment period (see Table 47 at 78 FR 74479), we 

finalized the following criteria for satisfactory reporting for the submission of individual quality 

measures via claims and registry for the 2014 PQRS incentive: For the 12-month reporting 

period for the 2014 PQRS incentive, the eligible professional would report at least 9 measures, 

covering at least 3 of the NQS domains, OR, if less than 9 measures apply to the eligible 

professional, report 1—8 measures, AND report each measure for at least 50 percent of the 

Medicare Part B FFS patients seen during the reporting period to which the measure applies. 

Measures with a 0 percent performance rate would not be counted. For an eligible professional 

who reports fewer than 9 measures covering less than 3 NQS domains via the claims- or registrybased reporting mechanism, the eligible professional would be subject to the measure application 

validity (MAV) process, which would allow us to determine whether the eligible professional 

should have reported quality data codes for additional measures. 

To be consistent with the satisfactory reporting criterion we finalized for the 2014 PQRS 

incentive, we are proposing to modify §414.90(j) and propose the following criterion for 
 281 

individual eligible professionals reporting via claims and registry: For the 12-month reporting 

period for the 2017 PQRS payment adjustment, the eligible professional would report at least 9 

measures, covering at least 3 of the NQS domains AND report each measure for at least 50 

percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to which the measure applies. Of the measures reported, if the eligible professional sees 

at least 1 Medicare patient in a face-to-face encounter, as we propose to define that term below, 

the eligible professional would report on at least 2 measures contained in the proposed crosscutting measure set specified in Table 21. If less than 9 measures apply to the eligible 

professional, the eligible professional would report up to 8 measure(s), AND report each 

measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting 

period to which the measure applies. Measures with a 0 percent performance rate would not be 

counted. 

We note that, unlike the criterion we finalized for the 2014 PQRS incentive, we are 

proposing to require an eligible professional who sees at least 1 Medicare patient in a face-toface encounter, as we propose to define that term below, during the 12-month 2017 PQRS 

payment adjustment reporting period to report at least 2 measures contained in the proposed 

cross-cutting measure set specified in Table 21. As we noted in the CY 2014 PFS proposed rule 

(78 FR 43359), we are dedicated to collecting data that provides us with a better picture of the 

overall quality of care furnished by eligible professionals, particularly for the purpose of having 

PQRS reporting being used to assess quality performance under the VM. We believe that 

requiring an eligible professional to report on at least 2 broadly applicable, cross-cutting 

measures will provide us with quality data on more varied aspects of an eligible professional’s 

practice. We also note that in its 2014 pre-rulemaking final report (available at 

http://www.qualityforum.org/Publications/2014/01/MAP_Pre-
 282 

Rulemaking_Report__2014_Recommendations_on_Measures_for_More_than_20_Federal_Prog

rams.aspx), the Measure Applications Partnership (MAP) encouraged the development of a core 

measure set (see page 16 of the “MAP Pre-Rulemaking Report: 2014 Recommendations on 

Measures for More than 20 Federal Programs”). The MAP stated “a core [measure set] would 

address critical improvement gaps, align payment incentives across clinician types, and reduce 

reporting burden.” 

For what defines a “face-to-face” encounter, for purposes of proposing to require 

reporting of at least 2 cross-cutting measures specified in Table 21, we propose to determine 

whether an eligible professional had a “face-to-face” encounter by seeing whether the eligible 

professional billed for services under the PFS that are associated with face-to-face encounters, 

such as whether an eligible professional billed general office visit codes, outpatient visits, and 

surgical procedures. We would not include telehealth visits as face-to-face encounters for 

purposes of the proposals require reporting of at least 2 cross-cutting measures specified in Table 

21. 

In addition, we understand that there may be instances where an eligible professional may 

not have at least 9 measures applicable to an eligible professional’s practice. In this instance, 

like the criterion we finalized for the 2014 PQRS incentive (see Table 47 at 78 FR 74479), an 

eligible professional reporting on less than 9 measures would still be able to meet the satisfactory 

reporting criterion via claims and registry if the eligible professional reports on 1-8 measures, as 

applicable, to the eligible professional’s practice. If an eligible professional reports on 1-8 

measures, the eligible professional would be subject to the MAV process, which would allow us 

to determine whether an eligible professional should have reported quality data codes for 

additional measures. In addition, the MAV will also allow us to determine whether a group 

practice should have reported on any of the proposed cross-cutting measures specified in Table 
 283 

21. The MAV process we are proposing to implement for claims and registry is the same 

process that was established for reporting periods occurring in 2014 for the 2014 PQRS 

incentive. For more information on the claims MAV process, please visit 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013

.zip. For more information on the registry MAV process, please visit 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_1213201

3.zip. 

We seek public comment on our proposed satisfactory reporting criterion for individual 

eligible professionals reporting via claims or registry for the 2017 PQRS payment adjustment. 

b. Proposed Criterion for Satisfactory Reporting of Individual Quality Measures via EHR for 

Individual Eligible Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2013 PFS final rule with comment period, we finalized the following criterion 

for the satisfactory reporting for individual eligible professionals reporting individual measures 

via a direct EHR that is CEHRT or an EHR data submission vendor that is CEHRT for the 2014 

PQRS incentive: Report 9 measures covering at least 3 of the NQS domains. If an eligible 

professional's CEHRT does not contain patient data for at least 9 measures covering at least 3 

domains, then the eligible professional must report all of the measures for which there is 

Medicare patient data. An eligible professional must report on at least 1 measure for which there 

is Medicare patient data (see Table 47 at 78 FR 74479). 

To be consistent with the criterion we finalized for the 2014 PQRS incentive, as well as 

to continue to align with the final criterion for meeting the clinical quality measure (CQM) 

component of achieving meaningful use under the Medicare EHR Incentive Program, we are 
 284 

proposing to modify §414.90(j) and propose the following criterion for the satisfactory reporting 

for individual eligible professionals to report individual measures via a direct EHR that is 

CEHRT or an EHR data submission vendor that is CEHRT for the 2017 PQRS payment 

adjustment: The eligible professional would report 9 measures covering at least 3 of the NQS 

domains. If an eligible professional's CEHRT does not contain patient data for at least 9 

measures covering at least 3 domains, then the eligible professional would be required to report 

all of the measures for which there is Medicare patient data. An eligible professional would be 

required to report on at least 1 measure for which there is Medicare patient data. 

We seek public comment on this proposal. 

c. Proposed Criterion for Satisfactory Reporting of Measures Groups via Registry for Individual 

Eligible Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2013 PFS final rule with comment period, we finalized the following criterion 

for the satisfactory reporting for individual eligible professionals to report measures groups via 

registry for the 2014 PQRS incentive: For the 12-month reporting period for the 2014 PQRS 

incentive, report at least 1 measures group AND report each measures group for at least 20 

patients, the majority (11 patients) of which must be Medicare Part B FFS patients. Measures 

groups containing a measure with a 0 percent performance rate will not be counted (see Table 47 

at 78 FR 74479). 

To be consistent with the criterion we finalized for the 2014 PQRS incentive, we are 

proposing to modify §414.90(j) to indicate the following criterion for the satisfactory reporting 

for individual eligible professionals to report measures groups via registry for the 2017 PQRS 

payment adjustment: For the 12-month reporting period for the 2017 PQRS payment 

adjustment, the eligible professional would report at least 1 measures group AND report each 

measures group for at least 20 patients, the majority (11 patients) of which would be required to 
 285 

be Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 

performance rate would not be counted. 

Although we are proposing satisfactory reporting criterion for individual eligible 

professionals to report measures groups via registry for the 2017 PQRS payment adjustment that 

is consistent with criterion finalized for the 2014 PQRS incentive, please note, however, in this 

section III.K of this proposed rule, we are proposing to change the definition of a PQRS 

measures group. 

We seek public comment on our proposed satisfactory reporting criterion for individual 

eligible professionals reporting measures groups via registry for the 2017 PQRS payment 

adjustment. 

3. Satisfactory Participation in a QCDR by Individual Eligible Professionals 

Section 601(b) of the ATRA amended section 1848(m)(3) of the Act, by redesignating 

subparagraph (D) as subparagraph (F) and adding new subparagraphs (D) and (E), to provide for 

a new standard for individual eligible professionals to satisfy the PQRS beginning in 2014, based 

on satisfactory participation in a QCDR. 

a. Proposed Criterion for the Satisfactory Participation for Individual Eligible Professionals in a 

QCDR for the 2017 PQRS Payment Adjustment 

Section 1848(a)(8) of the Act provides that for covered professional services furnished by 

an eligible professional during 2015 or any subsequent year, if the eligible professional does not 

satisfactorily report data on quality measures for covered professional services for the quality 

reporting period for the year, the fee schedule amount for services furnished by such professional 

during the year shall be equal to the applicable percent of the fee schedule amount that would 

otherwise apply to such services. For 2016 and subsequent years, the applicable percent is 98.0 

percent. 
 286 

Section 1848(m)(3)(D) of the Act, as added by section 601(b) of the ATRA, authorizes 

the Secretary to treat an individual eligible professional as satisfactorily submitting data on 

quality measures under section 1848(m)(3)(A) of the Act if, in lieu of reporting measures under 

section 1848(k)(2)(C) of the Act, the eligible professional is satisfactorily participating in a 

QCDR for the year. “Satisfactory participation” is a new standard under the PQRS and is a 

substitute for the underlying standard of “satisfactory reporting” data on covered professional 

services that eligible professionals must meet to avoid the PQRS payment adjustment. 

Currently, §414.90(e)(2) states that individual eligible professionals must be treated as 

satisfactorily reporting data on quality measures if the individual eligible professional 

satisfactorily participates in a QCDR. 

In the CY 2014 PFS final rule with comment period, although we finalized satisfactory 

participation criteria for the 2016 PQRS payment adjustment that are less stringent than the 

satisfactory participation criteria we finalized for the 2014 PQRS incentive, we noted that it was 

“our intention to fully move towards the reporting of 9 measures covering at least 3 domains to 

meet the criteria for satisfactory participation for the 2017 PQRS payment adjustment” (78 FR 

74477). Specifically, we finalized the following two criteria for the satisfactory participation in a 

QCDR for the 2014 PQRS incentive at §414.90(i)(3): For the 12-month 2014 reporting period, 

report at least 9 measures available for reporting under the QCDR covering at least 3 of the NQS 

domains, and report each measure for at least 50 percent of the eligible professional’s applicable 

patients. Of the measures reported via a QCDR, the eligible professional must report on at least 

1 outcome measure. 

To be consistent with the number of measures reported for the satisfactory participation 

criterion we finalized for the 2014 PQRS incentive, for purposes of the 2017 PQRS payment 

adjustment (which would be based on data reported during the 12-month period that falls in CY 
 287 

2015), we propose to modify §414.90(k) to add the following criteria for individual eligible 

professionals to satisfactorily participate in a QCDR for the 2017 PQRS payment adjustment: 

For the 12-month reporting period for the 2017 PQRS payment adjustment, the eligible 

professional would report at least 9 measures available for reporting under a QCDR covering at 

least 3 of the NQS domains, AND report each measure for at least 50 percent of the eligible 

professional’s patients. Of these measures, the eligible professional would report on at least 3 

outcome measures, OR, if 3 outcomes measures are not available, report on at least 2 outcome 

measures and at least 1 of the following types of measures – resource use, patient experience of 

care, or efficiency/appropriate use. 

Unlike the satisfactory participation criteria that were established for the 2014 PQRS 

incentive, we are proposing to modify §414.90(k)(4) to require that an eligible professional 

report on not only 1 but at least 3 outcome measures (or, 2 outcome measures and at least 1 

resource use, patient experience of care, or efficiency/appropriate use if 3 outcomes measures are 

not available). We are proposing this increase because it is our goal to, when appropriate, move 

towards the reporting of more outcome measures. We believe the reporting of outcome 

measures (for example, unplanned hospital readmission after a procedure) better captures the 

quality of care an eligible professional provides than, for example, process measures (for 

example, whether a Hemoglobin A1c test was performed for diabetic patients). In establishing 

this proposal, we understand that a QCDR may not have 3 outcomes measures within its quality 

measure data set. Therefore, as an alternative to a third outcome measure, we are allowing an 

eligible professional to report on at least 1 resource use, patient experience of care, or 

efficiency/appropriate use measure in lieu of an outcome measure. 

We seek public comment on these proposals. 
 288 

4. Proposed Criteria for Satisfactory Reporting for Group Practices Selected to Participate in the 

Group Practice Reporting Option (GPRO) 

In lieu of reporting measures under section 1848(k)(2)(C) of the Act, section 

1848(m)(3)(C) of the Act provides the Secretary with the authority to establish and have in place 

a process under which eligible professionals in a group practice (as defined by the Secretary) 

shall be treated as satisfactorily submitting data on quality measures. Accordingly, this section 

III.K.4 contains our proposed satisfactory reporting criteria for group practices selected to 

participate in the GPRO. Please note that, for a group practice to participate in the PQRS GPRO 

in lieu of participating as individual eligible professionals, a group practice is required to register 

to participate in the PQRS GPRO. For more information on GPRO participation, please visit 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html. For more information on 

registration, please visit http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Self-Nomination-Registration.html. 

In the CY 2014 PFS final rule with comment period, we established a deadline of 

September 30 of the applicable reporting period (that is, September 30, 2014, for reporting 

periods occurring in 2014) for a group practice to register to participate in the GPRO (78 FR 

74456). While we still seek to provide group practices with as much time as feasible to decide 

whether to register to participate in the PQRS as a GPRO, we weigh this priority with others, 

such as our desire to provide more timely feedback to participants of the PQRS, as well as other 

CMS quality reporting programs such as the VM. Since participation in the VM is tied to PQRS 

participation as discussed in section III.N. of this proposed rule, we have found that having a 

GPRO registration deadline so late in time would not allow us to collect information related to 

group practice participation in time to provide PQRS and VM participants with feedback reports 
 289 

earlier in time. Therefore, in an effort to provide timelier feedback, we are proposing to change 

the deadline by which a group practice must register to participate in the GPRO to June 30 of the 

applicable 12-month reporting period (that is, June 30, 2015, for reporting periods occurring in 

2015). This proposed change would allow us to provide timelier feedback while still providing 

group practices with over 6 months to determine whether they should participate in the PQRS 

GPRO or, in the alternative, participate in the PQRS as individual eligible professionals. We 

invite public comment on this proposal. 

a. Proposed Criteria for Satisfactory Reporting on PQRS Quality Measures Via the GPRO Web 

Interface for the 2017 PQRS Payment Adjustment 

Consistent with the group practice reporting requirements under section 1848(m)(3)(C) of 

the Act, we propose to modify §414.90(j) to incorporate the following criterion for the 

satisfactory reporting of PQRS quality measures for group practices registered to participate in 

the GPRO for the 12-month reporting period for the 2017 PQRS payment adjustment using the 

GPRO web interface for groups practices of 25–99 eligible professionals: The group practice 

would 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 the group practice would report on 100 percent of assigned 

beneficiaries. In other words, we understand that, in some instances, the sampling methodology 

CMS provides will not be able to assign at least 248 patients on which a group practice may 

report, particularly those group practices on the smaller end of the range of 25–99 eligible 

professionals. If the group practice is assigned less than 248 Medicare beneficiaries, then the 

group practice would report on 100 percent of its assigned beneficiaries. A group practice would 

be required to report on at least 1 measure for which there is Medicare patient data. 
 290 

In addition, we propose to modify §414.90(j) to incorporate the following criteria for the 

satisfactory reporting of PQRS quality measures for group practices that registered to participate 

in the GPRO for the 12-month reporting period for the 2017 PQRS payment adjustment using 

the GPRO web interface for groups practices of 100 or more eligible professionals: The group 

practice would report all CAHPS for PQRS survey measures via a certified survey vendor. In 

addition, the group practice would report on all measures included in the GPRO 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 the group practice would report 

on 100 percent of assigned beneficiaries. A group practice would be required to report on at 

least 1 measure for which there is Medicare patient data. 

To maintain consistency in this reporting criteria, we note that this proposed criteria is 

similar to the criterion we finalized for the satisfactory reporting of PQRS quality measures for 

group practices selected to participate in the GPRO for the 12-month reporting periods for the 

2013 and 2014 PQRS incentives for group practices of 100 or more eligible professionals in the 

CY 2013 PFS final rule with comment period (see Table 49 at 78 FR 74486). However, we are 

proposing to reduce the patient sample size a group practice is required to report quality 

measures data from 411 to 248. We examined the sample size of this reporting criterion and 

determined that the sample size we are proposing reduces provider reporting burden while still 

allowing for statistically valid and reliable performance results. For the 25-99 sized groups 

reporting via the web interface, we recognize the proposal to move from reporting 218 to 248 

patients per sample represents a slight increase in reporting. However, based on experience with 

the 218 count and subsequent statistical analysis, we believe that there are increased performance 

reliabilities and validities gained when changing the minimum reporting requirement to 248. We 
 291 

believe statistical reliability and validity is extremely important when measuring provider 

performance, particularly given the implications of the Physician VM and Physician Compare 

public reporting, discussed in section III.N and section III.J respectively. Therefore, we believe 

this proposed criterion improves on the criterion previously finalized. 

For assignment of patients for group practices reporting via the GPRO web interface, in 

previous years, we have aligned with the Medicare Shared Savings Program methodology of 

beneficiary assignment (see 77 FR 69195). We note that, in section III.N. of this proposed rule, 

we are proposing to use a beneficiary attribution methodology for the VM for the claims-based 

quality measures and cost measures that is slightly different from the Medicare Shared Savings 

Program methodology, namely (1) eliminating the primary care service pre-step that is statutorily 

required for the Shared Savings Program and (2) including NPs, PA, and CNSs in step 1 rather 

than in step 2 of the attribution process. We believe that aligning with the VM’s proposed 

method of attribution is appropriate, as the VM is directly tied to participation in the PQRS. 

Therefore, to achieve further alignment with the VM and for the reasons proposed in section 

III.N., we propose to adopt the attribution methodology changes proposed for the VM into the 

GPRO web interface beneficiary assignment methodology. 

In addition, we note that, in the past, we have not provided guidance on those group 

practices that choose the GPRO web interface to report PQRS quality measures but have seen no 

Medicare patients for which the GPRO measures are applicable, or if they have no (i.e., 0 

percent) responses for a particular module or measure. Since we are moving solely towards the 

implementation of PQRS payment adjustments, we seek to clarify this scenario here. If a group 

practice has no Medicare patients for which any of the GPRO measures are applicable, the group 

practice will not meet the criteria for satisfactory reporting using the GPRO web interface. 

Therefore, to meet the criteria for satisfactory reporting using the GPRO web interface, a group 
 292 

practice must be assigned and have sampled at least 1 Medicare patient for any of the applicable 

GPRO web interface measures (specified in Table 21). If a group practice does not typically see 

Medicare patients for which the GPRO web interface measures are applicable, we advise the 

group practice to participate in the PQRS via another reporting mechanism. 

We invite public comment on these proposals. 

b. Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group 

Practices Registered To Participate in the GPRO via Registry and EHR for the 2017 PQRS 

Payment Adjustment 

For registry reporting in the GPRO, in the CY 2014 PFS final rule with comment period 

(see Table 49 at 78 FR 74486), we finalized the following satisfactory reporting criteria for the 

submission of individual quality measures via registry for group practices comprised of 2 or 

more eligible professionals in the GPRO for the 2014 PQRS incentive: Report at least 9 

measures, covering at least 3 of the NQS domains, OR, if less than 9 measures covering at least 3 

NQS domains apply to the group practice, report 1—8 measures covering 1-3 NQS domains for 

which there is Medicare patient data, AND report each measure for at least 50 percent of the 

group practice’s Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Measures with a 0 percent performance rate would not be counted. In the CY 

2014 PFS final rule with comment period, we signaled that it was “our intent to ramp up the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment to be on par or more 

stringent than the criteria for satisfactory reporting for the 2014 PQRS incentive” (78 FR 74465). 

Consistent with the criterion finalized for the 2014 PQRS incentive and the group 

practice reporting requirements under section 1848(m)(3)(C) of the Act, for those group 

practices that choose to report using a qualified registry, we propose here to modify §414.90(j) to 

include the following satisfactory reporting criterion via qualified registry for ALL group 
 293 

practices who select to participate in the GPRO for the 2017 PQRS payment adjustment: The 

group practice would report at least 9 measures, covering at least 3 of the NQS domains. Of 

these measures, if a group practice sees at least 1 Medicare patient in a face-to-face encounter, 

the group practice would report on at least 2 measures in the cross-cutting measure set specified 

in Table 21. If less than 9 measures covering at least 3 NQS domains apply to the eligible 

professional, the group practice would report up to 8 measures covering 1-3 NQS domains for 

which there is Medicare patient data, AND report each measure for at least 50 percent of the 

eligible professional’s Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. Measures with a 0 percent performance rate would not be counted. 

As with individual reporting, we understand that there may be instances where a group 

practice may not have at least 9 measures applicable to a group practice’s practice. In this 

instance, like the criterion we finalized for the 2014 PQRS incentive (see Table 49 at 78 FR 

74486), a group practice reporting on less than 9 measures would still be able to meet the 

satisfactory reporting criterion via registry if the group practice reports on as many measures as 

are applicable to the group practice’s practice. If a group practice reports on less than 9 

measures, the group practice would be subject to the MAV process, which would allow us to 

determine whether a group practice should have reported quality data codes for additional 

measures and/or measures covering additional NQS domains. In addition, if a group practice 

does not report on at least 1 cross-cutting measure and the group practice has at least 1 eligible 

professional who sees at least 1 Medicare patient in a face-to-face encounter, the MAV will also 

allow us to determine whether a group practice should have reported on any of the proposed 

cross-cutting measures specified in Table 21. The MAV process we are proposing to implement 

for registry reporting is the same process that was established for reporting periods occurring in 

2014 for the 2014 PQRS incentive. For more information on the registry MAV process, please 
 294 

visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_1213201

3.zip. 

For EHR reporting, consistent with the criterion finalized for the 2014 PQRS incentive 

that aligns with the criteria established for meeting the CQM component of meaningful use under 

the EHR Incentive Program and in accordance with the group practice reporting requirements 

under section 1848(m)(3)(C) of the Act, for those group practices that choose to report using an 

EHR, we propose to modify §414.90(j) to indicate the following satisfactory reporting criterion 

via a direct EHR product that is CEHRT or an EHR data submission vendor that is CEHRT for 

ALL group practices who select to participate in the GPRO for the 2017 PQRS payment 

adjustment: For the 12-month reporting period for the 2017 PQRS payment adjustment, the 

group practice would report 9 measures covering at least 3 domains. If the group practice’s 

CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then 

the group practice must report the measures for which there is patient data. A group practice 

must report on at least 1 measure for which there is Medicare patient data. 

We invite public comment on these proposals. 

c. Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group 

Practices Registered to Participate in the GPRO via a CMS-Certified Survey Vendor for the 2017 

PQRS Payment Adjustment 

In the CY 2014 PFS final rule with comment period, we introduced satisfactory reporting 

criterion for the 2014 PQRS incentive related to reporting the CG CAHPS survey measures via a 

CMS-certified survey vendor (see Table 49 at 78 FR 74486). Consistent with the criterion 

finalized for the 2014 PQRS incentive and the group practice reporting requirements under 

section 1848(m)(3)(C) of the Act, we are proposing the following 3 options (of which a group 
 295 

practice would be able to select 1 out of the 3 options) for satisfactory reporting for the 2017 

PQRS payment adjustment for group practices comprised of 25 or more eligible professionals: 

Proposed Option 1: If a group practice chooses to use a qualified registry, in conjunction 

with reporting the CAHPS for PQRS survey measures, for the 12-month reporting period for the 

2017 PQRS payment adjustment, the group practice would report all CAHPS for PQRS survey 

measures via a certified vendor, and report at least 6 additional measures, outside of CAHPS for 

PQRS, covering at least 2 of the NQS domains using the qualified registry. If less than 6 

measures apply to the group practice, the group practice must report all applicable measures. Of 

these 6 measures, if any eligible professional in the group practice sees at least 1 Medicare 

patient in a face-to-face encounter, the group practice would be required to report on at least 1 

measure in the cross-cutting measure set specified in Table 21. We note that this proposed 

option to report 6 additional measures, including at least 1 cross-cutting measure if a group 

practice sees at least 1 Medicare patient in a face-to-face encounter, is consistent with the 

proposed criterion for satisfactory reporting for the 2017 PQRS payment adjustment via qualified 

registry. However, unlike the proposed criterion for satisfactory reporting for the 2017 PQRS 

payment adjustment via qualified registry without CG-CAHPS, we are only proposing the 

requirement to report 1 measure in the cross-cutting measure set specified in Table 21 instead of 

2 measures as the CAHPS for PQRS measures are contained in the cross-cutting measure set. 

Consistent with the proposed group practice reporting option solely using a qualified 

registry for the 2017 PQRS payment adjustment, we understand that there may be instances 

where a group practice may not have at least 6 measures applicable to a group practice’s 

practice. In this instance, a group practice reporting on less than 6 measures would still be able 

to meet the satisfactory reporting criterion via registry if the group practice reports on as many 

measures as are applicable to the group practice’s practice. If a group practice reports on less 
 296 

than 6 individual measures using the qualified registry reporting mechanism in conjunction with 

a CMS-certified survey vendor to report CAHPS for PQRS, the group practice would be subject 

to a measure application validity process (MAV), which would allow us to determine whether a 

group practice should have reported quality data codes for additional measures and/or measures 

covering additional NQS domains. 

In addition, if a group practice does not report on at least 1 cross-cutting measure and the 

group practice has at least 1 eligible professional who sees at least 1 Medicare patient in a faceto-face encounter, the MAV will also allow us to determine whether a group practice should 

have reported on any of the proposed cross-cutting measures specified in Table 21. The MAV 

process we are proposing to implement for registry reporting is the same process that was 

established for reporting periods occurring in 2014 for the 2014 PQRS incentive. For more 

information on the registry MAV process, please visit http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_1213201

3.zip. 

Proposed Option 2: If a group practice chooses to use a direct EHR product that is 

CEHRT or EHR data submission vendor that is CEHRT in conjunction with reporting the 

CAHPS for PQRS survey measures, for the 12-month reporting period for the 2017 PQRS 

payment adjustment, the group practice would report all CAHPS for PQRS survey measures via 

a certified vendor, and report at least 6 additional measures, outside of CAHPS for PQRS, 

covering at least 2 of the NQS domains using the direct EHR product that is CEHRT or EHR 

data submission vendor that is CEHRT. If less than 6 measures apply to the group practice, the 

group practice must report all applicable measures. Of the additional 6 measures that must be 

reported in conjunction with reporting the CAHPS for PQRS survey measures, a group practice 
 297 

would be required to report on at least 1 measure for which there is Medicare patient data. We 

note that this proposed option to report 6 additional measures is consistent with the proposed 

criterion for satisfactory reporting for the 2017 PQRS payment adjustment via EHR without 

CAHPS for PQRS, since the CAHPS for PQRS survey only addresses 1 NQS domain. 

Proposed Option 3: Alternatively, if a group practice chooses to use the GPRO web 

interface in conjunction with reporting the CAHPS for PQRS survey measures, we propose the 

following criterion for satisfactory reporting for the 2017 PQRS payment adjustment: For the 

12-month reporting period for the 2017 PQRS payment adjustment, the group practice would 

report all CAHPS for PQRS survey measures via a certified vendor. In addition, the group 

practice would report on all measures included in the GPRO 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 the group practice would report on 100 percent of 

assigned beneficiaries. A group practice would be required to report on at least 1 measure for 

which there is Medicare patient data. 

Furthermore, as was required for reporting periods occurring in 2014 (78 FR 74485), we 

propose that all group practices comprised of 100 or more eligible professionals that register to 

participate in the PQRS GPRO, regardless of the reporting mechanism the group practice 

chooses, would be required to select a CMS-certified survey vendor to administer the CAHPS 

for PQRS survey on their behalf. As such, for purposes of meeting the criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment, a group practice participating in the PQRS 

GPRO would be required to use 1 of these 3 proposed reporting options mentioned above. We 

note that, for reporting periods occurring in 2014, we stated that we would administer and fund 

the collection of (CG-CAHPS) data for these groups (of 100 or more eligible professionals using 
 298 

the GPRO web interface that are required to report on CAHPS for PQRS survey measures) (78 

FR 74452). We stated that we would bear the cost of administering the CAHPS for PQRS 

survey measures, as we were requiring the group practices to report on CAHPS for PQRS survey 

measures. Unfortunately, beginning in 2015, it will no longer be feasible for CMS to continue to 

bear the cost of group practices of 100 or more eligible professionals to report the CAHPS for 

PQRS survey measures. Therefore, the group practice would be required to bear the cost of 

administering the CAHPS for PQRS survey measures. 

However, as CAHPS for PQRS was optional for group practices comprised of 25-99 

eligible professionals in 2014 (78 FR 74485) and whereas we are proposing to require reporting 

of CAHPS for PQRS for group practices comprised of 100 or more eligible professionals, we 

propose that CAHPS for PQRS would be optional for groups of 25-99 and 2-24 eligible 

professionals. We note that all group practices that would be required to report or voluntarily 

elect to report CAHPS for PQRS would need to select and pay for a CMS-certified survey 

vendor to administer the CAHPS for PQRS survey on their behalf. 

We invite public comment on these proposals. 

d. Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group 

Practices Selected To Participate in the GPRO to Report the CAHPS for PQRS Survey Measures 

via a CMS-Certified Survey Vendor for the 2018 PQRS Payment Adjustment and Subsequent 

Years 

We believe these patient surveys are important tools for assessing beneficiary experience 

of care and outcomes and, moving forward, we would like to emphasize the importance of 

collecting patient experience of care data through the use of CAHPS for PQRS. Therefore, 

based on our authority under section 1848(m)(3)(C) of the Act to determine the criteria for 

satisfactory reporting for group practices under section 1848(m)(3)(C) of the Act, we are 
 299 

proposing to require that, in conjunction with other satisfactory reporting criteria we establish in 

future years, beginning with the 12-month reporting period for the 2018 PQRS payment 

adjustment, and for subsequent years, group practices comprised of 25 or more eligible 

professionals that are participating in the GPRO report and pay for the collection of the CAHPS 

for PQRS survey measures. We understand that the cost of administering the CAHPS for PQRS 

survey may be significant, so we are proposing this requirement well in advance of the year in 

which it would be first effective in order to provide group practices with early notice so that their 

practices may adjust accordingly. 

We invite public comment on these proposals. 

e. The Consumer Assessment of Healthcare Providers Surgical Care Survey (S-CAHPS) 

In addition to CAHPS for PQRS, we received comments last year supporting the 

inclusion of the Consumer Assessment of Healthcare Providers Surgical Care Survey (SCAHPS). The commenters stated that the CG-CAHPS survey would not accurately reflect the 

care provided by single- or multispecialty surgical or anesthesia groups. The commenters noted 

that S-CAHPS has been tested by the same standards as CG-CAHPS and follows the same 

collection mechanism as the CG-CAHPS. The S-CAHPS expands on the CG-CAHPS by 

focusing on aspects of surgical quality, which are important from the patient’s perspective and 

for which the patient is the best source of information. The survey asks patients to provide 

feedback on surgical care, surgeons, their staff, and anesthesia care. It assesses patients' 

experiences with surgical care in both the inpatient and outpatient settings by asking respondents 

about their experience before, during and after surgery. We agree with the commenters on the 

importance of allowing for the administration of S-CAHPS reporting and wish to allow for 

reporting of S-CAHPS in the PQRS for reporting mechanisms other than the QCDR. However, 

at this time, due to the cost and time it would take to find vendors to collect S-CAHPS data, it is 
 300 

not technically feasible to implement the reporting of the S-CAHPS survey measures for the 

2017 PQRS payment adjustment. We seek comments on how to allow for reporting of the SCAHPS survey measures for the 2018 PQRS payment adjustment and beyond. 

5. Statutory Requirements and Other Considerations for the Selection of PQRS Quality 

Measures for Meeting the Criteria for Satisfactory Reporting for 2015 and Beyond for Individual 

Eligible Professionals and Group Practices 

CMS undergoes an annual Call for Measures that solicits new measures from the public 

for possible inclusion in the PQRS. During the Call for Measures, we request measures for 

inclusion in PQRS that meet the following statutory and non-statutory criteria. 

Sections 1848(k)(2)(C) and 1848(m)(3)(C)(i) of the Act, respectively, govern the quality 

measures reported by individual eligible professionals and group practices under the PQRS. 

Under section 1848(k)(2)(C)(i) of the Act, the PQRS quality measures shall be such measures 

selected by the Secretary from measures that have been endorsed by the entity with a contract 

with the Secretary under section 1890(a) of the Act, which is currently the National Quality 

Forum (NQF). However, in the case of a specified area or medical topic determined appropriate 

by the Secretary for which a feasible and practical measure has not been endorsed by the NQF, 

section 1848(k)(2)(C)(ii) of the Act authorizes the Secretary to specify a measure that is not so 

endorsed as long as due consideration is given to measures that have been endorsed or adopted 

by a consensus organization identified by the Secretary, such as the Ambulatory Quality Alliance 

(AQA). In light of these statutory requirements, we believe that, except in the circumstances 

specified in the statute, each PQRS quality measure must be endorsed by the NQF. Additionally, 

section 1848(k)(2)(D) of the Act requires that for each PQRS quality measure, ‘‘the Secretary 

shall ensure that eligible professionals have the opportunity to provide input during the 

development, endorsement, or selection of measures applicable to services they furnish.” The 
 301 

statutory requirements under section 1848(k)(2)(C) of the Act, subject to the exception noted 

previously, require only that the measures be selected from measures that have been endorsed by 

the entity with a contract with the Secretary under section 1890(a) of the Act (that is, the NQF) 

and are silent as to how the measures that are submitted to the NQF for endorsement are 

developed. 

The basic steps for developing measures applicable to physicians and other eligible 

professionals prior to submission of the measures for endorsement may be carried out by a 

variety of different organizations. We do not believe there need to be special restrictions on the 

type or make-up of the organizations carrying out this basic process of development of physician 

measures, such as restricting the initial development to physician-controlled organizations. Any 

such restriction would unduly limit the basic development of quality measures and the scope and 

utility of measures that may be considered for endorsement as voluntary consensus standards for 

purposes of the PQRS. 

In addition to section 1848(k)(2)(C) of the Act, section 1890A of the Act, which was 

added by section 3014(b) of the Affordable Care Act, requires that the Secretary establish a prerulemaking process under which certain steps occur with respect to the selection of certain 

categories of quality and efficiency measures, one of which is that the entity with a contract with 

the Secretary under section 1890(a) of the Act (that is, the NQF) convene multi-stakeholder 

groups to provide input to the Secretary on the selection of such measures. These categories are 

described in section 1890(b)(7)(B) of the Act, and include such measures as the quality measures 

selected for reporting under the PQRS. In accordance with section 1890A(a)(1) of the Act, the 

NQF convened multi-stakeholder groups by creating the Measure Applications Partnership 

(MAP). Section 1890A(a)(2) of the Act requires that the Secretary must make publicly available 

by December 1st of each year a list of the quality and efficiency measures that the Secretary is 
 302 

considering for selection through rulemaking for use in the Medicare program. The NQF must 

provide CMS with the MAP’s input on the selection of measures by February 1st of each year. 

The lists of measures under consideration for selection through rulemaking in 2014 are available 

at http://www.qualityforum.org/map/. 

As we noted above, section 1848(k)(2)(C)(ii) of the Act provides an exception to the 

requirement that the Secretary select measures that have been endorsed by the entity with a 

contract under section 1890(a) of the Act (that is, the NQF). We may select measures under this 

exception if there is a specified area or medical topic for which a feasible and practical measure 

has not been endorsed by the entity, as long as due consideration is given to measures that have 

been endorsed or adopted by a consensus organization identified by the Secretary. Under this 

exception, aside from NQF endorsement, we requested that stakeholders apply the following 

considerations when submitting measures for possible inclusion in the PQRS measure set: 

● Measures that are not duplicative of another existing or proposed measure. 

● Measures that are further along in development than a measure concept. 

● CMS is not accepting claims-based-only reporting measures in this process. 

● Measures that are outcome-based rather than clinical process measures. 

● Measures that address patient safety and adverse events. 

● Measures that identify appropriate use of diagnosis and therapeutics. 

● Measures that include the NQS domain for care coordination and communication. 

● Measures that include the NQS domain for patient experience and patient-reported 

outcomes. 

● Measures that address efficiency, cost and resource use. 

a. Proposed PQRS Quality Measures 
 303 

Taking into consideration the statutory and non-statutory criteria we described 

previously, this section contains our proposals for the inclusion or removal of measures in PQRS 

for 2015 and beyond. We are classifying all proposed measures against six domains based on 

the NQS’s six priorities, as follows: 

(1) Patient Safety. These are measures that reflect the safe delivery of clinical services in 

all healthcare settings. These measures may address a structure or process that is designed to 

reduce risk in the delivery of healthcare or measure the occurrence of an untoward outcome such 

as adverse events and complications of procedures or other interventions. 

(2) Person and Caregiver-Centered Experience and Outcomes. These are measures that 

reflect the potential to improve patient-centered care and the quality of care delivered to patients. 

They emphasize the importance of collecting patient-reported data and the ability to impact care 

at the individual patient level, as well as the population level. These are measures of 

organizational structures or processes that foster both the inclusion of persons and family 

members as active members of the health care team and collaborative partnerships with 

providers and provider organizations or can be measures of patient-reported experiences and 

outcomes that reflect greater involvement of patients and families in decision making, self-care, 

activation, and understanding of their health condition and its effective management. 

(3) Communication and Care Coordination. These are measures that demonstrate 

appropriate and timely sharing of information and coordination of clinical and preventive 

services among health professionals in the care team and with patients, caregivers, and families 

to improve appropriate and timely patient and care team communication. They may also be 

measures that reflect outcomes of successful coordination of care. 
 304 

 (4) Effective Clinical Care. These are measures that reflect clinical care processes 

closely linked to outcomes based on evidence and practice guidelines or measures of patientcentered outcomes of disease states.

 (5) Community/Population Health. These are measures that reflect the use of clinical and 

preventive services and achieve improvements in the health of the population served. They may 

be measures of processes focused on primary prevention of disease or general screening for early 

detection of disease unrelated to a current or prior condition-. 

(6) Efficiency and Cost Reduction. These are measures that reflect efforts to lower costs 

and to significantly improve outcomes and reduce errors. These are measures of cost, resource 

use and appropriate use of healthcare resources or inefficiencies in healthcare delivery. 

Please note that the PQRS quality measure specifications for any given proposed PQRS 

individual quality measure may differ from specifications for the same quality measure used in 

prior years. For example, for the proposed PQRS quality measures that were selected for 

reporting in 2014 and beyond, please note that detailed measure specifications, including the 

measure’s title, for the proposed individual PQRS quality measures for 2013 and beyond may 

have been updated or modified during the NQF endorsement process or for other reasons. 

In addition, due to our desire to align measure titles with the measure titles that have been 

finalized for 2013, 2014, 2015, and potentially subsequent years of the EHR Incentive Program, 

we note that the measure titles for measures available for reporting via EHR may change. To the 

extent that the EHR Incentive Program updates its measure titles to include version numbers (77 

FR 13744), we will use these version numbers to describe the PQRS EHR measures that will 

also be available for reporting for the EHR Incentive Program. We will continue to work toward 

complete alignment of measure specifications across programs whenever possible. 
 305 

Through NQF’s measure maintenance process, NQF-endorsed measures are sometimes 

updated to incorporate changes that we believe do not substantively change the nature of the 

measure. Examples of such changes could be updated diagnosis or procedure codes or changes 

to exclusions to the patient population or definitions. We believe these types of maintenance 

changes are distinct from substantive changes to measures that result in what are considered new 

or different measures. Further, we believe that non-substantive maintenance changes of this type 

do not trigger the same agency obligations under the Administrative Procedure Act. 

In the CY 2013 PFS final rule with comment period, we finalized our proposal providing 

that if the NQF updates an endorsed measure that we have adopted for the PQRS in a manner 

that we consider to not substantively change the nature of the measure, we would use a 

subregulatory process to incorporate those updates to the measure specifications that apply to the 

program (77 FR 69207). We believe this adequately balances our need to incorporate nonsubstantive NQF updates to NQF-endorsed measures in the most expeditious manner possible, 

while preserving the public’s ability to comment on updates that so fundamentally change an 

endorsed measure that it is no longer the same measure that we originally adopted. We also note 

that the NQF process incorporates an opportunity for public comment and engagement in the 

measure maintenance process. We will revise the Specifications Manual and post notices to 

clearly identify the updates and provide links to where additional information on the updates can 

be found. Updates will also be available on the CMS PQRS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

 CMS is not the measure steward for most of the measures available for reporting under 

the PQRS. We rely on outside measure stewards and developers to maintain these measures. In 

Table 24, we are proposing that certain measures be removed from the PQRS measure set due to 
 306 

the measure owner/developer indicating that it will not be able to maintain the measure. We note 

that this proposal is contingent upon the measure owner/developer not being able to maintain the 

measure. Should we learn that a certain measure owner/developer is able to maintain the 

measure, or that another entity is able to maintain the measure in a manner that allows the 

measure to be available for reporting under the PQRS for the CY 2017 PQRS payment 

adjustment, we propose to keep the measure available for reporting under the PQRS and 

therefore not finalize our proposal to remove the measure. In addition, if, after the display of this 

proposed rule, we discover additional measures within the current PQRS measure set that a 

measure owner/developer can no longer maintain, we propose to remove these measures from 

reporting for the PQRS beginning in 2015. We will discuss any such instances in the CY 2015 

PFS final rule with comment period. 

In addition, we note that we have received feedback from stakeholders, particularly firsttime participants who find it difficult to understand which measures are applicable to their 

particular practice. In an effort to aide eligible professionals and group practices to determine 

what measures best fit their practice, and in collaboration with specialty societies, we are 

beginning to group our final measures available for reporting according to specialty. The current 

listing of our measures by specialty can be found on our website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Please note that these groups of measures are meant to provide 

guidance to those eligible professionals seeking to determine what measures to report. Eligible 

professionals are not required to report measures according to these suggested groups of 

measures. In addition to group measures according to specialty, we also plan to have a measure 

subset for measures that specifically addresses multiple chronic conditions. As measures are 
 307 

adopted or revised, we will continue to update these groups to reflect the measures available 

under the PQRS, as well as add more specialties. 

 In the CY 2014 PFS final rule with comment period, we stated that “unless there are 

errors discovered in updated electronic measure specifications, the PQRS intends to use the most 

recent, updated versions of electronically specified clinical quality measures for that year” (78 

FR 74489). We propose that, if we discover errors in the most recently updated electronic 

measure specifications for a certain measure, we would use the version of electronic measure 

specifications that immediately precedes the most recently updated electronic measure 

specifications. 

Additionally, we noted that, with respect to the following e-measure CMS140v2, Breast 

Cancer Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) 

Positive Breast Cancer (NQF 0387), a substantive error was discovered in the June 2013 version 

of this electronically specified clinical quality measure. Therefore, the PQRS required the use of 

the prior, December 2012 version of this measure, which is CMS140v1 (78 FR 74489). Please 

note that, consistent with other EHR measures, since a more recent and corrected version of this 

measure has been developed, we will require the reporting of the most recent, updated versions 

of the measure Breast Cancer Hormonal Therapy for Stage IC–IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF 0387) – currently version 

CMS140v3 – for the year. 

b. Proposed Cross-Cutting Measure Set for 2015 and Beyond 

In accordance with our proposed criteria for the satisfactory reporting of PQRS measures 

for the 2017 PQRS payment adjustment via claims and registry that requires an eligible 

professional or group practice to report on at least 2 cross-cutting measures, we are proposing the 

following 18 cross-cutting measure set specified in Table 21 for 2015 and beyond. Please note 
 308 

that our rationale for proposing each of these measures is found below the measure description. 

We have also indicated the PQRS reporting mechanism or mechanisms through which each 

proposed measure could be submitted. In addition to seeking comment on this proposed crosscutting measure set specified in Table 21, we seek comment on other measures that commenters 

believe should be included in this proposed cross-cutting measure set for 2015 and beyond. 

TABLE 21: Proposed Individual Quality Cross-Cutting Measures for the PQRS to Be Available for 

Satisfactory Reporting Via Claims, Registry, and EHR Beginning in 2015 

NQF/ 

PQRS 

CMS 

E-Measure 

ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

N/A 

/N/A N/A 

Community

/Population 

Health 

Tobacco Use and Help with Quitting Among 

Adolescents: Percentage of adolescents 13 to 

20 years of age with a primary care visit during 

the measurement period for whom tobacco use 

status was documented and who received help 

quitting if identified as a tobacco user. 

Rationale: CMS is proposing this measure 

based on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This is a preventive 

measure targeting support of adolescent 

populations in quitting smoking, which 

represents a clinical gap in the program.Several 

provider types are able to report this measure in 

a variety of outpatient settings including 

Pediatricians, Family Practice physicians, and 

Internists. This measure is also applicable for a 

broad patient sample further positioning this 

measure as cross-cutting. 

NCQA / 

NCIQM X X 

0028 

/226 

138

v2 

Community

/Population 

Health 

Preventive Care and Screening: Tobacco 

Use: Screening and Cessation Intervention:

Percentage of patients aged 18 years and older 

who were screened for tobacco use one or more 

times within 24 months AND who received 

cessation counseling intervention if identified as 

a tobacco user. 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents a 

screening assessment for tobacco use that most 

eligible professionals may perform and is 

applicable to most adult patients. This measure 

is applicable in various outpatient settings and 

can be reported by most eligible professionals 

that see adult patients. This measure was 

finalized for reporting in the PQRS in the CY 

2014 PFS final rule (see Table 52 at 78 FR 

74498). 

AMAPCPI X X X X X 

ACO 

MU2 

Million 

Hearts 
 309 NQF/ PQRS CMS E-Measure ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

0038 

/240 

117

v2 

Community

/Population 

Health 

Childhood Immunization Status: Percentage 

of children 2 years of age who had four 

diphtheria, tetanus and acellular pertussis 

(DTaP); three polio (IPV), one measles, mumps 

and rubella (MMR); three H influenza type B 

(HiB); three hepatitis B (Hep B); one chicken 

pox (VZV); four pneumococcal conjugate 

(PCV); one hepatitis A (Hep A); two or three 

rotavirus (RV); and two influenza (flu) vaccines 

by their second birthday. 

Rationale: This measure is clincally significant 

for all pediatric patients and is applicable to a 

variety of eligible professionals that provide 

services to pediatric patients making it 

reportable by a large segment of eligible 

professionals.This measure was finalized for 

reporting in the PQRS in the CY 2013 PFS final 

rule (see Table 95 at 77 FR 69215).

NCQA X MU2 

0418 

/134 2v3 

Community

/Population 

Health 

Preventive Care and Screening: Screening 

for Clinical Depression and Follow-Up Plan:

Percentage of patients aged 12 years and older 

screened for clinical depression on the date of 

the encounter using an age appropriate 

standardized depression screening tool AND if 

positive, a follow-up plan is documented on the 

date of the positive screen. 

Rationale: This measure represents a screening 

assessment for depression that most eligible 

professionals may perform and is applicable to 

most adult patients, making it broadly 

reportable as a cross-cutting measure. This 

measure is also applicable in a variety of 

outpatient settings, enhancing the reportability 

of this measure. This measure was finalized for 

reporting in the PQRS in the CY 2013 PFS final 

rule (see Table 95 at 77 FR 69215). 

CMS/QIP X X X X X ACO 

MU2 

0419 

/130 

68v

3 

Patient 

Safety 

Documentation of Current Medications in 

the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the 

eligible professional attests to documenting a 

list of current medications using all immediate 

resources available on the date of the encounter. 

This list must include ALL known 

prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) 

supplements AND must contain the 

medications’ name, dosage, frequency and route 

of administration. 

 

Rationale: This measure targets the 

documentation of current medications in the 

medical record, which is a clinical process that 

most eligible professionals may perform and is 

applicable to most adult patients. This measure 

is also applicable in various outpatient settings. 

For these reasons, this measure is identified as 

cross-cutting.This measure was finalized for 

reporting in the PQRS in the CY 2014 PFS final 

rule (see Table 52 at 78 FR 74498). 

CMS/QIP X X X X X ACO 

MU2 
 310 NQF/ PQRS CMS E-Measure ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

0421 

/128 

69v

2 

Community

/Population 

Health 

Preventive Care and Screening: Body Mass 

Index (BMI) Screening and Follow-Up:

Percentage of patients aged 18 years and older 

with a documented BMI during the current 

encounter or during the previous 6 months AND 

when the BMI is outside of normal parameters, 

a follow-up plan is documented during the 

encounter or during the previous 6 months of 

the encounter. 

Normal Parameters: Age 65 years and older 

BMI ≥ 23 and < 30; Age 18-64 years BMI ≥

18.5 and < 25 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents a 

screening assessment for BMI that most eligible 

professionals may perform and is applicable to 

most adult patients in various outpatient 

settings. This measure was finalized for 

reporting in the PQRS in the CY 2014 PFS final 

rule (see Table 52 at 78 FR 74498). 

CMS/QIP X X X X X ACO 

MU2 

N/A 

/374 

50v

2 

Communica

tion and 

Care 

Coordinatio

n 

Closing the Referral Loop: Receipt of 

Specialist Report: Percentage of patients with 

referrals, regardless of age, for which the 

referring provider receives a report from the 

provider to whom the patient was referred. 

Rationale: This measure represents 

communication between a variety of eligible 

professionals and promotes positive outcomes 

for patients. It is reportable by a broad spectrum 

of providers. In addition,this measure is 

applicable to most adult patients, further 

enhancing its reportability across disciplines 

and speciaties.. This measure was finalized for 

reporting in the PQRS in the CY 2013 PFS final 

rule (see Table 95 at 77 FR 69215). 

CMS/BAH X MU2 

0097 

/046 N/A 

Communica

tion and 

Care 

Coordinatio

n 

Medication Reconciliation: Percentage of 

patients aged 65 years and older discharged 

from any inpatient facility (e.g. hospital, skilled 

nursing facility, or rehabilitation facility) and 

seen within 30 days following discharge in the 

office by the physician, prescribing practitioner, 

registered nurse, or clinical pharmacist 

providing on-going care who had a 

reconciliation of the discharge medications with 

the current medication list in the outpatient 

medical record documented. 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents the 

clinical process of medication reconciliation, 

which most eligible professionals may perform 

and is applicable to most elderly patients in 

various inpatient/outpatient settings, making 

this a broadly reportable measure. This measure 

was finalized for reporting in the PQRS in the 

CY 2013 PFS final rule (see Table 95 at 77 FR 

69215). 

AMAPCPI / 

NCQA 

 X 
 311 NQF/ PQRS CMS E-Measure ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

0041 

/110 

147

v2 

Community

/Population 

Health 

Preventive Care and Screening: Influenza 

Immunization: Percentage of patients aged 6 

months and older seen for a visit between 

October 1 and March 31 who received an 

influenza immunization OR who reported 

previous receipt of an influenza immunization. 

 

Rationale: This measure represents a screening 

assessmentfor influenza immunization that most 

eligible professionals may perform and is 

applicable to most adult and pediatric patients. 

This measure is applicable in various outpatient 

settings.This measure was finalized for 

reporting in the PQRS in the CY 2014 PFS final 

rule (see Table 52 at 78 FR 4498). 

AMAPCPI X X X X X ACO 

MU2 

0043 

/111 

127

v2 

Community

/Population 

Health 

Pneumonia Vaccination Status for Older 

Adults: Percentage of patients 65 years of age 

and older who have ever received a 

pneumococcal vaccine. 

Rationale: This measure represents a screening 

assessment for pneumonia vaccination that most 

eligible professionals may perform and is 

applicable to most elderly patients. This 

measure is also applicable in various outpatient 

settings, which further enhances its reportability 

across various disciplines and specialties. This 

measure was finalized for reporting in the 

PQRS in the CY 2013 PFS final rule (see Table 

95 at 77 FR 69215).

NCQA X X X X X ACO 

MU2 

N/A 

/317 

22v

2 

Community

/Population 

Health 

Preventive Care and Screening: Screening 

for High Blood Pressure and Follow-Up 

Documented: Percentage of patients aged 18 

years and older seen during the reporting period 

who were screened for high blood pressure (BP) 

AND a recommended follow-up plan is 

documented based on the current blood pressure 

reading as indicated. 

Rationale: This measure represents a common 

screening assessment for high blood pressure 

that most eligible professionals perform and is 

applicable to most adult and elderly patients in a 

variety of inpatient/outpatient settings. As such, 

this measure has been identified as crosscutting.This measure was finalized for reporting 

in the PQRS in the CY 2013 PFS final rule (see 

Table 95 at 77 FR 69215).

CMS/QIP X X X X X 

ACO 

MU2 

Million 

Hearts 

0101 

/318 

139

v2 

Patient 

Safety 

Falls: Screening for Fall Risk: Percentage of 

patients 65 years of age and older who were 

screened for future fall risk at least once during 

the measurement period. 

Rationale: This measure represents a fall risk 

screening assessment that most eligible 

professionals may perform and is applicable to 

most elderly patients. This screen tool may be 

commonly used by providers serving this 

patient population in a variety of outpatient 

settings and as such this measure has been 

identified as a cross-cutting measure. This 

measure was finalized for reporting in the 

PQRS in the CY 2013 PFS final rule (see Table 

95 at 77 FR 69215).

NCQA X X ACO 

MU2 
 312 NQF/ PQRS CMS E-Measure ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

0326 

/047 N/A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Care Plan: Percentage of patients aged 65 

years and older who have an care plan or 

surrogate decision maker documented in the 

medical record or documentation in the medical 

record that an care plan was discussed but the 

patient did not wish or was not able to name a 

surrogate decision maker or provide an care 

plan. 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents the 

development of a care plan that most eligible 

professionals may perform and is applicable to 

most elderly patients in various 

inpatient/outpatient settings. This measure was 

finalized for reporting in the PQRS in the CY 

2013 PFS final rule (see Table 95 at 77 FR 

69215).

AMAPCPI / 

NCQA 

X X X 

0420 

/131 N/A 

Communica

tion and 

Care 

Coordinatio

n 

Pain Assessment and Follow-Up: Percentage 

of visits for patients aged 18 years and older 

with documentation of a pain assessment using 

a standardized tool(s) on each visit AND 

documentation of a follow-up plan when pain is 

present. 

Rationale: This measure represents a screening 

assessment for pain and follow-up care that 

most eligible professionals may perform and is 

applicable to most adult patients seen in a 

variety of outpatient settings. For these reasons, 

this measure has been identified as a crosscutting measure. This measure was finalized for 

reporting in the PQRS in the CY 2013 PFS final 

rule (see Table 95 at 77 FR 69215).

CMS/QIP X X X 

AQA 

Adopt

ed 

/182 

N/A 

Communica

tion and 

Care 

Coordinatio

n 

Functional Outcome Assessment: Percentage 

of visits for patients aged 18 years and older 

with documentation of a current functional 

outcome assessment using a standardized 

functional outcome assessment tool on the date 

of encounter AND documentation of a care plan 

based on identified functional outcome 

deficiencies on the date of the identified 

deficiencies. 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents a 

functional assessment that physical 

therapist/chriopratic eligible professionals may 

perform and is applicable to most adult patients. 

This measure was finalized for reporting in the 

PQRS in the CY 2013 PFS final rule (see Table 

95 at 77 FR 69215).

CMS/QIP X X 

0005

&000

6 

/321 

N/A 

Person and 

Caregiver 

Experience 

and 

Outcomes 

CAHPS for PQRS Clinician/Group Survey: 

• Getting timely care, appointments,and 

information; 

• How well providers Communicate; 

• Patient’s Rating of Provider; 

• Access to Specialists; 

• Health Promotion & Education; 

• Shared Decision Making; 

• Health Status/Functional Status; 

• Courteous and Helpful Office Staff; 

• Care Coordination; 

• Between Visit Communication; 

• Helping Your to Take Medication as Directed; 

and 

AHRQ X ACO 
 313 NQF/ PQRS CMS E-Measure ID

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other Quality 

Reporting 

Programs 

• Stewardship of Patient Resources 

Rationale: This measure has been identified as 

an outcome-based cross-cutting measure due to 

it directly measureing patient satisfaction of 

office visits. The data collected by the survey 

provides information based on a group 

practice’s performance of the patient’s care. 

This information potentially impacts a variety of 

eligible professionals based on the survay data 

received from patients. This measure was 

finalized for reporting in the PQRS in the CY 

2013 PFS final rule (see Table 95 at 77 FR 

69215).

0018 

/236 

165

v2 

Effective 

Clinical 

Care 

Controlling High Blood Pressure: Percentage 

of patients 18-85 years of age who had a 

diagnosis of hypertension and whose blood 

pressure was adequately controlled (<140/90 

mmHg) during the measurement period. 

Rationale: This measure has been identified as 

a cross-cutting measure as it represents patient 

care that is clinically appropriate for many 

eligible professionals treating adult patients. 

This measure is applicable to most adult 

patients in various outpatient settings. This 

measure was finalized for reporting in the 

PQRS in the CY 2014 PFS final rule (see Table 

52 at 78 FR 4498).

NCQA X X X X X 

ACO 

MU2 

Million 

Hearts 

N/A/

N/A N/A 

Community

/Population 

Health 

Screening for Hepatitis C Virus (HCV) for 

Patients at High Risk: Percentage of patients 

with one or more of the following: a history of 

injection drug use, patients who received blood 

transfusions prior to 1992, OR patients who 

were born in the years 1945–1965 who received 

a one-time hepatitis C virus (HCV) antibody 

test. 

Rationale: CMS is proposing this measure 

based on our exception authority under I 

848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section I 890(a) of 

the Act (that is, the NQF). This measure is 

complementary of Hepatitis C measures 

currently in the program, representing a clinical 

gap not currently captured by PQRS. This 

measure is also proposed as a cross-cutting 

measure because screening for Hep C is 

applicable for a broad patient sample and a 

variety of eligible professionals in various 

outpatient settings.

AGA / 

AASLD / 

AMAPCPI 

 X 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing 

of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure 

specifications that apply for each of the reporting options/methods for specific measure details. 

c. Proposed New PQRS Measures Available for Reporting for 2015 and Beyond 

Table 22 contains the additional measures we are proposing to include in the PQRS 

measure set for CY 2015 and beyond. Please note that not all of the proposed cross-cutting 
 314 

measures may appear in Table 22, as some of the propose cross-cutting measures specified in 

Table 21 were finalized in the CY 2013 or CY 2014 PFS final rules with comment period. 

Please note that our rationale for proposing each of these measures is found below the measure 

description. We have also indicated the PQRS reporting mechanism or mechanisms through 

which each proposed measure could be submitted. 

TABLE 22: Proposed Individual Quality Measures and Those Included in Measures 

Groups for the PQRS to Be Available for Satisfactory Reporting Beginning in 2015

NQF/ 

PQRS 

CMS 

E-Measure 

ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

187

9 

/N/

A 

N/A Patient Safety 

Adherence to Antipsychotic Medications for 

Individuals with Schizophrenia: The 

percentage of individuals 18 years of age or 

greater as of the beginning of the measurement 

period with schizophrenia or schizoaffective 

disorder who are prescribed an antipsychotic 

medication, with adherence to the antipsychotic 

medication [defined as a Proportion of Days 

Covered (PDC)] of at least 0.8 during the 

measurement period (12 consecutive months). 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorsed. This measure represents a PQRS 

program gap of measures targeting a patient 

population with active psycosis or psychiatric 

disorders. This measure is also reportable by 

behavioral/mental health providers. 

CMS / 

FMQAI X 

N/A 

/N/

A 

N/A Patient Safety 

Adherence to Mood Stabilizers for 

Individuals with Bipolar I Disorder: The 

measure calculates the percentage of individuals 

18 years of age or greater as of the beginning 

ofthe measurement period with bipolar I disorder 

who are prescribed a mood stabilizer medication, 

with adherence to the mood stabilizer medication 

[defined as a Proportion of Days Covered 

(PDC)] of at least 0.8 during the measurement 

period (12 consecutive months). 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a PQRS program gap of measures 

targeting a patient population with active 

psychosis or psychiatric disorders. This measure 

is also reportable by behavioral/mental health 

providers. 

CMS/FMQ

AI X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Adult Primary Rhegmatogenous Retinal 

Detachment Reoperation Rate: % of surgeries 

for primary rhegmatogenous retinal detachment 

where the retina remains attached after only one 

surgery. 

AA X 
 315 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This is an outcome 

measure that represents a new clinical concept 

for PQRS. This measure will be reportable by 

Opthamologists. 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Adult Primary Rhegmatogenous Retinal 

Detachment Surgery Success Rate: Percentage 

(% ) of Retinal Detachment cases achieving flat 

retinas 6 months post surgery. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This is an outcome 

measure that represents a new clinical concept 

for PQRS. This measure will be reportable by 

Opthamologists. 

American 

Association 

of Eye and 

Ear Centers 

of 

Excellence 

/ The 

Australian 

Council on 

Healthcare 

Standards 

 X 

N/A 

/N/

A 

N/A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

ALS Patient Care Preferences: Percentage of 

patients diagnosed with ALS who were offered at 

least once annually assistance in planning for end 

of life issues (e.g., advance directives, invasive 

ventilation, hospice). 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This is a process 

measure that represents a new clinical concept 

for PQRS, filling a current clinical gap in the 

program for neurodegenerative disease. This 

measure would be reportable for eligible 

professionals within the scope of neurology. 

AAN X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Annual Hepatitis C Virus (HCV) Screening 

for Patients who are Active Injection Drug 

Users: Percentage of patients regardless of age 

who are active injection drug users who received 

a hepatitis C virus (HCV) antibody test or HCV 

ribonucleic acid (RNA) test within the 12 month 

reporting period. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

addresses a clinical gap in PQRS by targeting 

active injection drug users. This measure is 

reportable by Gastroenterologists, Hepatologists, 

Infectious Disease providers and Primary Care 

providers. 

AGA / 

AASLD / 

PCPI 

 X 

N/A 

/N/

A 

N/A 

Person and 

CaregiverCentered 

Experience 

Average change in functional status following 

lumbar spine fusion surgery: Average change 

from pre-operative functional status assessment 

to 1 year (9 to 15 months) post-operative 

MNCM X 
 316 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

and 

Outcomes 

functional status using the Oswestry Disability 

Index (ODI version 2.1a) patient reported 

outcome tool. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This outcome measure 

represents a clinical gap in the program and is 

reportable by Neurosurgery and Orthopedic 

Surgery providers. 

N/A 

/N/

A 

N/A 

Efficiency 

and Cost 

Reduction 

Avoidance of inappropriate use of imaging for 

adult ED patients with traumatic low back 

pain: Avoidance of inappropriate use of imaging 

for adult ED patients with atraumatic low back 

pain. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a program gap and targets a provider 

group currently under represented in the 

program, imaging specialists and radiologists.

ACEP X 

N/A 

/N/

A 

N/A Patient Safety 

Cataract Surgery with Intra-Operative 

Complications (Unplanned Rupture of 

Posterior Capsule requiring unplanned 

vitrectomy): Rupture of the posterior capsule 

during anterior segment surgery requiring 

vitrectomy. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This outcome measure 

is reportable by Opthamologists and is proposed 

to be included within the Cataracts Measure 

Group, complementing the existing cataracts 

measures with a clinical focus not currently 

caprtured within PQRS. 

AAEECE / 

ACHS X X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Cataract Surgery: Difference Between 

Planned and Final Refraction: Percentage of 

patients who achieve planned refraction within 

+-1,0 D. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This outcome measure 

is reportable by Opthamologists and is proposed 

to be included within the Cataracts Measure 

Group, complementing the existing catarcts 

measures with a clinical focus not currently 

caprtured within PQRS. 

AAEECE / 

ACHS X X 

188 N/A Person and Depression Response at Twelve Months- MNCM X 
 317 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

5 

/N/

A 

CaregiverCentered 

Experience 

and 

Outcomes 

Progress Towards Remission: Adult patients 

age 18 and older with major depression or 

dysthymia and an initial PHQ-9 score > 9 who 

demonstrate a response to treatment at twelve 

months defined as a PHQ-9 score that is reduced 

by 50% or greater from the initial PHQ-9 score. 

This measure applies to both patients with newly 

diagnosed and existing depression identified 

during the defined measurement period whose 

current PHQ-9 score indicates a need for 

treatment. 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorsed. This measure is an outcome 

measure that complements existing depression 

measures within the program. 

N/A 

/N/

A 

N/A Patient Safety 

Discontinuation of Antiviral Therapy for 

Inadequate Viral Response: Percentage of 

patients aged 18 years and older with a diagnosis 

of hepatitis C genotype 1 who have an 

inadequate response to antiviral treatment for 

whom antiviral treatment was discontinued. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This process measure 

represents a clinical complement to existing 

Hepatitis C measures currently included in the 

program. 

AGA / 

AASLD / 

PCPI 

 X 

N/A 

/N/

A 

N/A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Discussion and Shared Decision Making 

Surrounding Treatment Options: Percentage 

of patients aged 18 years and older with a 

diagnosis of hepatitis C with whom a physician 

or other clinician reviewed the range of treatment 

options appropriate to their genotype and 

demonstrated a shared decision making approach 

with the patient. To meet the measure, there must 

be documentation in the patient record of a 

discussion between the physician/clinician and 

the patient that includes all of the following: 

 • Treatment choices appropriate to genotype 

 • Risks and benefits 

 • Evidence of effectiveness 

 • Patient preferences toward the outcome of 

the treatment. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This patient 

experience measure represents a clinical 

complement to existing Hepatitis C measures 

currently included in the program. This measure 

is proposed to be included within the Hepatitis C 

Measure Group. 

AGA / 

AASLD / 

PCPI 

 X X 

N/A 

/N/

A 

N/A 

Communicati

on and Care 

Coordination 

Follow-up After Hospitalization for Mental 

Illness: The percentage of discharges for 

patients 6 years of age and older who were 

hospitalized for treatment of selected mental 

NCQA X 
 318 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

illness diagnoses and who had an outpatient visit, 

an intensive outpatient encounter or partial 

hospitalization with a mental health practitioner. 

Two rates are reported: 

- The percentage of discharges for which the 

patient received follow-up within 30 days of 

discharge 

- The percentage of discharges for which the 

patient received follow-up within 7 days of 

discharge. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a clinical gap in the program. This 

measure would complement the existing mental 

health clinical concepts within PQRS.

N/A 

/N/

A 

N/A Patient Safety 

HRS-12: Cardiac Tamponade and/or 

Pericardiocentesis Following Atrial 

Fibrillation Ablation: Rate of cardiac 

tamponade and/or pericardiocentesis following 

atrial fibrillation ablation. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a gap in care for patients who receive 

device therapy for heart arrythmia. This 

outcome measure expands upon measures that 

are available for electrophysiologist to report 

within PQRS. At this time, PQRS has one other 

measure, PQRS #348: HRS-3: Implantable 

Cardioverter Defibrillator (ICD) Complications 

Rate, reportable within the scope of 

electrophysiology. 

HRS X 

N/A 

/N/

A 

N/A Patient Safety 

HRS-9: Infection within 180 Days of Cardiac 

Implantable Electronic Device (CIED) 

Implantation, Replacement, or Revision:

Infection rate following CIED device 

implantation, replacement, or revision. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a gap in care for patients who receive 

device therapy for heart arrythmia. This 

outcome measure expands upon measures that 

are available for electrophysiologist to report 

within PQRS. At this time, PQRS has one other 

measure, PQRS #348: HRS-3: Implantable 

Cardioverter Defibrillator (ICD) Complications 

Rate, reportable within the scope of 

electrophysiology.

HRS X 

140

7 N/A Community/P

opulation 

Immunizations for Adolescents: The 

percentage of adolescents 13 years of age who NCQA X 
 319 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

/N/

A 

Health had the recommended immunizations by their 

13th birthday. 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorsed. This measure is a process 

measure that complements existing childhood 

immunication measures already in the program. 

This measure would be reportable by 

Pediatricians, Family Practice physicians, and 

Internists. 

N/A 

/N/

A 

N/A 

Communicati

on and Care 

Coordination 

Lung Cancer Reporting (Biopsy/Cytology 

Specimens): Pathology reports based on biopsy 

and/or cytology specimens with a diagnosis of 

non small cell lung cancer classified into specific 

histologic type or classified as NSCLC-NOS 

with an explanation included in the pathology 

report. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a program gap in measures for the 

pathology specialty. 

CAP X X 

N/A 

/N/

A 

N/A 

Communicati

on and Care 

Coordination 

Lung Cancer Reporting (Resection 

Specimens): Pathology reports based on 

resection specimens with a diagnosis of primary 

lung carcinoma that include the pT category, pN 

category and for non small cell lung cancer, 

histologic type. 

Rationale: We are proposing this measure based 

on our exception authority under section 1848 

(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a program gap in measures for the 

pathology specialty. 

CAP X X 

662 

/N/

A 

N/A 

Communicati

on and Care 

Coordination 

Median Time to Pain Management for Long 

Bone Fracture: Median time from emergency 

department arrival to time of initial oral or 

parenteral pain medication administration for 

emergency department patients with a principal 

diagnosis of long bone fracture (LBF). 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorsed. This outcome measure provides 

alignment across programs and settings and 

addresses a clinical gap in the program. 

CMS/OFM

Q X 

N/A 

/N/

A 

N/A 

Communicati

on and Care 

Coordination 

Melanoma Reporting: Pathology reports for 

primary malignant cutaneous melanoma that 

include the pT category and a statement on 

thickness and ulceration and for pT1, mitotic 

rate. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

CAP X X 
 320 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a program gap in measures for the 

pathology specialty. 

N/A 

/N/

A 

N/A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Optimal Asthma Care- Control Component:

Patients ages 5-50 (pediatrics ages 5-17) whose 

asthma is well-controlled as demonstrated by one 

of three age appropriate patient reported outcome 

tools. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This patient centered 

outcome measure will replace PQRS #064 

(Asthma: Assessment of Asthma ControlAmbulatory Care Setting) as it represents a more 

robust clinical outcome for asthma care. 

MNCM X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Post-procedural Optimal medical therapy 

Composite (percutaneous coronary 

intervention): Percentage of patients aged 18 

years and older for whom PCI is performed who 

are prescribed optimal medical therapy at 

discharge. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a clinical gap in the program for 

patients with percutaneous coronary intervention 

(PCI). This is a new clinical concept proposed 

for reporting within PQRS. 

ACC-AHA X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Recurrence or amputation following 

endovascular infrainquinal lower extremity 

revascularization: Percentage of patients 

undergoing endovascular infrainguinal 

revascularization for non-limb threatening 

ischemia (claudication or asymptomatic) require 

repeat ipsilateral revascularization or any 

amputation within 1 year. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure would 

complement the existing vascular health clinical 

concepts within PQRS. 

SVS X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Recurrence or amputation following open 

infrainquinal lower extremity 

revascularization: Percentage of patients 

undergoing open infrainguinal revascularization 

for non-limb threatening ischemia (claudication 

or asymptomatic) who require ipsilateral repeat 

revascularization or any amputation within 1 

year. 

Rationale: We are proposing this measure based 

SVS X 
 321 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure would 

complement the existing vascular health clinical 

concepts within PQRS. 

N/A 

/N/

A 

N/A 

Community/P

opulation 

Health 

Screening for Hepatitis C Virus (HCV) for 

Patients at High Risk: Percentage of patients 

with one or more of the following: a history of 

injection drug use, patients who received blood 

transfusions prior to 1992, OR patients who were 

born in the years 1945–1965 who received a onetime hepatitis C virus (HCV) antibody test. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure is 

complementary of Hepatitis C measures 

currently in the program, representing a clinical 

gap not currently captured. 

AGA / 

AASLD / 

AMA-PCPI 

 X 

N/A 

/N/

A 

N/A Effective 

Clinical Care 

Screening for Hepatocellular Carcinoma 

(HCC) in patients with Hepatitis C Cirrhosis:

Percentage of patients aged 18 years and older 

with a diagnosis of chronic hepatitis C cirrhosis 

who were screened with either ultrasound, triplecontrast CT or triple-contrast MRI for 

hepatocellular carcinoma (HCC) at least once 

within the 12 month reporting period. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This process, 

screening measure represents a clinical 

complement to existing Hepatitis C measures 

currently included in the program. This measure 

is proposed to be included within the Hepatitis C 

Measure Group. 

AGA / 

AASLD / 

AMA-PCPI 

 X X 

N/A 

/N/

A 

N/A 

Community/P

opulation 

Health 

Tobacco Use and Help with Quitting Among 

Adolescents: Percentage of adolescents 13 to 20 

years of age with a primary care visit during the 

measurement period for whom tobacco use status 

was documented and received help quitting if 

identified as a tobacco user. 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the Secretary 

select measures that have been endorsed by the 

entity with a contract under section 1890(a) of 

the Act (that is, the NQF). This measure 

represents a clinical gap in the program, targeting 

support of adolescent populations in quitting 

smoking. This preventive measure supports 

pediatric patients and is reportable by 

Pediatricians, Family Practice physicians, and 

Internists. This is also a cross cutting measure. 

NCQA / 

NCIQM X X 
 322 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing 

of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure 

specifications that apply for each of the reporting options/methods for specific measure details. 

In Table 23, we specify the measures for which we are proposing a NQS domain change 

for reporting under the PQRS. Please note the rationale we have for each measure for which we 

are proposing a NQS domain change below. 

TABLE 23: Proposed NQS Domain Changes for Individual Quality Measures and Those 

Included in Measures Groups for the PQRS Beginning in 2015

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

009

7/0

46 

N/

A 

Patient 

Safety 

Communi

cation and 

Care 

Coordinat

ion

Medication Reconciliation: Percentage of patients aged 65 

years and older discharged from any inpatient facility (e.g. 

hospital, skilled nursing facility, or rehabilitation facility) and 

seen within 30 days following discharge in the office by the 

physician, prescribing practitioner, registered nurse, or clinical 

pharmacist providing on-going care who had a reconciliation 

of the discharge medications with the current medication list 

in the outpatient medical record documented 

Rationale: CMS is recategorizing this measure from the 

patient safety domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

ensures that the key information needed to make clinical 

decisions is deliberatley organized in a conscious effort and 

available to patients and providers.

 X 

065

0/1

37 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion

Melanoma: Continuity of Care – Recall System: Percentage 

of patients, regardless of age, with a current diagnosis of 

melanoma or a history of melanoma whose information was 

entered, at least once within a 12 month period, into a recall 

system that includes: 

 • A target date for the next complete physical skin exam, 

AND 

 • A process to follow up with patients who either did not 

make an appointment within the specified timeframe or who 

missed a scheduled appointment 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

constitutes the deliberate organization of patient care activities 

to facilitate appropriate delivery of health care services. 

 X 

N/

A/2

88 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion 

Dementia: Caregiver Education and Support: Percentage 

of patients, regardless of age, with a diagnosis of dementia 

whose caregiver(s) were provided with education on dementia 

disease management and health behavior changes AND 

referred to additional sources for support within a 12 month 

period 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

 X 
 323 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

ensures that the key information needed to make clinical 

decisions is deliberatley organized in a conscious effort and is 

available to patients and their caregivers. 

N/

A/2

93 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion 

Parkinson’s Disease: Rehabilitative Therapy Options: All 

patients with a diagnosis of Parkinson’s disease (or 

caregiver(s), as appropriate) who had rehabilitative therapy 

options (e.g., physical, occupational, or speech therapy) 

discussed at least annually 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

ensures that the key information needed to make clinical 

decisions is deliberatley organized in a conscious effort and is 

available to patients and their caregivers. 

 X 

N/

A/2

94 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion 

Parkinson’s Disease: Parkinson’s Disease Medical and 

Surgical Treatment Options Reviewed: All patients with a 

diagnosis of Parkinson’s disease (or caregiver(s), as 

appropriate) who had the Parkinson’s disease treatment 

options (e.g., non-pharmacological treatment, pharmacological 

treatment, or surgical treatment) reviewed at least once 

annually 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

ensures that the key information needed to make clinical 

decisions is deliberatley organized in a conscious effort and is 

available to patients and their caregivers. 

 X 

N/

A/3

25 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion 

Adult Major Depressive Disorder (MDD): Coordination of 

Care of Patients with Specific Comorbid Conditions: 

Percentage of medical records of patients aged 18 years and 

older with a diagnosis of major depressive disorder (MDD) 

and a specific diagnosed comorbid condition (diabetes, 

coronary artery disease, ischemic stroke, intracranial 

hemorrhage, chronic kidney disease [stages 4 or 5], End Stage 

Renal Disease [ESRD] or congestive heart failure) being 

treated by another clinician with communication to the 

clinician treating the comorbid condition 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

ensures that the key information needed to make clinical 

decisions is deliberately organized in a conscious effort and is 

available to patients and providers as well as communicated 

between health care providers. 

 X 

N/

A/3

56 

N/

A 

Effective 

Clinical 

Care 

Communi

cation and 

Care 

Coordinat

ion 

Unplanned Hospital Readmission within 30 Days of 

Principal Procedure: Percentage of patients aged 18 years 

and older who had an unplanned hospital readmission within 

30 days of principal procedure 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

 X 
 324 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

coordination domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

constitutes the deliberate organization of patient care activities 

to facilitate appropriate delivery of health care services and 

outcomes that primarily reflect successful care coordination. 

N/

A/3

03 

N/

A 

Effective 

Clinical 

Care 

Person 

and 

Caregiver

-Centered 

Experienc

e and 

Outcomes 

Cataracts: Improvement in Patient’s Visual Function 

within 90 Days Following Cataract Surgery: Percentage of 

patients aged 18 years and older in sample who had cataract 

surgery and had improvement in visual function achieved 

within 90 days following the cataract surgery, based on 

completing a pre-operative and post-operative visual function 

survey 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the person and caregivercentered experience and outcomes domain in accordance with 

NQS priorities which follow the General Rules for 

Categorizing Measures in the HHS Decision Rule for 

Categorizing Measures. According to the HHS guidelines for 

categorizing measures, this measure encompases the inclusion 

of patient or family-reported experiences (outcomes) as 

members of the health care team in a collaborative 

partnerships with providers.

 X X 

N/

A/3

31 

N/

A 

Effective 

Clinical 

Care 

Efficiency 

and Cost 

Reduction 

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis 

(Appropriate Use): Percentage of patients, aged 18 years and 

older, with a diagnosis of acute sinusitis who were prescribed 

an antibiotic within 7 days of diagnosis or within 10 days after 

onset of symptoms 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the efficiency and cost 

reduction domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

reflects the efficient use of health care services in the 

provision of patient care. 

 X X 

N/

A/3

32 

N/

A 

Effective 

Clinical 

Care 

Efficiency 

and Cost 

Reduction 

Adult Sinusitis: Appropriate Choice of Antibiotic: 

Amoxicillin Prescribed for Patients with Acute Bacterial 

Sinusitis: Percentage of patients aged 18 years and older with 

a diagnosis of acute bacterial sinusitis that were prescribed 

amoxicillin, without clavulante, as a first line antibiotic at the 

time of diagnosis 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the efficiency and cost 

reduction domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

reflects the efficient use of health care services in the 

provision of patient care. 

 X X 

N/

A/3

47 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Rate of Endovascular Aneurysm Repair (EVAR) of Small 

or Moderate Non-Ruptured Abdominal Aortic Aneurysms 

(AAA) Who Die While in Hospital: Percent of patients 

undergoing endovascular repair of small or moderate 

abdominal aortic aneurysms (AAA) who die while in the 

hospital 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the patient safety domain in 

accordance with NQS priorities which follow the General 

Rules for Categorizing Measures in the HHS Decision Rule 

 X 
 325 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

for Categorizing Measures. According to the HHS guidelines 

for categorizing measures, this measure reflects an effort to 

reduce risk in the delivery of health care to patients and the 

occurance of a health outcome that results from the absence of 

appropriate structures or processed. 

N/

A/3

48 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

HRS-3: Implantable Cardioverter-Defibrillator (ICD) 

Complications Rate: Patients with physician-specific riskstandardized rates of procedural complications following the 

first time implantation of an ICD 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the patient safety domain in 

accordance with NQS priorities which follow the General 

Rules for Categorizing Measures in the HHS Decision Rule 

for Categorizing Measures. According to the HHS guidelines 

for categorizing measures, this measure reflects an effort to 

reduce risk in the delivery of health care to patients and the 

occurance of a health outcome that results from the absence of 

appropriate structures or processed. 

 X 

N/

A/3

54 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Anastomotic Leak Intervention: Percentage of patients aged 

18 years and older who required an anastomotic leak 

intervention following gastric bypass or colectomy surgery

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the patient safety domain in 

accordance with NQS priorities which follow the General 

Rules for Categorizing Measures in the HHS Decision Rule 

for Categorizing Measures. According to the HHS guidelines 

for categorizing measures, this measure reflects an effort to 

reduce risk in the delivery of health care to patients and the 

occurance of a health outcome that results from the absence of 

appropriate structures or processed.

 X 

N/

A/3

55 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Unplanned Reoperation within the 30 Day Postoperative 

Period: Percentage of patients aged 18 years and older who 

had any unplanned reoperation within the 30 day 

postoperative period 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the patient safety domain in 

accordance with NQS priorities which follow the General 

Rules for Categorizing Measures in the HHS Decision Rule 

for Categorizing Measures. According to the HHS guidelines 

for categorizing measures, this measure reflects an effort to 

reduce risk in the delivery of health care to patients and the 

occurance of a health outcome that results from the absence of 

appropriate structures or processed. 

 X 

004

3 

/11

1 

127

v2 

Effective 

Clinical 

Care 

Communi

ty/Populat

ion Health 

Pneumonia Vaccination Status for Older Adults:

Percentage of patients 65 years of age and older who have 

ever received a pneumococcal vaccine. 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the community/ population 

health domain in accordance with NQS priorities which follow 

the General Rules for Categorizing Measures in the HHS 

Decision Rule for Categorizing Measures. According to the 

HHS guidelines for categorizing measures, this measure is a 

measurement of process focused on the prevention of and 

screening for disease.

X X X X X ACO 

MU2 

032

1/0

82 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Effective 

Clinical 

Care

Adult Kidney Disease: Peritoneal Dialysis Adequacy: 

Solute: Percentage of patients aged 18 years and older with a 

diagnosis of End Stage Renal Disease (ESRD) receiving 

peritoneal dialysis who have a total Kt/V ≥ 1.7 per week 

measured once every 4 months 

Rationale: CMS is recategorizing this measure from the 

 X 
 326 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

communication and care coordination domain to the effective 

clinical care domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

reflects care that is consistent with systematically acquired 

evidence to determine whether an intervention, diagnostic test, 

or therapy produces better outcomes than alternatives. 

N/

A/1

80 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Effective 

Clinical 

Care

Rheumatoid Arthritis (RA): Glucocorticoid Management: 

Percentage of patients aged 18 years and older with a 

diagnosis of rheumatoid arthritis (RA) who have been 

assessed for glucocorticoid use and, for those on prolonged 

doses of prednisone ≥ 10 mg daily (or equivalent) with 

improvement or no change in disease activity, documentation 

of glucocorticoid management plan within 12 months 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the effective 

clinical care domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

reflects care that is consistent with systematically acquired 

evidence to determine whether an intervention, diagnostic test, 

or therapy produces better outcomes than alternatives. 

 X AQA 

N/

A/2

80 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Effective 

Clinical 

Care 

Dementia: Staging of Dementia: Percentage of patients, 

regardless of age, with a diagnosis of dementia whose severity 

of dementia was classified as mild, moderate or severe at least 

once within a 12 month period

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the effective 

clinical care domain in accordance with NQS priorities which 

follow the General Rules for Categorizing Measures in the 

HHS Decision Rule for Categorizing Measures. According to 

the HHS guidelines for categorizing measures, this measure 

reflects care that is consistent with systematically acquired 

evidence to determine whether an intervention, diagnostic test, 

or therapy produces better outcomes than alternatives.

 X 

065

4/0

93 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Efficiency 

and Cost 

Reduction

Acute Otitis Externa (AOE): Systemic Antimicrobial 

Therapy – Avoidance of 

Inappropriate Use: Percentage of patients aged 2 years and 

older with a diagnosis of AOE who were not prescribed 

systemic antimicrobial therapy 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the efficiency 

and cost reduction domain in accordance with NQS priorities 

which follow the General Rules for Categorizing Measures in 

the HHS Decision Rule for Categorizing Measures. According 

to the HHS guidelines for categorizing measures, this measure 

reflects the efficient use of health care services in the 

provision of patient care. 

X X 

N/

A/2

58 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Patient 

Safety 

Rate of Open Repair of Small or Moderate Non-Ruptured 

Abdominal Aortic Aneurysms (AAA) without Major 

Complications (Discharged to Home by Post-Operative 

Day #7): Percent of patients undergoing open repair of small 

or moderate sized non-ruptured abdominal aortic aneurysms 

who do not experience a major complication (discharge to 

home no later than post-operative day #7) 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the patient 

safety domain in accordance with NQS priorities which follow 

the General Rules for Categorizing Measures in the HHS 

 X 
 327 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

Decision Rule for Categorizing Measures. According to the 

HHS guidelines for categorizing measures, this measure 

reflects an effort to reduce risk in the delivery of health care to 

patients and the occurance of a health outcome that results 

from the absence of appropriate structures or processed. 

N/

A/2

59 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Patient 

Safety 

Rate of Endovascular Aneurysm Repair (EVAR) of Small 

or Moderate Non-Ruptured Abdominal Aortic Aneurysms 

(AAA) without Major Complications (Discharged to Home 

by Post-Operative Day #2): Percent of patients undergoing 

endovascular repair of small or moderate non-ruptured 

abdominal aortic aneurysms (AAA) that do not experience a 

major complication (discharged to home no later than postoperative day #2) 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the patient 

safety domain in accordance with NQS priorities which follow 

the General Rules for Categorizing Measures in the HHS 

Decision Rule for Categorizing Measures. According to the 

HHS guidelines for categorizing measures, this measure 

reflects an effort to reduce risk in the delivery of health care to 

patients and the occurrence of a health outcome that results 

from the absence of appropriate structures or processed. 

 X 

N/

A/2

60 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Patient 

Safety 

Rate of Carotid Endarterectomy (CEA) for Asymptomatic 

Patients, without Major Complications (Discharged to 

Home by Post-Operative Day #2): Percent of asymptomatic 

patients undergoing CEA who are discharged to home no later 

than post-operative day #2 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the patient 

safety domain in accordance with NQS priorities which follow 

the General Rules for Categorizing Measures in the HHS 

Decision Rule for Categorizing Measures. According to the 

HHS guidelines for categorizing measures, this measure 

reflects an effort to reduce risk in the delivery of health care to 

patients and the occurance of a health outcome that results 

from the absence of appropriate structures or processed. 

 X 

152

5/3

26 

N/

A 

Patient 

Safety 

Effective 

Clinical 

Care 

Atrial Fibrillation and Atrial Flutter: Chronic 

Anticoagulation Therapy: Percentage of patients aged 18 

years and older with a diagnosis of nonvalvular atrial 

fibrillation (AF) or atrial flutter whose assessment of the 

specified thromboembolic risk factors indicate one or more 

high-risk factors or more than one moderate risk factor, as 

determined by CHADS2 risk stratification, who are prescribed 

warfarin OR another oral anticoagulant drug that is FDA 

approved for the prevention of thromboembolism 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the patient 

safety domain in accordance with NQS priorities which follow 

the General Rules for Categorizing Measures in the HHS 

Decision Rule for Categorizing Measures. According to the 

HHS guidelines for categorizing measures, this measure 

reflects care that is consistent with systematically acquired 

evidence to determine whether an intervention, diagnostic test, 

or therapy produces better outcomes than alternatives. 

 X 

N/

A/3

21 

N/

A 

Communi

cation and 

Care 

Coordinat

ion 

Person 

and 

Caregiver 

Experienc

e and 

Outcomes 

CAHPS for PQRS Clinician/Group Survey: 

• Getting timely care, appointments,and information; 

• How well providers Communicate; 

• Patient’s Rating of Provider; 

• Access to Specialists; 

• Health Promotion & Education; 

• Shared Decision Making; 

• Health Status/Functional Status; 

 X ACO 
 328 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)*

Measures Groups 

Other Quality 

Reporting 

Programs 

• Courteous and Helpful Office Staff; 

• Care Coordination; 

• Between Visit Communication; 

• Helping Your to Take Medication as Directed; and 

• Stewardship of Patient Resources 

Rationale: CMS is recategorizing this measure from the 

communication and care coordination domain to the person 

and caregiver experience and outcomes domain in accordance 

with NQS priorities which follow the General Rules for 

Categorizing Measures in the HHS Decision Rule for 

Categorizing Measures. According to the HHS guidelines for 

categorizing measures, this measure encompases the inclusion 

of patient or family-reported experiences (outcomes) as 

members of the health care team in a collaborative 

partnerships with providers.

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing 

of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure 

specifications that apply for each of the reporting options/methods for specific measure details. 

In Table 24, we specify the measures we are proposing to remove from reporting under 

the PQRS. Please note that the rationale we have for each measure we are proposing to remove 

is specified after the measure title and description. 

TABLE 24: Measures Proposed for Removal from the Existing PQRS Measure Set 

Beginning in 2015 

NQF/ 

PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

0093 

/055 

Effective 

Clinical Care 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed for 

Syncope: Percentage of patients aged 60 years 

and older with an emergency department 

discharge diagnosis of syncope who had a 12-lead 

electrocardiogram (ECG) performed 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

AMA-PCPI 

/NCQA X X 

0232 

/056 

Effective 

Clinical Care 

Emergency Medicine: Community-Acquired 

Bacterial Pneumonia (CAP): Vital Signs:

Percentage of patients aged 18 years and older 

with a diagnosis of community-acquired bacterial 

pneumonia (CAP) with vital signs documented 

and reviewed 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

AMA-PCPI 

/NCQA X X 

0096 Effective Emergency Medicine: Community-Acquired AMA-PCPI X X 
 329 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

/059 Clinical Care Bacterial Pneumonia (CAP): Empiric 

Antibiotic: Percentage of patients aged 18 years 

and older with a diagnosis of communityacquired bacterial pneumonia (CAP) with an 

appropriate empiric antibiotic prescribed 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

/NCQA 

N/A 

/228 

Effective 

Clinical Care 

Heart Failure (HF): Left Ventricular Function 

(LVF) Testing: Percentage of patients 18 years 

and older with Left Ventricular Function (LVF) 

testing documented as being performed within the 

previous 12 months or LVF testing performed 

prior to discharge for patients who are 

hospitalized with a principal diagnosis of Heart 

Failure (HF) during the reporting period 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

does not add clinical value to PQRS. LVF testing 

is a basic assessment for patients with heart 

failure. Furthermore, the MAP strongly 

recommends removal of this measure as these 

types of process measures do not meaningfully 

contribute to improved outcomes based on a body 

of literature that demonstrates that lack of 

association. 

CMS/QIP X 

AQA 

Adopted 

/245 

Effective 

Clinical Care 

Chronic Wound Care: Use of Wound Surface 

Culture Technique in Patients with Chronic 

Skin Ulcers (Overuse Measure: Percentage of 

patient visits for those patients aged 18 years and 

older with a diagnosis of chronic skin ulcer 

without the use of a wound surface culture 

technique 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

AMA-PCPI 

/NCQA X X 

AQA 

Adopted 

/246 

Effective 

Clinical Care 

Chronic Wound Care: Use of Wet to Dry 

Dressings in Patients with Chronic Skin Ulcers 

(Overuse Measure): Percentage of patient visits 

for those patients aged 18 years and older with a 

diagnosis of chronic skin ulcer without a 

prescription or recommendation to use wet to dry 

dressings 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

AMA-PCPI 

/NCQA X X 

N/A 

/266 

Effective 

Clinical Care 

Epilepsy: Seizure Type(s) and Current Seizure 

Frequency(ies): Percentage of patient visits with 

a diagnosis of epilepsy who had the type(s) of 

seizure(s) and current seizure frequency(ies) for 

each seizure type documented in the medical 

record 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

AAN X X 
 330 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

rates close to 100% suggesting there is no gap in 

care. 

N/A295 Effective 

Clinical Care 

Hypertension: Use of Aspirin or Other 

Antithrombotic Therapy: Percentage of patients 

aged 30 through 90 years old with a diagnosis of 

hypertension and are eligible for aspirin or other 

antithrombotic therapy who were prescribed 

aspirin or other antithrombotic therapy. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

ABIM X 

N/A297 Effective 

Clinical Care 

Hypertension: Urine Protein Test: Percentage 

of patients aged 18 through 90 years old with a 

diagnosis of hypertension who either have 

chronic kidney disease diagnosis documented or 

had a urine protein test done within 36 months. 

Rationale: CMS recommends removal due tothe 

measure steward indicating they will no longer 

maintain this measure. In addition, this is a 

process measure that is distal to the outcome and 

has not been shown to improve patient outcomes.. 

Furthermore, MAP strongly recommends removal 

as these types of process measures do not 

meaningfully contribute to improved outcomes. 

ABIM X 

N/A298 Effective 

Clinical Care 

Hypertension: Annual Serum Creatinine Test:

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension who had a 

serum creatinine test done within 12 months. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

ABIM X 

N/A299 Effective 

Clinical Care 

Hypertension: Diabetes Mellitus Screening 

Test: Percentage of patients aged 18 through 90 

years old with a diagnosis of hypertension who 

had a diabetes screening test within 36 months. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

ABIM X 

N/A300 Effective 

Clinical Care 

Hypertension: Blood Pressure Control: 

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension whose most 

recent blood pressure was under control (< 

140/90 mmHg).

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

ABIM X 

N/A302 Effective 

Clinical Care 

Hypertension: Dietary and Physical Activity 

Modifications Appropriately Prescribed: 

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension who 

received dietary and physical activity counseling 

at least once within 12 months. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

ABIM X 

0087/0014 Effective 

Clinical Care 

Age-Related Macular Degeneration (AMD): 

Dilated Macular Examination: Percentage of 

patients aged 50 years and older with a diagnosis 

of age-related macular degeneration (AMD) who 

had a dilated macular examination performed 

AMA-PCPI 

NCQA X X 
 331 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

which included documentation of the presence or 

absence of macular thickening or hemorrhage 

AND the level of macular degeneration severity 

during one or more office visits within 12 months 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

0270/0020 Patient 

Safety 

Perioperative Care: Timing of Prophylactic 

Parenteral Antibiotic – Ordering Physician: 

Percentage of surgical patients aged 18 years and 

older undergoing procedures with the indications 

for prophylactic parenteral antibiotics, who have 

an order for prophylactic parenteral antibiotic to 

be given within one hour (if fluoroquinolone or 

vancomycin, 2 hours), prior to the surgical 

incision (or start of procedure when no incision is 

required) 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X X 

0268/0021 Patient 

Safety 

Perioperative Care: Selection of Prophylactic 

Antibiotic – First OR Second Generation 

Cephalosporin: Percentage of surgical patients 

aged 18 years and older undergoing procedures 

with the indications for a first OR second 

generation cephalosporin prophylactic antibiotic, 

who had an order for a first OR second generation 

cephalosporin for antimicrobial prophylaxis 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X X 

0271/0022 Patient 

Safety 

Perioperative Care: Discontinuation of 

Prophylactic Parenteral Antibiotics (NonCardiac Procedures): Percentage of non-cardiac 

surgical patients aged 18 years and older 

undergoing procedures with the indications for 

prophylactic parenteral antibiotics AND who 

received a prophylactic parenteral antibiotic, who 

have an order for discontinuation of prophylactic 

parenteral antibiotics within 24 hours of surgical 

end time 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X X 

0239/0023 Patient 

Safety 

Perioperative Care: Venous 

Thromboembolism (VTE) Prophylaxis (When 

Indicated in ALL Patients): Percentage of 

surgical patients aged 18 years and older 

undergoing procedures for which VTE 

prophylaxis is indicated in all patients, who had 

an order for Low Molecular Weight Heparin 

(LMWH), Low-Dose Unfractionated Heparin 

(LDUH), adjusted-dose warfarin, fondaparinux or 

mechanical prophylaxis to be given within 24 

AMA-PCPI 

NCQA X X X 
 332 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

hours prior to incision time or within 24 hours 

after surgery end time 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

0092/0028 Effective 

Clinical Care 

Aspirin at Arrival for Acute Myocardial 

Infarction (AMI): Percentage of patients, 

regardless of age, with an emergency department 

discharge diagnosis of acute myocardial 

infarction (AMI)who had documentation of 

receiving aspirin within 24 hours before 

emergency department arrival or during 

emergency department stay 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

has been substantially adopted for initial 

treatment of patients suffering from acute 

myocardial infarction when clinically indicated.

AMA-PCPI 

NCQA X X 

0269/0030 Patient 

Safety 

Perioperative Care:Timing of Prophylactic 

Antiobiotic—Administering Physician: 

Percentage of surgical patients aged 18 years and 

older who receive an anesthetic when undergoing 

procedures with the indications for prophylactic 

parenteral antibiotics for whom administration of 

a prophylactic parenteral antibiotic ordered has 

been initiated within 1 hour (if fluoroquinolone or 

vancomycin, 2 hours) prior to the surgical 

incision (or start of procedure when no incision is 

required) 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X 

0240/0031 Effective 

Clinical Care 

Stroke and Stroke Rehabilitation: Venous 

Thromboembolism (VTE) Prophylaxis for 

Ischemic Stroke or Intracranial Hemorrhage: 

Percentage of patients aged 18 years and older 

with a diagnosis of ischemic stroke or intracranial 

hemorrhage who were administered venous 

thromboembolism (VTE) prophylaxis the day of 

or the day after hospital admission 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently included within inpatient standards 

of care to improve patient outcomes for those 

diagnosed with ischemic or intracranial stroke 

when clincially indicated. 

AMA-PCPI 

NCQA X X 

0325/0032 Effective 

Clinical Care 

Stroke and Stroke Rehabilitation: Discharged 

on Antithrombotic Therapy: Percentage of 

patients aged 18 years and older with a diagnosis 

of ischemic stroke or transient ischemic attack 

(TIA) who were prescribed antithrombotic 

therapy at discharge 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently included within inpatient standard of 

care to decrease risk of complications in patients 

diagnosed with ischemic or intracranial stroke 

AMA-PCPI 

NCQA X X 
 333 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

when clinically indicated.

0241/0033 Effective 

Clinical Care 

Stroke and Stroke Rehabilitation: 

Anticoagulant Therapy Prescribed for Atrial 

Fibrillation (AF) at Discharge: Percentage of 

patients aged 18 years and older with a diagnosis 

of ischemic stroke or transient ischemic attack 

(TIA) with documented permanent, persistent, or 

paroxysmal atrial fibrillation who were prescribed 

an anticoagulant at discharge 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently included within inpatient standard of 

care to decrease risk of complications in patients 

diagnosed with ischemic or intracranial stroke 

when clinically indicated.

AMA-PCPI 

NCQA X 

0243/0035 Effective 

Clinical Care 

Stroke and Stroke Rehabilitation: Screening 

for Dysphagia: Percentage of patients aged 18 

years and older with a diagnosis of ischemic 

stroke or intracranial hemorrhage who receive 

any food, fluids or medication by mouth (PO) for 

whom a dysphagia screening was performed prior 

to PO intake in accordance with a dysphagia 

screening tool approved by the institution in 

which the patient is receiving care 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently included within hospital standard of 

care to decrease risk of choking for patients 

diagnosed with ischemic or intracranial stroke 

when clinically indicated.

AMA-PCPI 

NCQA X X 

0244/0036 Effective 

Clinical Care 

Stroke and Stroke Rehabilitation: 

Rehabilitation Services Ordered: Percentage of 

patients aged 18 years and older with a diagnosis 

of ischemic stroke or intracranial hemorrhage for 

whom occupational, physical, or speech 

rehabilitation services were ordered at or prior to 

inpatient discharge OR documentation that no 

rehabilitation services are indicated at or prior to 

inpatient discharge 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently included within inpatient standard of 

care to improve quality of life for patients 

diagnosed with ischemic or intracranial stroke 

when clinically indicated.

AMA-PCPI 

NCQA X X 

0637/0045 Patient 

Safety 

Perioperative Care: Discontinuation of 

Prophylactic Parenteral Antibiotics (Cardiac 

Procedures): Percentage of cardiac surgical 

patients aged 18 years and older undergoing 

procedures with the indications for prophylactic 

parenteral antibiotics AND who received a 

prophylactic parenteral antibiotic, who have an 

order for discontinuation of prophylactic 

parenteral antibiotics within 48 hours of surgical 

end time 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X 

0099/0049 Effective 

Clinical Care 

Urinary Incontinence: Characterization of 

Urinary Incontinence in Women Aged 65 

AMA-PCPI 

NCQA X X 
 334 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

Years and Older: Percentage of female patients 

aged 65 years and older with a diagnosis of 

urinary incontinence whose urinary incontinence 

was characterized at least once within 12 months 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

0001/0064 Effective 

Clinical Care 

Asthma: Assessment of Asthma Control – 

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64 years with a diagnosis 

of asthma who were evaluated at least once 

during the measurement period for asthma control 

(comprising asthma impairment and asthma risk) 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

does not add clinical value to PQRS because in 

order to provide effective treatment for asthma 

assessment of asthma control is essential.

AMA-PCPI 

NCQA X X 

0393/0083 Effective 

Clinical Care 

Hepatitis C: Confirmation of Hepatitis C 

Viremia: Percentage of patients aged 18 years 

and older who are hepatitis C antibody positive 

seen for an initial evaluation for whom hepatitis 

C virus (HCV) RNA testing was ordered or 

previously performed 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI X 

0103/0106 Effective 

Clinical Care 

Adult Major Depressive Disorder (MDD): 

Comprehensive Depression Evaluation: 

Diagnosis and Severity: Percentage of patients 

aged 18 years and older with a new diagnosis or 

recurrent episode of major depressive disorder 

(MDD) with evidence that they met the 

Diagnostic and Statistical Manual of Mental 

Disorders (DSM)-5 criteria for MDD AND for 

whom there is an assessment of depression 

severity during the visit in which a new diagnosis 

or recurrent episode was identified 

Rationale: CMS recommends removal due to 

this measure representing a clinically diagnostic 

reference that is commonly utilized in order to 

determine mental health disorders, therefore it 

does not add clinical value to PQRS.

AMA-PCPI X X 

1666/0123 Effective 

Clinical Care 

Adult Kidney Disease: Patients On 

Erythropoiesis-Stimulating Agent (ESA) - 

Hemoglobin Level > 12.0 g/dL: Percentage of 

calendar months within a 12-month period during 

which a hemoglobin level is measured for 

patients aged 18 years and older with a diagnosis 

of advanced chronic kidney disease (CKD) (stage 

4 or 5, not receiving Renal Replacement Therapy 

([RRT]) or End Stage Renal Disease (ESRD) 

(who are on hemodialysis or peritoneal dialysis) 

who are also receiving erythropoiesis-stimulating 

agent (ESA) therapy AND have a hemoglobin 

level > 12.0 g/dL 

Rationale: CMS recommends removal due to 

AMA-PCPI X X X 
 335 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

this measure representing a medical concept of 

completion of a required diagnostic level in order 

to provide erythropoiesis-stimulating agent when 

clinically appropriate.

0566/0140 Effective 

Clinical Care 

Age-Related Macular Degeneration (AMD): 

Counseling on Antioxidant Supplement: 

Percentage of patients aged 50 years and older 

with a diagnosis of age-related macular 

degeneration (AMD) or their caregiver(s) who 

were counseled within 12 months on the benefits 

and/or risks of the Age-Related Eye Disease 

Study (AREDS) formulation for preventing 

progression of AMD 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X 

0051/0142 Effective 

Clinical Care 

Osteoarthritis (OA): Assessment for Use of 

Anti-Inflammatory or Analgesic Over-theCounter (OTC) Medications: Percentage of 

patient visits for patients aged 21 years and older 

with a diagnosis of osteoarthritis (OA) with an 

assessment for use of anti-inflammatory or 

analgesic over-the-counter (OTC)medications 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

does not add clinical value to PQRS due to 

assessment of patients’ current medications is 

crucial to patient safety. Furthermore, the 

measure steward has indicated they will no longer 

maintain this measure.

AMA-PCPI X X 

0508/0146 

Efficiency 

and Cost 

Reduction 

Radiology: Inappropriate Use of “Probably 

Benign” Assessment Category in 

Mammography Screening: Percentage of final 

reports for screening mammograms that are 

classified as “probably benign” 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X 

2080/341 

Efficiency 

and Cost 

Reduction 

Gap in HIV Medical Visits: Percentage of 

patients, regardless of age, with a diagnosis of 

HIV who did not have a medical visit in the last 6 

months 

Rationale: CMS recommends removal as this 

measure is duplicated within PQRS with current 

measure HIV Medica Visit Frequency (PQRS 

#340)s. 

HRSA X X 

N/A/ 

301 

Effective 

Clinical Care 

Hypertension: Low Density Lipoprotein (LDLC) Control: Percentage of patients aged 18 

through 90 years old with a diagnosis of 

hypertension who had most recent LDL 

cholesterol level under control (at goal) 

Rationale: CMS recommends removal as 

evidence-based guidelines have changed 

regarding lipid control.

ABIM X 

N/A/ 

272 

Effective 

Clinical Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Influenza Immunization: 

Percentage of patients aged 18 years and older 

AGA X 
 336 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

with a diagnosis of inflammatory bowel disease 

for whom influenza immunization was 

recommended, administered or previously 

received during the reporting year 

Rationale: CMS recommends removal as this 

measure is duplicated within PQRS with current 

measure Preventive Care and Screening: 

Influenza Immunization (PQRS #110).

N/A/ 

273 

Effective 

Clinical Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Pneumococcal 

Immunization: Percentage of patients aged 18 

years and older with a diagnosis of inflammatory 

bowel disease that had pneumococcal vaccination 

administered or previously received 

Rationale: CMS recommends removal as this 

measure is duplicated within PQRS with current 

measure Pneumonia Vaccination Status for Older 

Adults (PQRS #111). 

AGA X 

N/A/ 

269 

Effective 

Clinical Care 

Inflammatory Bowel Disease (IBD): Type, 

Anatomic Location and Activity All 

Documented: Percentage of patients aged 18 

years and older with a diagnosis of inflammatory 

bowel disease who have documented the disease 

type, anatomic location and activity, at least once 

during the reporting period 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

does not add clinical value to PQRS because in 

order to provide effective treatment for IBD, 

documentation of type, anatomic location and 

activity would be essential for effective treatment 

of IBD.

AGA X 

N/A/ 

267 

Effective 

Clinical Care 

Epilepsy: Documentation of Etiology of 

Epilepsy or Epilepsy Syndrome: All visits for 

patients with a diagnosis of epilepsy who had 

their etiology of epilepsy or with epilepsy 

syndrome(s) reviewed and documented if known, 

or documented as unknown or cryptogenic 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AAN X X 

N/A/ 

261 

Communicat

ion and Care 

Coordination 

Referral for Otologic Evaluation for Patients 

with Acute or Chronic Dizziness: Percentage of 

patients aged birth and older referred to a 

physician (preferably a physician specially 

trained in disorders of the ear) for an otologic 

evaluation subsequent to an audiologic evaluation 

after presenting with acute or chronic dizziness 

Rationale: CMS recommends removal due to the 

clinical concept of medical referral being a 

common practice in order to provide effective 

treatment for patients.

AQC X X 

0643/243 Effective 

Clinical Care 

Cardiac Rehabilitation Patient Referral from 

an Outpatient Setting: Percentage of patients 

evaluated in an outpatient setting who within the 

previous 12 months have experienced an acute 

myocardial infarction (MI), coronary artery 

bypass graft (CABG) surgery, a percutaneous 

ACCF 

AHA X 
 337 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

coronary intervention (PCI), cardiac valve 

surgery, or cardiac transplantation, or who have 

chronic stable angina (CSA) and have not already 

participated in an early outpatient cardiac 

rehabilitation/secondary prevention (CR) program 

for the qualifying event/diagnosis who were 

referred to a CR program 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is initiated within the inpatient setting and does 

not add clinical value to PQRS as an outpatient 

based measure.

AQA 

Adopted/2

47 

Effective 

Clinical Care 

Substance Use Disorders: Counseling 

Regarding Psychosocial and Pharmacologic 

Treatment Options for Alcohol Dependence: 

Percentage of patients aged 18 years and older 

with a diagnosis of current alcohol dependence 

who were counseled regarding psychosocial AND 

pharmacologic treatment options for alcohol 

dependence within the 12-month reporting period 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

AMA-PCPI 

NCQA X X AQA 

AQA 

Adopted/2

48 

Effective 

Clinical Care 

Substance Use Disorders: Screening for 

Depression Among Patients with Substance 

Abuse or Dependence: Percentage of patients 

aged 18 years and older with a diagnosis of 

current substance abuse or dependence who were 

screened for depression within the 12-month 

reporting period 

Rationale: CMS recommends removal as this 

measure is duplicated within the Physician 

Quality Reporting System as a subset of an 

existing measure Preventive Care and Screening 

for Clinical Depression for Follow-up Plan 

(PQRS #134)).

AMA-PCPI 

NCQA X X AQA 

N/A/231 Effective 

Clinical Care 

Asthma: Tobacco Use: Screening - 

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64years with a diagnosis 

of asthma (or their primary caregiver) who were 

queried about tobacco use and exposure to second 

hand smoke within their home environment at 

least once during the one-year measurement 

period 

Rationale: CMS recommends removal as this 

measure is duplicated within PQRS with current 

measure Preventive Care and Screening: Tobacco 

Use: Screening and Cessation Intervention 

(PQRS 226).

AMA-PCPI 

NCQA X X X 

N/A/232 Effective 

Clinical Care 

Asthma: Tobacco Use: Intervention - 

Ambulatory Care Setting: Percentage of 

patients aged 5 through64 years with a diagnosis 

of asthma who were identified as tobacco users 

(or their primary caregiver) who received tobacco 

cessation intervention at least once during the 

one-year measurement period 

Rationale: CMS recommends removal as this 

measure is duplicated within PQRS with current 

measure Preventive Care and Screening: Tobacco 

AMA-PCPI 

NCQA X X X 
 338 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

Use: Screening and Cessation Intervention 

(PQRS 226).

0457/233 Effective 

Clinical Care 

Thoracic Surgery: Recording of Performance 

Status Prior to Lung or Esophageal Cancer 

Resection: Percentage of patients aged 18 years 

and older undergoing resection for lung or 

esophageal cancer for whom performance status 

was documented and reviewed within 2 weeks 

prior to surgery 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X 

0458/234 Patient 

Safety 

Thoracic Surgery: Pulmonary Function Tests 

Before Major Anatomic Lung Resection 

(Pneumonectomy, Lobectomy, or Formal 

Segmentectomy): Percentage of thoracic surgical 

patients aged 18 years and older undergoing at 

least one pulmonary function test within 12 

months prior to a major lung resection 

(pneumonectomy, lobectomy, or formal 

segmentectomy) 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X 

0074/197 Effective 

Clinical Care 

Coronary Artery Disease (CAD): Lipid 

Control: Percentage of patients aged 18 years 

and older with a diagnosis of coronary artery 

disease seen within a 12 month period who have a 

LDL-C result < 100 mg/dL OR patients who have 

a LDL-C result ≥ 100 mg/dL and have a 

documented plan of care to achieve LDL-C <100 

mg/dL, including at a minimum the prescription 

of a statin 

Rationale: CMS recommends removal as 

evidence-based guidelines have changed 

regarding lipid control. This measure is also 

being proposed for removal from the GPRO WI.

AMA-PCPI 

ACCF 

AHA 

 X X X 

0079/198 Effective 

Clinical Care 

Heart Failure: Left Ventricular Ejection 

Fraction (LVEF) Assessment: Percentage of 

patients aged 18 years and older with a diagnosis 

of heart failure for whom the quantitative or 

qualitative results of a recent or prior [any time in 

the past] LVEF assessment is documented within 

a 12 month period 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

does not add clinical value to PQRS. LVF testing 

is basic assessment for patients with heart failure.

AMA-PCPI 

ACCF 

AHA 

 X X 

0115/168 Effective 

Clinical Care 

Coronary Artery Bypass Graft (CABG): 

Surgical Re-Exploration: Percentage of patients 

aged 18 years and older undergoing isolated 

CABG surgery who require a return to the 

operating room (OR) during the current 

hospitalization for mediastinal bleeding with or 

without tamponade, graft occlusion, valve 

dysfunction, or other cardiac reason 

Rationale: CMS recommends removal due to 

STS X X 
 339 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

0116/169 Effective 

Clinical Care 

Coronary Artery Bypass Graft (CABG): 

Antiplatelet Medications at Discharge: 

Percentage of patients aged 18 years and older 

undergoing isolated CABG surgery who were 

discharged on antiplatelet medication 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X X 

0117/170 Effective 

Clinical Care 

Coronary Artery Bypass Graft (CABG): BetaBlockers Administered at Discharge: 

Percentage of patients aged 18 years and older 

undergoing isolated CABG surgery who were 

discharged on beta-blockers 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X X 

0118/171 Effective 

Clinical Care 

Coronary Artery Bypass Graft (CABG): AntiLipid Treatment at Discharge: Percentage of 

patients aged 18 years and older undergoing 

isolated CABG surgery who were discharged on a 

statin or other lipid-lowering regimen 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X X 

0455/157 Patient 

Safety 

Thoracic Surgery: Recording of Clinical Stage 

Prior to Lung Cancer or Esophageal Cancer 

Resection: Percentage of surgical patients aged 

18 years and older undergoing resection for lung 

or esophageal cancer who had clinical staging 

provided prior to surgery 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

STS X X 

0404/159 Effective 

Clinical Care 

HIV/AIDS: CD4+ Cell Count or CD4+ 

Percentage Performed: Percentage of patients 

aged 6 months and older with a diagnosis of 

HIV/AIDS for whom a CD4+ cell count or CD4+ 

cell percentage was performed at least once every 

6 months 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care.

AMA-PCPI 

NCQA X X 

N/A/ 

257 

Effective 

Clinical Care 

Statin Therapy at Discharge after Lower 

Extremity Bypass (LEB): Percentage of patients 

aged 18 years and older undergoing infra-inguinal 

lower extremity bypass who are prescribed a 

statin medication at discharge 

SVS X 
 340 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

Rationale: CMS recommends removal due to 

this measure representing a clinical concept that 

is currently accepted standard treatment for 

patients that receive lower extremity 

revascularization when clinically indicated.

N/A/ 

296 

Effective 

Clinical Care 

Hypertension: Complete Lipid Profile:

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension who 

received a complete lipid profile within 60 

months 

Rationale: CMS recommends removal due to 

measure steward indicating they will no longer 

maintain this measure.

ABIM X 

0322/148 Efficiency 

and Cost 

Reduction 

Back Pain: Initial Visit: The percentage of 

patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back 

surgery who had back pain and function assessed 

during the initial visit to the clinician for the 

episode of back pain 

Rationale: CMS recommends removal due to 

this measure representing clinical assessments 

commonly utilized to provide effective treatment 

for patients diagnosed with back pain. 

NCQA X 

0319/149 Effective 

Clinical Care 

Back Pain: Physical Exam: Percentage of 

patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back 

surgery who received a physical examination at 

the initial visit to the clinician for the episode of 

back pain 

Rationale: CMS recommends removal due to 

this measure representing clinical assessments 

commonly utilized to provide effective treatment 

for patients diagnosed with back pain.

NCQA X 

0314/150 Effective 

Clinical Care 

Back Pain: Advice for Normal Activities: The 

percentage of patients aged 18 through 79 years 

with a diagnosis of back pain or undergoing back 

surgery who received advice for normal activities 

at the initial visit to the clinician for the episode 

of back pain 

Rationale: CMS recommends removal due to 

this measure representing clinical 

recommendations that are commonly provided for 

patients diagnosed with back pain when clinically 

indicated.

NCQA X 

0313/151 Effective 

Clinical Care 

Back Pain: Advice Against Bed Rest: The 

percentage of patients aged 18 through 79 years 

with a diagnosis of back pain or undergoing back 

surgery who received advice against bed rest 

lasting four days or longer at the initial visit to the 

clinician for the episode of back pain 

Rationale: CMS recommends removal due to 

this measure representing clinical 

recommendations that are commonly provided for 

patients diagnosed with back pain when clinically 

indicated. 

NCQA X 

0091/051 Effective 

Clinical Care 

Chronic Obstructive Pulmonary Disease 

(COPD): Spirometry Evaluation: Percentage of 

patients aged 18 years and older with a diagnosis 

of COPD who had spirometry evaluation results 

documented 

AMA-PCPI X X 
 341 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

0102/052 Effective 

Clinical Care 

Chronic Obstructive Pulmonary Disease 

(COPD): Inhaled Bronchodilator Therapy: 

Percentage of patients aged 18 years and older 

with a diagnosis of COPD and who have an 

FEV1/FVC less than 60% and have symptoms 

who were prescribed an inhaled bronchodilator 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X X 

0050/109 Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Osteoarthritis (OA): Function and Pain 

Assessment: Percentage of patient visits for 

patients aged 21 years and older with a diagnosis 

of osteoarthritis (OA) with assessment for 

function and pain 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X 

N/A/276 Effective 

Clinical Care 

Sleep Apnea: Assessment of Sleep Symptoms:

Percentage of visits for patients aged 18 years and 

older with a diagnosis of obstructive sleep apnea 

that includes documentation of an assessment of 

sleep symptoms, including presence or absence of 

snoring and daytime sleepiness 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMAPCPI/NCQ

A 

 X 

N/A/277 Effective 

Clinical Care 

Sleep Apnea: Severity Assessment at Initial 

Diagnosis: Percentage of patients aged 18 years 

and older with a diagnosis of obstructive sleep 

apnea who had an apnea hypopnea index (AHI) 

or a respiratory disturbance index (RDI) 

measured at the time of initial diagnosis 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMAPCPI/NCQ

A 

 X 

N/A/278 Effective 

Clinical Care 

Sleep Apnea: Positive Airway Pressure 

Therapy Prescribed: Percentage of patients aged 

18 years and older with a diagnosis of moderate 

or severe obstructive sleep apnea who were 

prescribed positive airway pressure therapy 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMAPCPI/NCQ

A 

 X 

N/A/279 Effective 

Clinical Care 

Sleep Apnea: Assessment of Adherence to 

Positive Airway Pressure Therapy: Percentage 

of visits for patients aged 18 years and older with 

a diagnosis of obstructive sleep apnea who were 

prescribed positive airway pressure therapy who 

had documentation that adherence to positive 

airway pressure therapy was objectively 

measured 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMAPCPI/NCQ

A 

 X 
 342 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)* 

Measures 

Groups 

Other 

Quality 

Reporting 

Programs 

N/A/147 Communicat

ion and Care 

Coordination

Nuclear Medicine: Correlation with Existing 

Imaging Studies for All Patients Undergoing 

Bone Scintigraphy: Percentage of final reports 

for all patients, regardless of age, undergoing 

bone scintigraphy that include physician 

documentation of correlation with existing 

relevant imaging studies (e.g., x-ray, MRI, CT, 

etc.) that were performed. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X X 

AQA 

Adopted/1

73

Community/

Population 

Health

Preventive Care and Screening: Unhealthy 

Alcohol Use – Screening: Percentage of patients 

aged 18 years and older who were screened for 

unhealthy alcohol use using a systematic 

screening method within 24 months.

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X X 

N/A/335 Patient 

Safety

Maternity Care: Elective Delivery or Early 

Induction Without Medical Indication at ≥ 37 

and < 39 Weeks: Percentage of patients, 

regardless of age, who gave birth during a 12-

month period who delivered a live singleton at ≥

37 and < 39 weeks of gestation completed who 

had elective deliveries or early inductions without 

medical indication.

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X 

N/A/336 Communicat

ion and Care 

Coordination

Maternity Care: Post-Partum Follow-Up and 

Care Coordination: Percentage of patients, 

regardless of age, who gave birth during a 12-

month period who were seen for post-partum care 

within 8 weeks of giving birth who received a 

breast feeding evaluation and education, postpartum depression screening, post-partum glucose 

screening for gestational diabetes patients, and 

family and contraceptive planning

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure.

AMA-PCPI X 

 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the 

timing of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure 

specifications that apply for each of the reporting options/methods for specific measure details. 

In Table 25 below, we specify our proposals to change the way in which previously 

established measures in the PQRS will be reported beginning in 2015. Please note that, in Table 

25, we provide our explanation as to how we are proposing to change the way the measure is 

reported, as well as a corresponding rationale for this proposed change. 
 343 

TABLE 25: Existing Individual Quality Measures and Those Included in Measures Groups 

for the PQRS for Which Measure Reporting Updates will be Effective Beginning in 2015 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

006

7/6 

Effective 

Clinical Care 

Coronary Artery Disease (CAD): Antiplatelet 

Therapy: Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease 

seen within a 12 month period who were 

prescribed aspirin or clopidogrel 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

AMAPCPI 

ACCF 

AHA 

 X X X ACO 

008

6/12 

143

v2 

Effective 

Clinical Care 

Primary Open-Angle Glaucoma (POAG): Optic 

Nerve Evaluation: Percentage of patients aged 18 

years and older with a diagnosis of primary openangle glaucoma (POAG) who have an optic nerve 

head evaluation during one or more office visits 

within 12 months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X X MU2 

008

9/19 

142

v2 

Effective 

Clinical Care 

Diabetic Retinopathy: Communication with the 

Physician Managing Ongoing Diabetes Care: 

Percentage of patients aged 18 years and older with 

a diagnosis of diabetic retinopathy who had a 

dilated macular or fundus exam performed with 

documented communication to the physician who 

manages the ongoing care of the patient with 

diabetes mellitus regarding the findings of the 

macular or fundus exam at least once within 12 

months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X X MU2 

004

5/24 

Communicati

on and Care 

Coordination 

Osteoporosis: Communication with the 

Physician Managing On-going Care PostFracture of Hip, Spine or Distal Radius for Men 

and Women Aged 50 Years and Older: 

Percentage of patients aged 50 years and older 

treated for a hip, spine or distal radial fracture with 

documentation of communication with the 

physician managing the patient’s on-going care 

that a fracture occurred and that the patient was or 

should be tested or treated for osteoporosis 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 
 344 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

004

6/39 

Effective 

Clinical Care 

Screening or Therapy for Osteoporosis for 

Women Aged 65 Years and Older: Percentage of 

female patients aged 65 years and older who have 

a central dual-energy X-ray absorptiometry (DXA) 

measurement ordered or performed at least once 

since age 60 or pharmacologic therapy prescribed 

within 12 months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X X 

004

8/40 

Effective 

Clinical Care 

Osteoporosis: Management Following Fracture 

of Hip, Spine or Distal Radius for Men and 

Women Aged 50 Years and Older: Percentage of 

patients aged 50 years and older with fracture of 

the hip, spine, or distal radius who had a central 

dual-energy X-ray absorptiometry (DXA) 

measurement ordered or performed or 

pharmacologic therapy prescribed 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 

013

4/43 

Effective 

Clinical Care 

Coronary Artery Bypass Graft (CABG): Use of 

Internal Mammary Artery (IMA) in Patients 

with Isolated CABG Surgery: Percentage of 

patients aged 18 years and older undergoing 

isolated CABG surgery who received an IMA graft 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

STS X X 

009

7/46 

Communicati

on and Care 

Coordination 

Medication Reconciliation: Percentage of patients 

aged 65 years and older 

discharged from any inpatient facility (e.g., 

hospital, skilled nursing facility, or rehabilitation 

facility) and seen within 30 days following 

discharge in the office by the physician, 

prescribing practitioner, registered nurse, or 

clinical pharmacist providing on-going care who 

had a reconciliation of the discharge medications 

with the current medication list in the outpatient 

medical record documented 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 

010

0/50 

Person and 

CaregiverCentered 

Urinary Incontinence: Plan of Care for Urinary 

Incontinence in Women Aged 65 Years and 

Older: Percentage of female patients aged 65 

AMAPCPI 

NCQA 

 X 
 345 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

Experience 

and 

Outcomes 

years and older with a diagnosis of urinary 

incontinence with a documented plan of care for 

urinary incontinence at least once within 12 

months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

009

0/54 

Effective 

Clinical Care 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain: Percentage of patients 

aged 40 years and older with an emergency 

department discharge diagnosis of non-traumatic 

chest pain who had a 12-lead electrocardiogram 

(ECG) performed 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 

037

7/67 

Effective 

Clinical Care 

Hematology: Myelodysplastic Syndrome (MDS) 

and Acute Leukemias: Baseline Cytogenetic 

Testing Performed on Bone Marrow: Percentage 

of patients aged 18 years and older with a 

diagnosis of myelodysplastic syndrome (MDS) or 

an acute leukemia who had baseline cytogenetic 

testing performed on bone marrow 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ASH 

 X 

037

8/68 

Effective 

Clinical Care 

Hematology: Myelodysplastic Syndrome 

(MDS): Documentation of Iron Stores in 

Patients Receiving Erythropoietin Therapy: 

Percentage of patients aged 18 years and older with 

a diagnosis of myelodysplastic syndrome (MDS) 

who are receiving erythropoietin therapy with 

documentation of iron stores within 60 days prior 

to initiating erythropoietin therapy 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ASH 

 X 

038

0/69 

Effective 

Clinical Care 

Hematology: Multiple Myeloma: Treatment 

with Bisphosphonates: Percentage of patients 

aged 18 years and older with a diagnosis of 

multiple myeloma, not in remission, who were 

prescribed or received intravenous bisphosphonate 

therapy within the 12-month reporting period 

Rationale: CMS proposes to remove the claims 

AMAPCPI 

ASH 

 X 
 346 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

037

9/70 

Effective 

Clinical Care 

Hematology: Chronic Lymphocytic Leukemia 

(CLL): Baseline Flow Cytometry: Percentage of 

patients aged 18 years and older seen within a 12 

month reporting period with a diagnosis of chronic 

lymphocytic leukemia (CLL) made at any time 

during or prior to the reporting period who had 

baseline flow cytometry studies performed and 

documented in the chart 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ASH 

 X 

038

7/71 

140

v1 

Effective 

Clinical Care 

Breast Cancer: Hormonal Therapy for Stage IC 

- IIIC Estrogen Receptor/Progesterone 

Receptor (ER/PR) Positive Breast Cancer: 

Percentage of female patients aged 18 years and 

older with Stage IC through IIIC, ER or PR 

positive breast cancer who were prescribed 

tamoxifen or aromatase inhibitor (AI) during the 

12-month reporting period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ASCO 

NCCN 

 X X X MU2 

038

5/72 

141

v3 

Effective 

Clinical Care 

Colon Cancer: Chemotherapy for AJCC Stage 

III Colon Cancer Patients: Percentage of patients 

aged 18 through 80 years with AJCC Stage III 

colon cancer who are referred for adjuvant 

chemotherapy, prescribed adjuvant chemotherapy, 

or have previously received adjuvant 

chemotherapy within the 12-month reporting 

period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ASCO 

NCCN 

 X X X MU2 

038

9 

/102 

129

v3 

Efficiency 

and Cost 

Reduction 

Prostate Cancer: Avoidance of Overuse of Bone 

Scan for Staging Low Risk Prostate Cancer 

Patients: Percentage of patients, regardless of age, 

with a diagnosis of prostate cancer at low risk of 

recurrence receiving interstitial prostate 

brachytherapy, OR external beam radiotherapy to 

the prostate, OR radical prostatectomy, OR 

cryotherapy who did not have a bone scan 

performed at any time since diagnosis of prostate 

cancer 

Rationale: CMS proposes to remove the claims 

AMAPCPI X X MU2 
 347 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

039

0 

/104 

Effective 

Clinical Care 

Prostate Cancer: Adjuvant Hormonal Therapy 

for High Risk Prostate Cancer Patients: 

Percentage of patients, regardless of age, with a 

diagnosis of prostate cancer at high risk of 

recurrence receiving external beam radiotherapy to 

the prostate who were prescribed adjuvant 

hormonal therapy (GnRH agonist or antagonist) 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI X 

N/A

/112 

Effective 

Clinical Care 

Breast Cancer Screening: Percentage of women 

50 through 74 years of age who had a 

mammogram to screen for breast cancer within 27 

months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

NCQA X X X X MU2 

003

4 

/113 

130

v2 

Effective 

Clinical Care 

Colorectal Cancer Screening: Percentage of 

patients 50 through 75 years of age who had 

appropriate screening for colorectal cancer 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

NCQA X X X X MU2 

005

5 

/117 

131

v2 

Effective 

Clinical Care 

Diabetes: Eye Exam: Percentage of patients 18 

through 75 years of age with a diagnosis of 

diabetes (type 1 and type 2) who had a retinal or 

dilated eye exam in the measurement period or a 

negative retinal or dilated eye exam (negative for 

retinopathy) in the year prior to the measurement 

period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

NCQA X X X X ACO 

MU2 

006

2 

/119 

134

v2 

Effective 

Clinical Care 

Diabetes: Medical Attention for Nephropathy: 

The percentage of patients 18-75 years of age with 

diabetes who had a nephropathy screening test or 

evidence of nephropathy during the measurement 

period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

NCQA X X X MU2 
 348 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

reporting.

166

8 

/121 

Effective 

Clinical Care 

Adult Kidney Disease: Laboratory Testing 

(Lipid Profile): Percentage of patients aged 18 

years and older with a diagnosis of chronic kidney 

disease (CKD) (stage 3, 4, or 5, not receiving 

Renal Replacement Therapy [RRT]) who had a 

fasting lipid profile performed at least once within 

a 12-month period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI X X 

AQ

A 

Ado

pted 

/122 

Effective 

Clinical Care 

Adult Kidney Disease: Blood Pressure 

Management: Percentage of patient visits for 

those patients aged 18 years and older with a 

diagnosis of chronic kidney disease (CKD) (stage 

3, 4, or 5, not receiving Renal Replacement 

Therapy [RRT]) and proteinuria with a blood 

pressure < 130/80 mmHg OR ≥ 130/80 mmHg 

with a documented plan of care 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI X X AQA 

056

3 

/141 

Communicati

on and Care 

Coordination 

Primary Open-Angle Glaucoma (POAG): 

Reduction of Intraocular Pressure (IOP) by 

15% OR Documentation of a Plan of Care: 

Percentage of patients aged 18 years and older with 

a diagnosis of primary open-angle glaucoma 

(POAG) whose glaucoma treatment has not failed 

(the most recent IOP was reduced by at least 15% 

from the pre- intervention level) OR if the most 

recent IOP was not reduced by at least 15% from 

the pre- intervention level, a plan of care was 

documented within 12 months 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 

005

6 

/163 

123

v2 

Effective 

Clinical Care 

Diabetes: Foot Exam: Percentage of patients aged 

18-75 years of age with diabetes who had a foot 

exam during the measurement period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

NCQA X X X X 

ACO 

MU2 

065

9 

/185 

Communicati

on and Care 

Coordination 

Endoscopy /Polyp Surveillance: Colonoscopy 

Interval for Patients with a History of 

Adenomatous Polyps – Avoidance of 

AMAPCPI 

ASCO 

 X 
 349 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

Inappropriate Use: Percentage of patients aged 

18 years and older receiving a surveillance 

colonoscopy with a history of a prior adenomatous 

polyp(s) in previous colonoscopy findings, who 

had an interval of 3 or more years since their last 

colonoscopy 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

038

6 

/194 

Effective 

Clinical Care 

Oncology: Cancer Stage Documented: 

Percentage of patients, regardless of age, with a 

diagnosis of cancer who are seen in the ambulatory 

setting who have a baseline American Joint 

Committee on Cancer (AJCC) cancer stage or 

documentation that the cancer is metastatic in the 

medical record at least once during the 12 month 

reporting period 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

NCQA 

 X 

065

1 

/254 

Effective 

Clinical Care 

Ultrasound Determination of Pregnancy 

Location for Pregnant Patients with Abdominal 

Pain: Percentage of pregnant female patients aged 

14 to 50 who present to the emergency department 

(ED) with a chief complaint of abdominal pain or 

vaginal bleeding who receive a trans-abdominal or 

trans-vaginal ultrasound to determine pregnancy 

location 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

ACEP 

 X 

065

2 

/255 

Effective 

Clinical Care 

Rh Immunoglobulin (Rhogam) for Rh-Negative 

Pregnant Women at Risk of Fetal Blood 

Exposure: Percentage of Rh-negative pregnant 

women aged 14-50 years at risk of fetal blood 

exposure who receive Rh-Immunoglobulin 

(Rhogam) in the emergency department (ED) 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

ACEP 

 X 

N/A 

/268 

Effective 

Clinical Care 

Epilepsy: Counseling for Women of 

Childbearing Potential with Epilepsy: All 

female patients of childbearing potential (12-44 

years old) diagnosed with epilepsy who were 

counseled about epilepsy and how its treatment 

may affect contraception and pregnancy at least 

AAN 

 X 
 350 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

once a year 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

065

8 

/320 

Communicati

on and Care 

Coordination 

Endoscopy/Polyp Surveillance: Appropriate 

Follow-Up Interval for Normal Colonoscopy in 

Average Risk Patients: Percentage of patients 

aged 50 years and older receiving a screening 

colonoscopy without biopsy or polypectomy who 

had a recommended follow-up interval of at least 

10 years for repeat colonoscopy documented in 

their colonoscopy report 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI X 

152

5 

/326 

Effective 

Clinical Care 

Atrial Fibrillation and Atrial Flutter: Chronic 

Anticoagulation Therapy: Percentage of patients 

aged 18 and older with a diagnosis of nonvalvular 

atrial fibrillation ( AF) or atrial flutter whose 

assessment of the specified thromboembolic risk 

factors indicate one or more high-risk factors or 

more than one moderate risk factor, as determined 

by CHADS2 risk stratification, who were 

prescribed warfarin OR another oral anticoagulant 

drug that is FDA approved for the prevention of 

thromboembolism 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

ACCF 

AHA 

 X 

N/A 

/327 

Effective 

Clinical Care 

Pediatric Kidney Disease: Adequacy of Volume 

Management: Percentage of calendar months 

within a 12-month period during which patients 

aged 17 years and younger with a diagnosis of End 

Stage Renal Disease (ESRD) undergoing 

maintenance hemodialysis in an outpatient dialysis 

facility have an assessment of the adequacy of 

volume management from a nephrologist 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

AMAPCPI 

 X 

166

7 

/328 

Effective 

Clinical Care 

Pediatric Kidney Disease: ESRD Patients 

Receiving Dialysis: Hemoglobin Level < 10g/dL: 

Percentage of calendar months within a 12-month 

period during which patients aged 17 years and 

younger with a diagnosis of End Stage Renal 

Disease (ESRD) receiving hemodialysis or 

AMAPCPI 

 X 
 351 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

peritoneal dialysis have a hemoglobin level < 10 

g/dL 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting.

010

4/10

7 

161

v2 

Effective 

Clinical Care 

Adult Major Depressive Disorder (MDD): 

Suicide Risk Assessment: Percentage of patients 

aged 18 years and older with a diagnosis of major 

depressive disorder (MDD) with a suicide risk 

assessment completed during the visit in which a 

new diagnosis or recurrent episode was identified 

Rationale: CMS initially wanted to propose 

removal of this measure as it is a process measure 

that is low bar. However, to maintain alignment 

with the EHR Incentive Program, under which this 

measure is also available for reporting in 2015, 

CMS proposes to maintain this measure in PQRS 

for EHR reporting only, removing all other 

reporting options.

AMAPCPI X MU2 

010

5/9 

128

v2 

Effective 

Clinical Care 

Anti-Depressant Medication Management: 

"Percentage of patients 18 years of age and older 

who were diagnosed with major depression and 

treated with antidepressant medication, and who 

remained on antidepressant medication treatment. 

Two rates are reported 

a. Percentage of patients who remained on an 

antidepressant medication for at least 84 days (12 

weeks). 

b. Percentage of patients who remained on an 

antidepressant medication for at least 180 days (6 

months). 

Rationale: CMS initially wanted to propose 

removal of this measure as it is a process measure 

that is analytically challenging to report. However, 

to maintain alignment with the EHR Incentive 

Program, under which this measure is also 

available for reporting in 2015, CMS proposes to 

maintain this measure in PQRS for EHR reporting 

only, removing all other reporting options. 

NCQA X MU2 

006

4/2 

163

v2 

Effective 

Clinical Care 

Diabetes: Low Density Lipoprotein (LDL-C) 

Control (<100 mg/Dl: Percentage of patients 18–

75 years of age with diabetes whose LDL-C was 

adequately controlled (< 100 mg/dL) during the 

measurement period 

Rationale: CMS initially wanted to propose 

removal of this measure as it would be duplicative 

of the new diabetes composite. However, to 

maintain alignment with the EHR Incentive 

Program, under which this measure is also 

NCQA X 

MU2 

Million 

Hearts 
 352 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

available for reporting in 2015, CMS proposes to 

maintain this measure in PQRS for EHR reporting 

only, removing all other reporting options.

008

8/00

18 

167

v2 

Effective 

Clinical Care 

Diabetic Retinopathy: Documentation of 

Presence or Absence of Macular Edema and 

Level of Severity of Retinopathy: Percentage of 

patients aged 18 years and older with a diagnosis 

of diabetic retinopathy who had a dilated macular 

or fundus exam performed which included 

documentation of the level of severity of 

retinopathy and the presence or absence of macular 

edema during one or more office visits within 12 

months 

Rationale: CMS initially wanted to propose 

removal of this measure as eligible professionals 

are consistently meeting performance on this 

measure with performance rates close to 100%. 

However, to maintain alignment with the EHR 

Incentive Program, under which this measure is 

also available for reporting in 2015, CMS proposes 

to maintain this measure in PQRS for EHR 

reporting only, removing all other reporting 

options. 

AMAPCPI 

NCQA 

 X MU2 

006

8/20

4 

164

v2 

Effective 

Clinical Care 

Ischemic Vascular Disease (IVD): Use of 

Aspirin or Another Antithrombotic: Percentage 

of patients 18 years of age and older who were 

discharged alive for acute myocardial infarction 

(AMI), coronary artery bypass graft (CABG) or 

percutaneous coronary interventions (PCI) in the 

12 months prior to the measurement period, or who 

had an active diagnosis of ischemic vascular 

disease (IVD) during the measurement period and 

who had documentation of use of aspirin or 

another antithrombotic during the measurement 

period 

Rationale: CMS initially wanted to propose 

removal of this measure due to changing clinical 

guidelines (ATP-4). However, to maintain 

alignment with the EHR Incentive Program, under 

which this measure is also available for reporting 

in 2015, CMS proposes to maintain this measure in 

PQRS for EHR reporting only, removing all other 

reporting options. 

NCQA X 

MU2 

Million 

Hearts 

007

5/24

1 

182

v3 

Effective 

Clinical Care 

Ischemic Vascular Disease (IVD): Complete 

Lipid Profile and LDL-C Control (<100 

mg/dL): Percentage of patients 18 years of age and 

older who were discharged alive for acute 

myocardial infarction (AMI), coronary artery 

bypass graft (CABG) or percutaneous coronary 

interventions (PCI) in the 12 months prior to the 

measurement period, or who had an active 

diagnosis of ischemic vascular disease (IVD) 

NCQA X 

MU2 

Million 

Hearts 
 353 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

during the measurement period, and who had each 

of the following during the measurement period: a 

complete lipid profile and LDL-C was adequately 

controlled (< 100 mg/dL) 

Rationale: CMS initially wanted to propose 

removal of this measure due to changing clinical 

guidelines (ATP-4). However, to maintain 

alignment with the EHR Incentive Program, under 

which this measure is also available for reporting 

in 2015, CMS proposes to maintain this measure in 

PQRS for EHR reporting only, removing all other 

reporting options.

002

2/23

8 

156

v2 Patient Safety 

Use of High-Risk Medications in the Elderly: 

Percentage of patients 66 years of age and older 

who were ordered high-risk medications. Two 

rates are reported. 

a. Percentage of patients who were ordered at least 

one high-risk medication. 

b. Percentage of patients who were ordered at least 

two different high-risk medications. 

Rationale: CMS proposes to add registry as a 

reporting option for this measure to enhance 

reporting by more providers.

NCQA X X MU2 

039

5 

/84 

Effective 

Clinical Care 

Hepatitis C: Ribonucleic Acid (RNA) Testing 

Before Initiating Treatment: Percentage of 

patients aged 18 years and older with a diagnosis 

of chronic hepatitis C who started antiviral 

treatment within the 12 month reporting period for 

whom quantitative hepatitis C virus (HCV) RNA 

testing was performed within 12 months prior to 

initiation of antiviral treatment 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Hepatitis C measures group 

allows CMS to evaluate patients diagnosed with 

Hepatitis C to be assessed in a more 

comprehensive manner.

AMAPCPI 

 X 

039

6 

/85 

Effective 

Clinical Care 

Hepatitis C: HCV Genotype Testing Prior to 

Treatment: Percentage of patients aged 18 years 

and older with a diagnosis of chronic hepatitis C 

who started antiviral treatment within the 12 month 

reporting period for whom hepatitis C virus (HCV) 

genotype testing was performed within 12 months 

prior to initiation of antiviral treatment 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

AMAPCPI 

 X 
 354 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Hepatitis C measures group 

allows CMS to evaluate patients diagnosed with 

Hepatitis C to be assessed in a more 

comprehensive manner.

039

8/87 

Effective 

Clinical Care 

Hepatitis C: Hepatitis C Virus (HCV) 

Ribonucleic Acid (RNA) Testing Between 4-12 

Weeks After Initiation of Treatment: Percentage 

of patients aged 18 years and older with a 

diagnosis of chronic hepatitis C who are receiving 

antiviral treatment for whom quantitative hepatitis 

C virus (HCV) RNA testing was performed 

between 4-12 weeks after the initiation of antiviral 

treatment 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Hepatitis C measures group 

allows CMS to evaluate patients diagnosed with 

Hepatitis C to be assessed in a more 

comprehensive manner.

AMAPCPI 

 X 

005

4 

/108 

Effective 

Clinical Care 

Rheumatoid Arthritis (RA): Disease Modifying 

Anti-Rheumatic Drug (DMARD) Therapy: 

Percentage of patients aged 18 years and older who 

were diagnosed with RA and were prescribed, 

dispensed, or administered at least one ambulatory 

prescription for a DMARD 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner.

NCQA X 

040

5 

/160 

52v

2 

Effective 

Clinical Care 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia 

(PCP) Prophylaxis: Percentage of patients aged 6 

weeks and older with a diagnosis of HIV/AIDS 

who were prescribed Pneumocystis Jiroveci 

Pneumonia (PCP) prophylaxis 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

NCQA X MU2 
 355 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the HIV/AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HIV/AIDS to be assessed in a more comprehensive 

manner.

AQ

A 

Ado

pted

/176 

Effective 

Clinical Care 

Rheumatoid Arthritis (RA): Tuberculosis 

Screening: Percentage of patients aged 18 years 

and older with a diagnosis of rheumatoid arthritis 

(RA) who have documentation of a tuberculosis 

(TB) screening performed and results interpreted 

within 6 months prior to receiving a first course of 

therapy using a biologic disease-modifying antirheumatic drug (DMARD) 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner.

AMAPCPI X AQA 

AQ

A 

Ado

pted

/177 

Effective 

Clinical Care 

Rheumatoid Arthritis (RA): Periodic 

Assessment of Disease Activity: Percentage of 

patients aged 18 years and older with a diagnosis 

of rheumatoid arthritis (RA) who have an 

assessment and classification of disease activity 

within 12 months 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner.

AMAPCPI X AQA 

AQ

A 

Ado

pted

/179 

Effective 

Clinical Care 

Rheumatoid Arthritis (RA): Assessment and 

Classification of Disease Prognosis: Percentage 

of patients aged 18 years and older with a 

diagnosis of rheumatoid arthritis (RA) who have 

an assessment and classification of disease 

prognosis at least once within 12 months 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

AMAPCPI X AQA 
 356 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner.

AQ

A 

Ado

pted 

/180 

Effective 

Clinical Care 

Rheumatoid Arthritis (RA): Glucocorticoid 

Management: Percentage of patients aged 18 

years and older with a diagnosis of rheumatoid 

arthritis (RA) who have been assessed for 

glucocorticoid use and, for those on prolonged 

doses of prednisone ≥ 10 mg daily (or equivalent) 

with improvement or no change in disease activity, 

documentation of glucocorticoid management plan 

within 12 months 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner.

AMAPCPI X AQA 

039

9 

/183 

Community/ 

Population 

Health 

Hepatitis C: Hepatitis A Vaccination in Patients 

with Hepatitis C Virus (HCV): Percentage of 

patients aged 18 years and older with a diagnosis 

of chronic hepatitis C who have received at least 

one injection of hepatitis A vaccine, or who have 

documented immunity to hepatitis A 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Hepatitis C measures group 

allows CMS to evaluate patients diagnosed with 

Hepatitis C to be assessed in a more 

comprehensive manner.

AMAPCPI 

 X 

040

9 

/205 

Effective 

Clinical Care 

HIV/AIDS: Sexually Transmitted Disease 

Screening for Chlamydia, Gonorrhea, and 

Syphilis: Percentage of patients aged 13 years and 

older with a diagnosis of HIV/AIDS for whom 

chlamydia, gonorrhea and syphilis screenings were 

performed at least once since the diagnosis of HIV 

infection 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

AMAPCPI 

 X 
 357 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface)* Measures Groups Other Quality Reporting Programs 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the HIV/AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HIV/AIDS to be assessed in a more comprehensive 

manner.

208

2 

/338 

Effective 

Clinical Care 

HIV Viral Load Suppression: The percentage of 

patients, regardless of age, with a diagnosis of HIV 

with a HIV viral load less than 200 copies/mL at 

last viral load test during the measurement year 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the HIV/AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HIV/AIDS to be assessed in a more comprehensive 

manner.

HRSA X 

208

3 

/339 

Effective 

Clinical Care 

Prescription of HIV Antiretroviral Therapy: 

Percentage of patients, regardless of age, with a 

diagnosis of HIV prescribed antiretroviral therapy 

for the treatment of HIV infection during the 

measurement year 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the HIV/AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HIV/AIDS to be assessed in a more comprehensive 

manner.

HRSA X 

207

9 

/340 

Efficiency 

and Cost 

Reduction 

HIV Medical Visit Frequency: Percentage of 

patients, regardless of age with a diagnosis of HIV 

who had at least one medical visit in each 6 month 

period of the 24 month measurement period, with a 

minimum of 60 days between medical visits 

Rationale: CMS proposes to make this individual 

measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of 9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the HIV/AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HIV/AIDS to be assessed in a more comprehensive 

manner.

HRSA X 
 358 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program 

year. This is due to the timing of measure specification preparation and the measure versions used by the various 

reporting options/methods. Please refer to the measure specifications that apply for each of the reporting 

options/methods for specific measure details.

We seek comment on these proposals. 

d. PQRS Measures Groups 

Section 414.90(b) defines a measures group as a subset of four or more Physician Quality 

Reporting System measures that have a particular clinical condition or focus in common. The 

denominator definition and coding of the measures group identifies the condition or focus that is 

shared across the measures within a particular measures group. 

In the CY 2014 PFS proposed rule, we proposed (78 FR 43448) to increase the number of 

measures that may be included in a measures group from a minimum of 4 measures to a 

minimum of 6. We proposed increasing the minimum number of measures that may be 

contained in a measures group in accordance with increasing the number of individual measures 

to be reported via claims and registry. However, we did not finalize this proposal, stating that, 

although we still plan to increase the minimum number of measures in a measures group in the 

future, we would work with the measure developers and owners of these measures groups to 

appropriately add measures to measures groups that only contain four measures within the 

measures group (78 FR 74730). We have worked with the measure owners and developers and 

are again proposing to increase the number of measures that may be included in a measures 

group from a minimum of 4 measures to a minimum of 6. 

Specifically, we are proposing to modify section 414.90(b) to define a measures group as 

a subset of six or more Physician Quality Reporting System measures that have a particular 

clinical condition or focus in common. 

In addition, we are proposing two new measures groups that will be available for 

reporting in the PQRS beginning in 2015: 
 359 

● The sinusitis measures group: We are proposing a new sinusitis measures group 

because this measures group represents a clinical gap within the measure group reporting option. 

The measures in the sinusitis measures group reflect a variety of measure types, and make up a 

clinically coherent and meaningful set of measures. 

● The Acute Otits Externa (AOE) measures group: We are proposing the addition of the 

AOE measures group, as it focuses on the quality of care of patients with AOE by combining 

existing disease-specific measures with relevant cross-cutting (generic) measures. 

Furthermore, we are proposing to remove the following measures groups for reporting 

beginning in 2015 for the following reasons: 

● Perioperative care measures group: We are proposing to remove the perioperative care 

measures group from reporting in the PQRS beginning in 2015 because this measures group does 

not add value to the PQRS and eligible professionals are consistently meeting performance on 

this measure with performance rates close to 100 percent. 

● Back pain measures group: We are proposing to remove the back pain measures group 

because the measure steward is not preparing these measures for re-endorsement by the National 

Quality Forum. We are also proposing to remove the measures group because it reflects clinical 

concepts that do not add clinical value to PQRS. Specifically, the measures in this group are 

entirely clinical process measures that do not meaningfully contribute to improved patient 

outcomes.

● Cardiovascular prevention measures group: We are proposing to remove the 

cardiovascular prevention measures group because a number of individual measures contained in 

this measures group are proposed to be removed from all PQRS program reporting options with 

the exception of EHR reporting.
 360 

● Ischemic Vascular Disease (IVD) measures group: We are proposing to remove the 

IVD measures group because a number of individual measures contained in this measures group 

are proposed to be removed from all PQRS program reporting options with the exception 

of EHR reporting. 

● Sleep Apnea measures group: We are proposing to remove the Sleep Apnea measures 

group from reporting in the PQRS beginning in 2015 because, for a number of measures 

included in this group, the measure steward has indicated they will no longer maintain those 

measures. Those measures and their associated measure groups are proposed for removal from 

the program. As a result, the measures group would have less than the 6 measures proposed to 

be required in a measures group. Please note that this proposal is contingent on the measure 

steward not being able to maintain ownership of certain measures. Should we learn that a 

measure owner/developer is able to maintain certain measures, or that another entity is able to 

maintain certain measures, such that the measure group maintains a sufficient number of 

measures for reporting under the PQRS for the CY 2017 PQRS payment adjustment, we propose 

to keep the measure group available for reporting under the PQRS and therefore not finalize our 

proposal to remove the measure group. 

● Chronic obstructive pulmonary disease (COPD) measures group: We are proposing to 

remove the COPD measures group from reporting in the PQRS beginning in 2015 because, for a 

number of measures included in this group, the measure steward has indicated they will no 

longer maintain those measures. Those measures and their associated measure groups are 

proposed for removal from the program. As a result, the measures group would have less than 

the 6 measures proposed to be required in a measures group. Please note that this proposal is 

contingent on the measure steward not being able to maintain ownership of certain measures. 

Should we learn that a measure owner/developer is able to maintain certain measures, or that 
 361 

another entity is able to maintain certain measures, such that the measure group maintains a 

sufficient number of measures for reporting under the PQRS for the CY 2017 PQRS payment 

adjustment, we propose to keep the measure group available for reporting under the PQRS and 

therefore not finalize our proposal to remove the measure group. 

Tables 26 through 48 specify our proposed measures groups in light of our proposal to 

increase the minimum number of measures in a measures group in previously established 

measures groups, so that each measures group contains at least 6 measures. We invite public 

comment on these proposals. 

TABLE 26: Proposed Asthma Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0047/053 

Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting: Percentage of 

patients aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term 

control medication 

AMA-PCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin / mineral / dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients aged 18 years and older who were screened for tobacco use one or more times within 24 months 

AND who received cessation counseling intervention if identified as a tobacco user

AMA-PCPI 

N/A/N/A 

Tobacco Use and Help with Quitting Among Adolescents: Percentage of adolescents 13 to 20 years of 

age with a primary care visit during the measurement period for whom tobacco use status was 

documented and received help quitting if identified as a tobacco user.

NCQA / NCIQM 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of 

patients aged 18 years and older with a documented BMI during the current encounter or during 

the previous 6 months AND when the BMI is outside of normal parameters, a follow-up plan is 

documented during the encounter or during the previous 6 months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and 

< 25 

CMS/QIP 

TABLE 27: Proposed Acute Otitis Externa (AOE) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0653/091 Acute Otitis Externa (AOE): Topical Therapy: Percentage of patients aged 2 years and older with a 

diagnosis of AOE who were prescribed topical preparations AMA-PCPI 

0654/093 

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: 

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic 

antimicrobial therapy

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin / mineral / dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 
 362 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0420/131 

Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with 

documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a 

follow-up plan when pain is present

CMS/QIP 

0101/154 Falls: Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a 

risk assessment for falls completed within 12 months AMA-PCPI 

0101/155 Falls: Plan of Care: Percentage of patients aged 65 years and older with a history of falls who had a plan 

of care for falls documented within 12 months AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/317 

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for 

high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood 

pressure reading as indicated. 

CMS/QIP 

TABLE 28: Proposed Cataracts Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0565/191 

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery: Percentage of 

patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and 

no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual 

acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery 

AMA-PCPI/NCQA 

0564/192 

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional 

Surgical Procedures: Percentage of patients aged 18 years and older with a diagnosis of uncomplicated 

cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days 

following cataract surgery which would indicate the occurrence of any of the following major 

complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal 

detachment, or wound dehiscence 

AMA-PCPI/NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/303 

Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery:

Percentage of patients aged 18 years and older in sample who had cataract surgery and had improvement 

in visual function achieved within 90 days following the cataract surgery, based on completing a preoperative and post-operative visual function survey 

AAO 

N/A/304 

Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery: Percentage of patients 

aged 18 years and older in sample who had cataract surgery and were satisfied with their care within 90 

days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare 

Providers and Systems Surgical Care Survey 

AAO 

N/A/358 

Patient-Centered Surgical Risk Assessment and Communication: Percentage of patients who 

underwent a non-emergency surgery who had their personalized risks of postoperative complications 

assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator 

and who received personal discussion of those risks with the surgeon 

ACS 

N/A/N/A 

Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule 

requiring unplanned vitrectomy): Rupture of the posterior capsule during anterior segment surgery 

requiring vitrectomy 

AAEECE/ACHS 

N/A/N/A Cataract Surgery: Difference Between Planned and Final Refraction: Percentage of patients who 

achieve planned refraction within +-1,0 D. AAEECE/ACHS 

TABLE 29: Proposed Chronic Kidney Disease (CKD) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 
 363 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision maker 

documented in the medical record or documentation in the medical record that an care plan was discussed but 

the patient did not wish or was not able to name a surrogate decision maker or provide an care plan 

AMAPCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older 

seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported 

previous receipt of an influenza immunization 

AMA-PCPI 

1668/121 

Adult Kidney Disease: Laboratory Testing (Lipid Profile): Percentage of patients aged 18 years and older 

with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy 

[RRT]) who had a fasting lipid profile performed at least once within a 12-month period 

AMA-PCPI 

N/A/122 

Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for those patients aged 18 

years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal 

Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80 mmHg OR ≥ 130/80 mmHg with 

a documented plan of care 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 

years and older for which the eligible professional attests to documenting a list of current medications using all 

immediate resources available on the date of the encounter. This list must include ALL known prescriptions, 

over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the 

medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who 

received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 30: Proposed Chronic Obstructive Pulmonary Disorder (COPD) Measures Group for 2015 and 

Beyond 

(Please note that we are proposing to remove this measure group contingent on the measure steward not being able 

to maintain certain measures contained in these measures group. If a measure steward is able to maintain ownership 

of these measures, we plan to keep this measures group in the PQRS measure set. This Table Q10 indicates the 

measures that we propose will be available in this measures group should we keep this measures group in the PQRS 

measure set.)

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision maker 

documented in the medical record or documentation in the medical record that an care plan was discussed but 

the patient did not wish or was not able to name a surrogate decision maker or provide an care plan 

AMAPCPI/NCQA 

0091/051 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of patients aged 18 

years and older with a diagnosis of COPD who had spirometry evaluation results documented AMA-PCPI 

0102/052 

Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy: Percentage of 

patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 60% and 

have symptoms who were prescribed an inhaled bronchodilator 

AMA-PCPI 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older 

seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported 

previous receipt of an influenza immunization 

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have 

ever received a pneumococcal vaccine NCQA 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 

years and older for which the eligible professional attests to documenting a list of current medications using all 

immediate resources available on the date of the encounter. This list must include ALL known prescriptions, 

over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the 

medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who 

received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 31: Proposed Coronary Artery Bypass Graft (CABG) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 
 364 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0134/043 

Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with 

Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing isolated CABG 

surgery who received an IMA graft 

STS 

0236/044 

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated 

CABG Surgery: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients 

aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision 

CMS/QIP 

0129/164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients aged 18 years 

and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours STS 

0130/165 

Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate: Percentage of patients 

aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop 

deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative 

intervention 

STS 

0131/166 

Coronary Artery Bypass Graft (CABG): Stroke: Percentage of patients aged 18 years and older 

undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological 

deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 

hours 

STS 

0114/167 

Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure: Percentage of patients aged 18 

years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop 

postoperative renal failure or require dialysis 

STS 

TABLE 32: Proposed Coronary Artery Disease (CAD) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0067/006 

Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed 

aspirin or clopidogrel 

AMAPCPI/ACCF/AHA 

0070/007 

Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or 

Left Ventricular Systolic Dysfunction (LVEF < 40%: Percentage of patients aged 18 years and older 

with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a 

current or LVEF < 40% who were prescribed beta-blocker therapy

AMA-PCPI 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of 

patients aged 18 years and older with a documented BMI during the current encounter or during the 

previous 6 months AND when the BMI is outside of normal parameters, a follow-up plan is documented 

during the encounter or during the previous 6 months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and < 25 

CMS/QIP 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/242 

Coronary Artery Disease (CAD): Symptom Management: Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease seen within a 12 month period with results of an 

evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with 

appropriate management of anginal symptoms within a 12 month period 

AMAPCPI/ACCF/AHA 

TABLE 33: Proposed Dementia Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision 

maker documented in the medical record or documentation in the medical record that an care plan was 

discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an 

care plan 

AMA-PCPI/NCQA 

N/A/280 

Dementia: Staging of Dementia: Percentage of patients, regardless of age, with a diagnosis of dementia 

whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month 

period 

AMA-PCPI 
 365 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/281 

Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a diagnosis of 

dementia for whom an assessment of cognition is performed and the results reviewed at least once within 

a 12 month period 

AMA-PCPI 

N/A/282 

Dementia: Functional Status Assessment: Percentage of patients, regardless of age, with a diagnosis of 

dementia for whom an assessment of functional status is performed and the results reviewed at least once 

within a 12 month period 

AMA-PCPI 

N/A/283 

Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of age, with a 

diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and 

results reviewed at least once in a 12 month period 

AMA-PCPI 

N/A/284 

Dementia: Management of Neuropsychiatric Symptoms: Percentage of patients, regardless of age, 

with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were 

recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period 

AMA-PCPI 

N/A/285 Dementia: Screening for Depressive Symptoms: Percentage of patients, regardless of age, with a 

diagnosis of dementia who were screened for depressive symptoms within a 12 month period AMA-PCPI 

N/A/286 

Dementia: Counseling Regarding Safety Concerns: Percentage of patients, regardless of age, with a 

diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding 

safety concerns within a 12 month period 

AMA-PCPI 

N/A/287 

Dementia: Counseling Regarding Risks of Driving: Percentage of patients, regardless of age, with a 

diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the 

alternatives to driving at least once within a 12 month period 

AMA-PCPI 

N/A/288 

Dementia: Caregiver Education and Support: Percentage of patients, regardless of age, with a 

diagnosis of dementia whose caregiver(s) were provided with education on dementia disease 

management and health behavior changes AND referred to additional sources for support within a 12 

month period 

AMA-PCPI 

TABLE 34: Proposed Diabetes Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0059/001 Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-75 years of age with diabetes who 

had hemoglobin A1c > 9.0% during the measurement period NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization 

AMA-PCPI 

0055/117 

Diabetes: Eye Exam: Percentage of patients 18 through 75 years of age with a diagnosis of diabetes 

(type 1 and type 2) who had a retinal or dilated eye exam in the measurement period or a negative retinal 

or dilated eye exam (negative for retinopathy) in the year prior to the measurement period 

NCQA 

0062/119 

Diabetes: Medical Attention for Neuropathy: The percentage of patients 18-75 years of age with 

diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement 

period 

NCQA 

0056/163 Diabetes: Foot Exam: Percentage of patients aged 18-75 years of age with diabetes who had a foot exam 

during the measurement period NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 35: Proposed General Surgery Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/354 Anastomotic Leak Intervention: Percentage of patients aged 18 years and older who required an 

anastomotic leak intervention following gastric bypass or colectomy surgery ACS 
 366 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/355 Unplanned Reoperation within the 30 Day Postoperative Period: Percentage of patients aged 18 years 

and older who had any unplanned reoperation within the 30 day postoperative period ACS 

N/A/356 Unplanned Hospital Readmission within 30 Days of Principal Procedure: Percentage of patients aged 

18 years and older who had an unplanned hospital readmission within 30 days of principal procedure ACS 

N/A/357 Surgical Site Infection (SSI): Percentage of patients aged 18 years and older who had a surgical site 

infection (SSI) ACS 

N/A/358 

Patient-Centered Surgical Risk Assessment and Communication: Percentage of patients who 

underwent a non-emergency surgery who had their personalized risks of postoperative complications 

assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator 

and who received personal discussion of those risks with the surgeon 

ACS 

TABLE 36: Proposed Heart Failure (HF) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0081/005 

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor 

Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients 

aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular 

ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 

month period when seen in the outpatient setting OR at each hospital discharge 

AMAPCPI/ACCF/AHA 

0083/008 

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD):

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or 

prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either 

within a 12 month period when seen in the outpatient setting OR at each hospital discharge 

AMAPCPI/ACCF/AHA 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision 

maker documented in the medical record or documentation in the medical record that an care plan was 

discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an 

care plan 

AMA-PCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR 

who reported previous receipt of an influenza immunization.

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients 

aged 18 years and older for which the eligible professional attests to documenting a list of current 

medications using all immediate resources available on the date of the encounter. This list must include 

ALL known prescriptions, over-the-counters, herbals, and vitamin / mineral / dietary (nutritional) 

supplements AND must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage 

of patients 18 years and older who were screened for tobacco use one or more times within 24 months 

AND who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 37: Proposed Hepatitis C Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0395/084 

Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment: Percentage of patients aged 

18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 

month reporting period for whom quantitative hepatitis C virus (HCV) RNA testing was performed within 

12 months prior to initiation of antiviral treatment 

AMA-PCPI 

0396/085 

Hepatitis C: HCV Genotype Testing Prior to Treatment: Percentage of patients aged 18 years and older 

with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period 

for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of 

antiviral treatment 

AMA-PCPI 

0398/087 

Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After 

Initiation of Treatment: Percentage of patients aged 18 years and older with a diagnosis of chronic 

hepatitis C who are receiving antiviral treatment for whom quantitative hepatitis C virus (HCV) RNA 

testing was performed between 4-12 weeks after the initiation of antiviral treatment 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 

years and older for which the eligible professional attests to documenting a list of current medications using 

all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must 

contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 
 367 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0399/183 

Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV): Percentage of patients 

aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of 

hepatitis A vaccine, or who have documented immunity to hepatitis A 

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/N/A 

Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis: Percentage of 

patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who were screened with 

either ultrasound, triple-contrast CT or triple-contrast MRI for hepatocellular carcinoma (HCC) at least 

once within the 12 month reporting period 

AGA/AASLD/AMAPCPI 

N/A/N/A 

Discussion and Shared Decision Making Surrounding Treatment Options: Percentage of patients aged 

18 years and older with a diagnosis of hepatitis C with whom a physician or other clinician reviewed the 

range of treatment options appropriate to their genotype and demonstrated a shared decision making 

approach with the patient. To meet the measure, there must be documentation in the patient record of a 

discussion between the physician/clinician and the patient that includes all of the following: 

•Treatment choices appropriate to genotype 

•Risks and benefits 

•Evidence of effectiveness 

•Patient preferences toward the outcome of the treatment 

AGA/AASLD/AMAPCPI 

TABLE 38: Proposed HIV/AIDS Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision 

maker documented in the medical record or documentation in the medical record that an care plan was 

discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an 

care plan 

AMA-PCPI/NCQA 

0418/134 

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan: Percentage 

of patients aged 12 years and older screened for clinical depression on the date of the encounter using an 

age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented 

on the date of the positive screen. 

CMS/QIP 

0405/160 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients aged 6 

weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia 

(PCP) prophylaxis 

NCQA 

0409/205 

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis:

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, 

gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection 

AMA-PCPI/NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients aged 18 years and older who were screened for tobacco use one or more times within 24 months 

AND who received cessation counseling intervention if identified as a tobacco user

AMA-PCPI 

2082/338 HIV Viral Load Suppression: The percentage of patients, regardless of age, with a diagnosis of HIV 

with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year HRSA 

2083/339 Prescription of HIV Antiretroviral Therapy: Percentage of patients, regardless of age, with a diagnosis 

of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year HRSA 

2079/340 

HIV Medical Visit Frequency: Percentage of patients, regardless of age with a diagnosis of HIV who 

had at least one medical visit in each 6 month period of the 24 month measurement period, with a 

minimum of 60 days between medical visits 

HRSA 

TABLE 39: Proposed Inflammatory Bowel Disease (IBD) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/270 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy: Percentage 

of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have been 

managed by corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days that 

have been prescribed corticosteroid sparing therapy in the last reporting year 

AGA 
 368 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/271 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – 

Bone Loss Assessment: Percentage of patients aged 18 years and older with a diagnosis of inflammatory 

bowel disease who have received dose of corticosteroids greater than or equal to 10 mg/day for 60 or 

greater consecutive days and were assessed for risk of bone loss once per the reporting year 

AGA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization 

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who 

have ever received a pneumococcal vaccine NCQA 

N/A/274 

Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating AntiTNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a 

diagnosis of inflammatory bowel disease for whom a tuberculosis (TB) screening was performed and 

results interpreted within 6 months prior to receiving a first course of anti-TNF (tumor necrosis factor) 

therapy 

AGA 

N/A/275 

Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before 

Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and 

older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status 

assessed and results interpreted within 1 year prior to receiving a first course of anti-TNF (tumor necrosis 

factor) therapy 

AGA 

TABLE 40: Proposed Oncology Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0387/071 

Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor 

(ER/PR) Positive Breast Cancer: Percentage of female patients aged 18 years and older with Stage IC 

through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor 

(AI) during the 12-month reporting period 

AMAPCPI/ASCO/NCCN 

0385/072 

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients: Percentage of patients 

aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant 

chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy 

within the 12-month reporting period 

AMAPCPI/ASCO/NCCN 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR 

who reported previous receipt of an influenza immunization 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients 

aged 18 years and older for which the eligible professional attests to documenting a list of current 

medications using all immediate resources available on the date of the encounter. This list must include 

ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) 

supplements AND must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0384/143 

Oncology: Medical and Radiation – Pain Intensity Quantified: Percentage of patients, regardless of 

patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which 

pain intensity is quantified 

AMA-PCPI 

0383/144 

Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of visits for patients, 

regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy 

who report having pain with a documented plan of care to address pain 

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage 

of patients 18 years and older who were screened for tobacco use one or more times within 24 months 

AND who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 41: Proposed Optimizing Patient Exposure to Ionizing Radiation Measures Group for 2015 and 

Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/359 

Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature 

for Computed Tomography (CT) Imaging Description: Percentage of computed tomography (CT) 

imaging reports for all patients, regardless of age, with the imaging study named according to a 

standardized nomenclature and the standardized nomenclature is used in institution’s computer systems 

AMA-PCPI 
 369 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/360 

Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation 

Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies: Percentage 

of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging 

reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) 

and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month 

period prior to the current study 

AMA-PCPI 

N/A/361 

Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry:

Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that 

are reported to a radiation dose index registry AND that include at a minimum selected data elements 

AMA-PCPI 

N/A/362 

Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images 

Available for Patient Follow-up and Comparison Purposes: Percentage of final reports for computed 

tomography (CT) studies performed for all patients, regardless of age, which document that Digital 

Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated 

external entities on a secure, media free, reciprocally searchable basis with patient authorization for at 

least a 12-month period after the study 

AMA-PCPI 

N/A/363 

Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) 

Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive: Percentage of final 

reports of computed tomography (CT) studies performed for all patients, regardless of age, which 

document that a search for Digital Imaging and Communications in Medicine (DICOM) format images 

was conducted for prior patient CT imaging studies completed at non-affiliated external entities within 

the past 12-months and are available through a secure, authorized, media free, shared archive prior to an 

imaging study being performed 

AMA-PCPI 

N/A/364 

Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for 

Incidentally Detected Pulmonary Nodules According to Recommended Guidelines: Percentage of 

final reports for CT imaging studies of the thorax for patients aged 18 years and older with documented 

follow-up recommendations for incidentally detected pulmonary nodules (eg, follow-up CT imaging 

studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk 

factors 

AMA-PCPI 

TABLE 42: Proposed Parkinson’s Disease Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an care plan or surrogate decision 

maker documented in the medical record or documentation in the medical record that an care plan was 

discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an 

care plan 

AMA-PCPI/NCQA 

N/A/289 

Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review: All patients with a diagnosis of 

Parkinson’s disease who had an annual assessment including a review of current medications (e.g., 

medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical 

features (e.g., falls at presentation and early in the disease course, poor response to levodopa, symmetry 

at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at 

least annually 

AAN 

N/A/290 

Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment: All patients with a 

diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or disturbances (e.g., 

psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually 

AAN 

N/A/291 Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment: All patients with a diagnosis 

of Parkinson’s disease who were assessed for cognitive impairment or dysfunction at least annually AAN 

N/A/292 Parkinson’s Disease: Querying about Sleep Disturbances: All patients with a diagnosis of Parkinson’s 

disease (or caregivers, as appropriate) who were queried about sleep disturbances at least annually AAN 

N/A/293 

Parkinson’s Disease: Rehabilitative Therapy Options: All patients with a diagnosis of Parkinson’s 

disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, 

occupational, or speech therapy) discussed at least annually 

AAN 

N/A/294 

Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed: All 

patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s 

disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical 

treatment) reviewed at least once annually 

AAN 
 370 

TABLE 43: Proposed Preventive Care Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0046/039 

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older: Percentage of female 

patients aged 65 years and older who have a central dual-energy X- ray absorptiometry (DXA) 

measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 

12 months 

AMA-PCPI/NCQA 

0098/48 

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women 

Aged 65 Years and Older: Percentage of female patients aged 65 years and older who were assessed for 

the presence or absence of urinary incontinence within 12 months 

AMA-PCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization 

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who 

have ever received a pneumococcal vaccine NCQA 

N/A/112 Breast Cancer Screening: Percentage of women 50 through 74 years of age who had a mammogram to 

screen for breast cancer within 27 months NCQA 

0034/113 Colorectal Cancer Screening: Percentage of patients 50 through 75 years of age who had appropriate 

screening for colorectal cancer NCQA 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of 

patients aged 18 years and older with a documented BMI during the current encounter or during the 

previous 6 months AND when the BMI is outside of normal parameters, a follow-up plan is documented 

during the encounter or during the previous 6 months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and < 25 

CMS/QIP 

0418/134 

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan: Percentage 

of patients aged 12 years and older screened for clinical depression on the date of the encounter 

using an age appropriate standardized depression screening tool AND if positive, a follow-up plan 

is documented on the date of the positive screen. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

TABLE 44: Proposed Rheumatoid Arthritis (RA) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0054/108 

Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy:

Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed, 

dispensed, or administered at least one ambulatory prescription for a DMARD 

NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and 

older seen for a visit between October 1 and March 31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization.

AMA-PCPI 

N/A/176 

Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 years and older 

with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening 

performed and results interpreted within 6 months prior to receiving a first course of therapy using a 

biologic disease-modifying anti-rheumatic drug (DMARD) 

AMA-PCPI 

 N/A/177 

Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of patients aged 18 

years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification 

of disease activity within 12 months 

AMA-PCPI 

N/A/178 

Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 years 

and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment 

was performed at least once within 12 months 

AMA-PCPI 

N/A/179 

Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: Percentage of 

patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment 

and classification of disease prognosis at least once within 12 months 

AMA-PCPI 

N/A/180 

Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 18 years and 

older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, 

for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change 

in disease activity, documentation of glucocorticoid management plan within 12 months 

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 
 371 

TABLE 45: Proposed Sinusitis Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients 

aged 18 years and older for which the eligible professional attests to documenting a list of current 

medications using all immediate resources available on the date of the encounter. This list must 

include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) 

supplements AND must contain the medications’ name, dosage, frequency and route of 

administration. 

CMS/QIP 

0420/131 

Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with 

documentation of a pain assessment using a standardized tool(s) on each visit AND 

documentation of a follow-up plan when pain is present 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage 

of patients 18 years and older who were screened for tobacco use one or more times within 24 months 

AND who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/331 

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use): Percentage of 

patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic 

within 7 days of diagnosis or within 10 days after onset of symptoms 

AMA-PCPI 

N/A/332 

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with 

Acute Bacterial Sinusitis: Percentage of patients aged 18 years and older with a diagnosis of acute 

bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a first line antibiotic at the 

time of diagnosis 

AMA-PCPI 

N/A/333 

Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse): Percentage of patients 

aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) 

scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of 

diagnosis 

AMA-PCPI 

TABLE 46: Proposed Sleep Apnea Measures Group for 2015 and Beyond 

(Please note that we are proposing to remove this measure group contingent on the measure steward not being able 

to maintain certain measures contained in these measures group. If a measure steward is able to maintain ownership 

of these measures, we plan to keep this measures group in the PQRS measure set. This Table Q26 indicates the 

measures that we propose will be available in this measures group should we keep this measures group in the PQRS 

measure set.)

NQF/ 

PQRS Measure Title and Description Measure Developer 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of 

patients aged 18 years and older with a documented BMI during the current encounter or during the 

previous 6 months AND when the BMI is outside of normal parameters, a follow-up plan is documented 

during the encounter or during the previous 6 months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and < 25 

CMS/QIP 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/276 

Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older 

with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep 

symptoms, including presence or absence of snoring and daytime sleepiness 

AMA-PCPI/NCQA 

N/A/277 

Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 years and older 

with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory 

disturbance index (RDI) measured at the time of initial diagnosis 

AMA-PCPI/NCQA 

N/A/278 

Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 18 years and 

older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway 

pressure therapy 

AMA-PCPI/NCQA 
 372 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/279 

Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy: Percentage of visits 

for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed 

positive airway pressure therapy who had documentation that adherence to positive airway pressure 

therapy was objectively measured 

AMA-PCPI/NCQA 

TABLE 47: Proposed Total Knee Replacement (TKR) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 

18 years and older for which the eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. This list must include ALL known 

prescriptions, over-the-counters, herbals, and vitamin / mineral / dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of administration. 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of 

patients 18 years and older who were screened for tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if identified as a tobacco user 

AMA-PCPI 

N/A/350 

Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy:

Percentage of patients regardless of age or gender undergoing a total knee replacement with documented 

shared decision-making with discussion of conservative (non-surgical) therapy prior to the procedure 

AAHKS 

N/A/351 

Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation:

Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated 

for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days 

prior to the procedure including history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial 

Infarction, Arrhythmia and Stroke 

AAHKS 

N/A/352 

Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet: Percentage 

of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic 

completely infused prior to the inflation of the proximal tourniquet 

AAHKS 

N/A/353 

Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: Percentage of 

patients regardless of age or gender undergoing total knee replacement whose operative report identifies 

the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the 

prosthetic implant and the size of prosthetic implant 

AAHKS 

e. Proposals for Measures Available for Reporting in the GPRO Web Interface 

We finalized the measures that are available for reporting in the GPRO web interface for 

2014 and beyond in the CY 2013 PFS final rule (77 FR 69269). However, we are proposing to 

remove and add measures in the GPRO web interface measure set as reflected in Tables 47 and 

48 for 2015 and beyond. Specifically, Table 47 specifies the measures we are proposing to 

remove for reporting from the GPRO web interface, and Table 48 specifies the measures we are 

proposing to add for reporting in the GPRO web interface. CMS is proposing to adopt 

Depression Remission at Twelve Months (NQF #0710) in the 2015 GPRO Web Interface 

reporting option for ACOs and group practices. This measure is currently reportable in 

the PQRS program through the EHR reporting option only and has not been tested using claims 
 373 

level data or sampling methodology. Depression Remission at Twelve Months (NQF #0710) 

requires a look-back period and a look-forward period possibly spanning multiple calendar years. 

Additionally, this measure requires utilization of a PHQ-9 depression screening tool with a score 

greater than 9 and a diagnosis of depression/dysthymia to identify the beginning of the episode 

(initial patient population). Successful completion of the quality action for this measure looks 

for a PHQ-9 score of less than 5 at the twelve month mark (plus or minus 30 days) from the 

initial onset of the episode. CMS is soliciting comments regarding this proposal, including 

operational concerns and the technical feasibility for implementation in the 2015 GPRO Web 

Interface. We note that, in addition to addressing changes in evidence-based practices, we are 

modifying the GPRO web interface in an effort to align with the proposed measure changes in 

the Medicare Shared Savings Program specified in section III.M. 
 374 

TABLE 48: Proposed Measures for Removal from the Group Practice Reporting Option Web 

Interface Beginning in 2015 and Beyond 

NQF/ 

PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other 

Quality 

Reporting 

Programs 

0097/ 

46 

Care 

Coordination/ 

Patient Safety 

Patient 

Safety 

Medication Reconciliation: 

Percentage of patients aged 65 years and older discharged from any 

inpatient facility (e.g., hospital, skilled nursing facility, or 

rehabilitation facility) and seen within 30 days following discharge in 

the office by the physician, prescribing practitioner, registered nurse, or 

clinical pharmacist providing on-going care who had a reconciliation of 

the discharge medications with the current medication list in the 

outpatient medical record documented 

Rationale: This measure is designed to determine that medication 

reconciliation was done immediately following a hospital discharge 

whereas the medical community has indicated to us that it is better 

clinical practice to perform medication reconciliation at every office 

visit. Therefore, we propose replacing this measure with NQF #0419 

Documentation of Medications in the Medical Record is designed to 

measure. In addition, this new replacement measure aligns with the 

measure used in other PQRS reporting options and MU. It is also 

proposed for the Medicare Shared Savings Program and proposed for a 

domain change to communication and care coordination to be 

consistent with the domain used by NQF for this measure. 

NCQA 

0074/ 

197 

Coronary 

Artery 

Disease 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): Lipid Control: Percentage of 

patients aged 18 years and older with a diagnosis of coronary artery 

disease seen within a 12 month period who have a LDL-C result < 100 

mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a 

documented plan of care to achieve LDL-C < 100 mg/dL, including at 

a minimum the prescription of a statin 

Rationale: We propose to retire this and the two other lipid control 

measures listed as a result of new clinical guidelines released in 2013 

by the American College of Cardiology and American Heart 

Association 

(**https://circ.ahajournals.org/content/early/2013/11/11/01.cir.000043

7738.63853.7a.full.pdf ***). The new guidelines recommend treating 

individuals with moderate to high dose statin therapy based on cardiac 

risk rather than only treating high cholesterol to specific targets.

AMAPCPI/ 

ACCF/ 

AHA 
 375 NQF/ PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other 

Quality 

Reporting 

Programs 

0729/ 

319 

Diabetes 

Mellitus 

Effective 

Clinical 

Care 

Diabetes Composite: Optimal Diabetes Care: Patients ages 18 

through 75 with a diagnosis of diabetes, who meet all the numerator 

targets of this composite measure: 

● Diabetes Mellitus: High Blood Pressure Control. 

● Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control. 

● Diabetes Mellitus: Hemoglobin A1c Control (< 8%). 

● Diabetes Mellitus: Tobacco Non-Use

Rationale: We propose retiring 4 components of the 5 part diabetes 

composite measure as noted above. Specifically, we believe: 

● The blood pressure component is somewhat duplicative of the 

measure Controlling High Blood Pressure (NQF #0018) and that the 

diabetes measure may capture a subpopulation of the broader 

Controlling High Blood Pressure measure. 

● We propose to retire the LDL component as a result of new 

clinical guidelines released in 2013 by the American College of 

Cardiology and American Heart Association 

(**https://circ.ahajournals.org/content/early/2013/11/11/01.cir.000043

7738.63853.7a.full.pdf***). The new guidelines recommend treating 

individuals with moderate to high dose statin therapy based on cardiac 

risk rather than only treating high cholesterol to specific targets 

 ● The Tobacco Non-Use component of the Diabetes Mellitus 

composite is being proposed for removal from the 2015 GPRO Web 

Interface as this component is somewhat duplicative of the Tobacco 

Screening and Cessation Counseling measure (NQF 0028) and NQF 

0028 is more broadly applicable. 

 ● The Hemoglobin A1c Control (<8%) component is being 

proposed for removal as there are concerns that the A1c level 

monitored in this measure is considered too low to comprehensively 

evaluate the A1c is in control for the elder, frail population. 

MNC

M 

0075/ 

241 

Ischemic 

Vascular 

Disease 

Effective 

Clinical 

Care 

Ischemic Vascular Disease (IVD): Complete Lipid Profile and 

LDL-C Control (< 100 mg/dL): Percentage of patients 18 years of 

age and older who were discharged alive for acute myocardial 

infarction (AMI), coronary artery bypass graft (CABG) or 

percutaneous coronary interventions (PCI) in the 12 months prior to the 

measurement period, or who had an active diagnosis of ischemic 

vascular disease (IVD) during the measurement period, and who had 

each of the following during the measurement period: a complete lipid 

profile and LDL-C was adequately controlled (< 100 mg/dL)

Rationale: We propose to retire this lipid control related measure 

because of the new clinical guidelines for statin treatment, as discussed 

for other LDL measures in this table. 

NCQA MU2 

Million 

Hearts 

0068/ 

204 

Ischemic 

Vascular 

Disease 

Effective 

Clinical 

Care 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another 

Antithrombotic: Percentage of patients 18 years of age and older who 

were discharged alive for acute myocardial infarction (AMI), coronary 

artery bypass graft (CABG) or percutaneous coronary interventions 

(PCI) in the 12 months prior to the measurement period, or who had an 

active diagnosis of ischemic vascular disease (IVD) during the 

measurement period and who had documentation of use of aspirin or 

another antithrombotic during the measurement period

Rationale: CMS proposes removing this measure and replacing it with 

Coronary Artery Disease (CAD): Antiplatelet Therapy (NQF #0067), 

added to the existing CAD composite measure in GPRO Web 

Interface. 

NCQA MU2 

Million 

Hearts 
 376 

TABLE 49: Proposed New Measures That Will Be Available for Reporting by the Group Practice 

Reporting Option Web Interface Beginning in 2015 and Beyond 

NQF/ 

PQRS 

GPRO 

Module NQS Domain Measure and Title Description¥

Measure 

Steward 

Other 

Quality 

Reporting 

Programs 

0059/ 

1 

Diabetes 

Mellitus 

Effective 

Clinical Care 

Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-

75 years of age with diabetes who had hemoglobin A1c > 9.0% during 

the measurement period. 

Rationale: This is an existing measure that is being proposed as part of 

the new Diabetes Management composite as a more appropriate A1c 

component. 

NCQA MU2 

0067/

6 

Coronary 

Artery 

Disease 

Effective 

Clinical Care 

Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage 

of patients aged 18 years and older with a diagnosis of coronary artery 

disease seen within a 12 month period who were prescribed aspirin or 

clopidogrel. 

Rationale: This is a new measure that is proposed as part of a new 

Coronary Artery Disease (CAD) composite due to updated clinical 

guidelines that affected CAD-2 (NQF 0074) Coronary Artery Disease 

(CAD): Lipid Control. 

AMAPCPI/ 

ACCF/ 

AHA 

MU2 

0070/

7 

Coronary 

Artery 

Disease 

Effective 

Clinical Care 

Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior 

Myocardial Infarction (MI) or Left Ventricular Systolic 

Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease seen within a 12 month 

period who also have prior MI OR a current or LVEF < 40% who were 

prescribed beta-blocker therapy 

Rationale: This is a new measure that is being proposed to create a new 

Coronary Artery Disease (CAD) composite due to updated clinical 

guidelines that affected CAD-2 (NQF 0074) Coronary Artery Disease 

(CAD): Lipid Control.

AMAPCPI/ 

ACCF/ 

AHA 

MU2 

0055/

117 

Diabetes 

Mellitus 

Effective 

Clinical Care 

Diabetes: Eye Exam: Percentage of patients 18 through 75 years of age 

with a diagnosis of diabetes (type 1 and type 2) who had a retinal or 

dilated eye exam in the measurement period or a negative retinal or 

dilated eye exam (negative for retinopathy) in the year prior to the 

measurement period 

Rationale: This is a new measure that is being proposed to create a new 

Diabetes Management composite due to some components of the 

current MNCM composite being impacted by the updated ATP4 and 

JNC8 clinical guidelines. We believe eye exams are an important part 

of quality care for diabetic patients. 

NCQA MU2 

0419/

130 

Care 

Coordinatio

n/ 

Patient 

Safety 

Patient Safety Documentation of Current Medications in the Medical Record:

Percentage of visits for patients aged 18 years and older for which the 

eligible professional attests to documenting a list of current medications 

using all immediate resources available on the date of the encounter. 

This list must include ALL known prescriptions, over-the-counters, 

herbals, and vitamin/mineral/dietary (nutritional) supplements AND 

must contain the medications’ name, dosage, frequency and route of 

administration 

Rationale: This is a new measure being proposed to replace CARE-1 

(PQRS #46) Medication Reconciliation: Reconciliation After Discharge 

from an Inpatient Facility as this measure was not appropriate for the 

GPRO Web Interface per feedback from the measure steward (NCQA). 

Also, we received feedback from the measures community that 

Medication Reconciliation should be performed at all office visits and 

not just those visits occurring after an inpatient discharge. 

CMS/QIP MU2 

0056/

163 

Diabetes 

Mellitus 

Effective 

Clinical Care 

Diabetes: Foot Exam: Percentage of patients aged 18-75 years of age 

with diabetes who had a foot exam during the measurement period 

Rationale: This is a new measure being proposed as part of the 

Diabetes Management composite due to some components of the 

current MNCM composite being affected by the updated ATP4 and 

JNC8 clinical guidelines. We believe foot exams are an important part 

of quality care for diabetic patients. 

NCQA MU2 
 377 NQF/ PQRS 

GPRO 

Module NQS Domain Measure and Title Description¥

Measure 

Steward 

Other 

Quality 

Reporting 

Programs 

N/A/2

42 

Coronary 

Artery 

Disease 

Effective 

Clinical Care 

Coronary Artery Disease (CAD): Symptom Management: 

Percentage of patients aged 18 years and older with a diagnosis of 

coronary artery disease seen within a 12 month period with results of an 

evaluation of level of activity and an assessment of whether anginal 

symptoms are present or absent with appropriate management of 

anginal symptoms within a 12 month period 

Rationale: This is a new measure that is being proposed to create a new 

Coronary Artery Disease (CAD) composite due to updated clinical 

guidelines that affected CAD-2 (NQF 0074) Coronary Artery Disease 

(CAD): Lipid Control.

AMAPCPI/ 

ACCF/ 

AHA 

0729/ 

319 

Diabetes 

Mellitus 

Effective 

Clinical Care 

Diabetes Composite: Optimal Diabetes Care: Patients ages 18 

through 75 with a diagnosis of diabetes, who meet all the numerator 

targets of this composite measure: 

● For patients with a diagnosis of ischemic vascular disease, daily 

aspirin use unless contraindicated

Rationale: CMS proposes to maintain this component of the Optimal 

Diabetes Care composite and adding it to the new CMS Diabetes 

Management composite, as it represents an important quality measure 

for patients with multiple chronic conditions, such as diabetes and IVD. 

MNCM 

0710/

370 

 Effective 

Clinical Care 

Depression Remission at Twelve Months: Adult patients age 18 and 

older with major depression or dysthymia and an initial PHQ-9 score > 

9 who demonstrate remission at twelve months defined as PHQ-9 score 

less than 5. This measure applies to both patients with newly diagnosed 

and existing depression whose current PHQ-9 score indicates a need for 

treatment. 

Rationale: This is a new measure being proposed as it reflects a clinical 

concept not currently addressed. While we currently have a depression 

screening and follow-up measure in the GPRO WI, the Depression 

Remission measure represents an important outcome. Depression 

management is particularly important due the effects on patient 

adherence with treatment for other chronic conditions. 

MNCM MU2 

Please note that, if these proposals are finalized, the GPRO measure set will contain 21 

measures available for reporting. 

f. The Clinician Group (CG) Consumer Assessment of Healthcare Providers and Systems 

(CAHPS) Survey 

In the CY 2014 PFS final rule with comment period, we finalized the CG-CAHPS 

survey available for reporting under the PQRS for 2014 and beyond (78 FR 74750 through 

74751), to which we are now referring as the CAHPS for PQRS. Please note that, in the CY 

2014 PFS final rule with comment period, we classified the CAHPS for PQRS survey under the 

care coordination and communication NQS domain. We note that this was an error on our part, 

as the CAHPS for PQRS survey has typically been classified under the Person and Caregiver-
 378 

Centered Experience and Outcomes domain as the CAHPS for PQRS survey assesses beneficiary 

experience of care and outcomes. Therefore, as we indicate in Table 21, we are proposing to 

reclassify the CAHPS for PQRS survey under the Person and Caregiver-Centered Experience 

and Outcomes domain. We invite public comment on this proposal. 

6. Statutory Requirements and Other Considerations for the Selection of PQRS Quality 

Measures for Meeting the Criteria for Satisfactory Participation in a QCDR for 2014 and Beyond 

for Individual Eligible Professionals 

For the measures which eligible professionals participating in a QCDR must report, 

section 1848(m)(3)(D) of the Act, as amended and added by section 601(b) of the ATRA, 

provides that the Secretary shall treat eligible professionals as satisfactorily submitting data on 

quality measures if they satisfactorily participate in a QCDR. Section 1848(m)(3)(E) of the Act, 

as added by section 601(b) of the ATRA, provides some flexibility with regard to the types of 

measures applicable to satisfactory participation in a QCDR, by specifying that for measures 

used by a QCDR, sections 1890(b)(7) and 1890A(a) of the Act shall not apply, and measures 

endorsed by the entity with a contract with the Secretary under section 1890(a) of the Act may be 

used. 

In the CY 2014 PFS final rule with comment period, we finalized requirements related to 

the parameters for the measures that would have to be reported to CMS by a QCDR for the 

purpose of its individual eligible professionals meeting the criteria for satisfactory participation 

under the PQRS (78 FR 74751 through 74753). Although we are not proposing to remove any of 

the requirements we finalized related to these parameters, we are proposing to modify the 

following parameters we finalized in the CY 2014 PFS final rule with comment period related to 

measures that may be reported by a QCDR: 
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● The QCDR must have at least 1 outcome measure available for reporting, which is a 

measure that assesses the results of health care that are experienced by patients (that is, patients’ 

clinical events; patients’ recovery and health status; patients’ experiences in the health system; 

and efficiency/cost). 

As we are proposing that for an eligible professional to meet the criterion for satisfactory 

participation in a QCDR for the 2017 PQRS payment adjustment, the eligible professional must 

report on at least 3 outcome measures or, in lieu of 3 outcome measures, at least 2 outcome 

measures and 1 resource use, patient experience of care, or efficiency/appropriate use measure, 

we are modifying this requirement to conform to this proposed satisfactory participation 

criterion. Therefore, we are proposing that a QCDR must have at least 3 outcome measures 

available for reporting, which is a measure that assesses the results of health care that are 

experienced by patients (that is, patients’ clinical events; patients’ recovery and health status; 

patients’ experiences in the health system; and efficiency/cost). In lieu of having 3 outcome 

measures available for reporting, the QCDR must have at least 2 outcome measures available for 

reporting and at least 1 resource use, patient experience of care, or efficiency/appropriate use 

measure. 

We are proposing to define resource use, patient experience of care, or 

efficiency/appropriate use measures in the following manner: 

● A resource use measure is a measure that is a comparable measure of actual dollars or 

standardized units of resources applied to the care given to a specific population or event, such as 

a specific diagnosis, procedure, or type of medical encounter. 

● A patient experience of care measure is a measure of person- or family-reported 

experiences (outcomes) of being engaged as active members of the health care team and in 

collaborative partnerships with providers and provider organizations. 
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● An efficiency/appropriate use measure is a measure of the appropriate use of health 

care services (such as diagnostics or therapeutics) based upon evidence-based guidelines of care, 

or for which the potential for harm exceeds the possible benefits of care. 

Please note that, for purposes of meeting the criteria for satisfactory participation in a 

QCDR, we allow QCDRs to report on any measure provided that it meets the measure 

parameters we finalize. We note that we would allow and encourage the reporting of the 

Consumer Assessment of Healthcare Providers Surgical Care Survey (S-CAHPS) through a 

QCDR. 

Finally, in the CY 2014 PFS final rule with comment period, we stated that a QCDR must 

provide to CMS descriptions and narrative specifications for the measures for which it will report 

to CMS by no later than March 31, 2014. In keeping with this timeframe, we propose that a 

QCDR must provide to CMS descriptions for the measures for which it will report to CMS for a 

particular year by no later than March 31 of the applicable reporting period for which the QCDR 

wishes to submit quality measures data. For example, if a QCDR wishes to submit quality 

measures data for the 2017 PQRS payment adjustment (the 12-month reporting period of which 

occurs in 2015), the QCDR must provide to CMS descriptions for the measures for which it will 

report to CMS by no later than March 31, 2015. The descriptions must include: name/title of 

measures, NQF # (if NQF endorsed), descriptions of the denominator, numerator, and when 

applicable, denominator exceptions and denominator exclusions of the measure. The narrative 

specifications provided must be similar to the narrative specifications we provide in our 

measures list, available at 

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaimsRegis

try_MeasureSpecs_SupportingDocs_12132013.zip. 
 381 

Related to this proposal, we propose that, 15 days following CMS approval of these 

measure specifications, the QCDR must publicly post the measures specifications for the 

measures it intends to report for the PQRS using any public format it prefers. Immediately 

following posting of the measures specification information, the QCDR must provide CMS with 

the link to where this information is posted. CMS will then post this information when it 

provides its list of QCDRs for the year. We believe providing this information will further aide 

in creating transparency of reporting. 

We invite public comment on these proposals. 

7. Informal Review 

In the CY 2013 PFS final rule with comment period (77 FR 69289), we established that 

“an eligible professional electing to utilize the informal review process must request an informal 

review by February 28 of the year in which the payment adjustment is being applied. For 

example, if an eligible professional requests an informal review related to the 2015 payment 

adjustment, the eligible professional would be required to submit his/her request for an informal 

review by February 28, 2015.” As stated in the CY 2013 PFS final rule with comment period, 

we believed this deadline provided ample time for eligible professionals and group practices 

after their respective claims begin to be adjusted due to the payment adjustment. However, 

because PQRS data is used to establish the quality composite of the VM, we believe it is 

necessary to expand the informal review process to allow for some limited corrections of the 

PQRS data to be made. Therefore, we propose to modify the payment adjustment informal 

review deadline to within 30 days of the release of the feedback reports. For example, if the 

feedback reports for the 2016 payment adjustment (based on data collected for 2014 reporting 

periods) are released on August 31, 2015, an eligible professional or group practice would be 

required to submit a request for an informal review by September 30, 2015. We believe that by 
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being able to notify eligible professionals and group practices of CMS’ decision on the informal 

review request much earlier than we would have been able to do with the previous informal 

review request deadline we can provide a brief period for an eligible or group practice to make 

some limited corrections to its PQRS data. This resubmitted data could then be used to make 

corrections to the VM calculations, when appropriate. 

The PQRS regulations at §414.90(m)(1) currently require an eligible professional or 

group practice to submit an informal review request to CMS within 90 days of the release of the 

feedback reports. Therefore, we propose to revise §414.90(m)(1). 

Regarding the eligible professional’s or group practice’s ability to provide additional 

information to assist in the informal review process, we propose to provide the following 

limitations as to what information may be taken into consideration: 

● CMS would only allow resubmission of data that was submitted using a third-party 

vendor using either the qualified registry, EHR data submission vendor, or QCDR reporting 

mechanisms. Therefore, CMS would not allow resubmission of data submitted via claims, direct 

EHR, or the GPRO web interface reporting mechanisms. We are limiting resubmission to thirdparty vendors, because we believe that third-party vendors are more easily able to detect errors 

than direct users. 

CMS would only allow resubmission of data that was already previously submitted to 

CMS. Submission of new data – such as new measures data not previously submitted or new 

data for eligible professionals for which data was not submitted during the original submission 

period – would not be accepted. 

● For any given resubmission period, CMS would only accept data that was previously 

submitted for the reporting periods for which the corresponding informal review period applies. 

For example, the resubmission period immediately following the informal review period for the 
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2017 PQRS payment adjustment would only allow resubmission for data previously submitted 

for the 2017 PQRS payment adjustment reporting periods occurring in 2015. 

As such, we are proposing to add §414.90(m)(3) to reflect this proposal as follows: (3) 

If, during the informal review process, CMS finds errors in data that was submitted using a thirdparty vendor using either the qualified registry, EHR data submission vendor, or QCDR 

reporting mechanisms, CMS may allow for the resubmission of data to correct these errors. (i) 

CMS will not allow resubmission of data submitted via claims, direct EHR, and the GPRO web 

interface reporting mechanisms. (ii) CMS will only allow resubmission of data that was already 

previously submitted to CMS. (iii) CMS will only accept data that was previously submitted for 

the reporting periods for which the corresponding informal review period applies. 

We invite public comment on these proposals. 
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L. Electronic Health Record (EHR) Incentive Program 

The HITECH Act (Title IV of Division B of the ARRA, together with Title XIII of 

Division A of the ARRA) authorizes incentive payments under Medicare and Medicaid for the 

adoption and meaningful use of certified EHR technology (CEHRT). Section 1848(o)(2)(B)(iii) 

of the Act requires that in selecting CQMs for eligible professionals (EPs) to report under the 

EHR Incentive Program, and in establishing the form and manner of reporting, the Secretary 

shall seek to avoid redundant or duplicative reporting otherwise required. As such, we have 

taken steps to establish alignments among various quality reporting and payment programs that 

include the submission of CQMs. 

For CY 2012 and subsequent years, §495.8(a)(2)(ii) requires an EP to successfully report 

the clinical quality measures selected by CMS to CMS or the states, as applicable, in the form 

and manner specified by CMS or the states, as applicable. 

In the CY 2014 PFS final rule with comment period (78 FR 74756), we finalized our 

proposal to require EPs who seek to report CQMs electronically under the Medicare EHR 

Incentive Program to use the most recent version of the electronic specifications for the CQMs 

and have CEHRT that is tested and certified to the most recent version of the electronic 

specifications for the CQMs. We noted it is important for EPs to electronically report the most 

recent versions of the electronic specifications for the CQMs as updated measure versions 

correct minor inaccuracies found in prior measure versions. We stated that to ensure that 

CEHRT products can successfully transmit CQM data using the most recent version of the 

electronic specifications for the CQMs, it is important that the product be tested and certified to 

the most recent version of the electronic specifications for the CQMs. 

Since finalizing this proposal, we have received feedback from stakeholders regarding the 

difficulty and expense of having to test and recertify CEHRT products to the most recent version 
 385 

of the electronic specifications for the CQMs. While we still believe EPs should test and certify 

their products to the most recent version of the electronic specifications for the CQMs when 

feasible, we understand the burdens associated with this requirement. Therefore, to eliminate 

this added burden, we are proposing that, beginning in CY 2015, EPs would not be required to 

ensure that their CEHRT products are recertified to the most recent version of the electronic 

specifications for the CQMs. Please note that, although we are not requiring recertification, EPs 

must still report the most recent version of the electronic specifications for the CQMs. 

In the CY 2014 PFS final rule with comment period, we established the requirement that 

EPs who seek to report CQMs electronically under the Medicare EHR Incentive Program must 

use the most recent version of the electronic specifications for the CQMs (78 FR 74756). When 

establishing this requirement, we did not account for instances where errors are discovered in the 

updated electronic measure specifications. To account for these instances and consistent with the 

proposal set forth in the PQRS in section III.K, we propose that, beginning in CY 2015, if we 

discover errors in the most recently updated electronic measure specifications for a certain 

measure, we would use the version of electronic measure specifications that immediately 

precedes the most recently updated electronic measure specifications. 

Additionally, we noted that, with respect to the following measure CMS140v2, Breast 

Cancer Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) 

Positive Breast Cancer (NQF 0387), a substantive error was discovered in the June 2013 version 

of this electronically specified clinical quality measure (78 FR 74757). If an EP chooses to 

report this measure electronically under the EHR Incentive Program in CY 2014, the prior, 

December 2012 version of the measure, which is CMS140v1, must be used (78 FR 74757). 

Since a more recent and corrected version of this measure has been developed, we will require 

the reporting of the most recent, updated version of the measure Breast Cancer Hormonal 
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Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast 

Cancer (NQF 0387), if an EP chooses to report the measure electronically in CY 2015. 

In the EHR Incentive Program Stage 2 final rule, we established CQM reporting options 

for the Medicare EHR Incentive Program for CY 2014 and subsequent years that include one 

individual reporting option that aligns with the PQRS’s EHR reporting option (77 FR 54058) and 

two group reporting options that align with the PQRS GPRO and Medicare Shared Savings 

Program (MSSP) and Pioneer ACOs (77 FR 54076 to 54078). In the CY 2014 PFS final rule 

with comment period, we finalized two additional aligned options for EPs to report CQMs for 

the Medicare EHR Incentive Program for CY 2014 and subsequent years with the intention of 

minimizing the reporting burden on EPs (78 FR 74753 through 74757). One of the aligned 

options finalized in the CY 2014 PFS final rule with comment period (78 FR 74754 through 

74755) is a reporting option for CQMs for the Medicare EHR Incentive Program under which 

EPs can submit CQM information using qualified clinical data registries, according the definition 

and requirements for qualified clinical data registries established under the PQRS. 

The second aligned option finalized in the CY 2014 PFS final rule with comment period 

(78 FR 74755 through 74756) is a group reporting option for CQMs for the Medicare EHR 

Incentive Program beginning in CY 2014 under which EPs who are part of a Comprehensive 

Primary Care (CPC) initiative practice site that successfully reports at least nine electronically 

specified CQMs across three domains for the relevant reporting period in accordance with the 

requirements established for the CPC initiative and using CEHRT would satisfy the CQM 

reporting component of meaningful use for the Medicare EHR Incentive Program. If a CPC 

practice site is not successful in reporting, EPs who are part of the site would still have the 

opportunity to report CQMs in accordance with the requirements established for the Medicare 

EHR Incentive Program in the Stage 2 final rule. Additionally, only those EPs who are beyond 
 387 

their first year of demonstrating meaningful use may use this CPC group reporting option. The 

CPC practice sites must submit the CQM data in the form and manner required by the CPC 

initiative. Therefore, whether CPC required electronic submission or attestation of CQMs, the 

CPC practice site must submit the CQM data in the form and manner required by the CPC 

initiative. 

The CPC initiative, under the authority of section 3021 of the Affordable Care Act, is a 

multi-payer initiative fostering collaboration between public and private health care payers to 

strengthen primary care. Under this initiative, we will pay participating primary care practices a 

care management fee to support enhanced, coordinated services. Simultaneously, participating 

commercial, state, and other federal insurance plans are also offering enhanced support to 

primary care practices that provide high-quality primary care. There are approximately 483 CPC 

practice sites across 7 health care markets in the U.S. More details on the CPC initiative can be 

found at http://innovation.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html. 

 Under the CPC initiative, CPC practice sites are required to report to CMS a subset of the 

CQMs that were selected in the EHR Incentive Program Stage 2 final rule for EPs to report 

under the EHR Incentive Program beginning in CY 2014 (for a list of CQMs that were selected 

in the EHR Incentive Program Stage 2 final rule for EPs to report under the EHR Incentive 

Program beginning in CY 2014, see 77 FR 54069 through 54075). We propose to retain the 

group reporting option for CPC practice sites as finalized in the CY 2014 PFS final rule, but to 

relax the requirement for the CQMs to cover three domains. Instead, we propose that, for CY 2015 

only, under this group reporting option, the CPC practice site must report a minimum of nine CQMs from 

the CPC subset, and the nine CQMs reported must cover at least 2 domains, although we strongly 

encourage practice sites to report across more domains if feasible. Although the requirement to report 
 388 

across three domains is important because the domains are linked to the National Quality 

Strategy and used throughout CMS quality programs, the CPC practice sites are required to 

report from a limited number of CQMs that were selected for the EHR Incentive Program and 

are focused on a primary care population. Therefore, these CPC practice sites may not have 

measures to select from that cover three domains. Additionally, CPC practice sites are assessed 

for quality performance on measures other than electronically specified CQMs which do cover 

other National Quality Strategy domains. We invite public comment on this proposal. 
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M. Medicare Shared Savings Program 

Under section 1899 of the Act, CMS has established the Medicare Shared Savings 

program (Shared Savings Program) to facilitate coordination and cooperation among providers to 

improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate 

of growth in health care costs. Eligible groups of providers and suppliers, including physicians, 

hospitals, and other health care providers, may participate in the Shared Savings Program by 

forming or participating in an Accountable Care Organization (ACO). The final rule 

implementing the Shared Savings Program appeared in the November 2, 2011 Federal Register 

(Medicare Shared Savings Program: Accountable Care Organizations Final Rule (76 FR 67802)). 

Section 1899(b)(3)(A) of the Act requires the Secretary to determine appropriate 

measures to assess the quality of care furnished by ACOs, such as measures of clinical processes 

and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization 

such as rates of hospital admission for ambulatory sensitive conditions. Section 1899(b)(3)(B) of 

the Act requires ACOs to submit data in a form and manner specified by the Secretary on 

measures that the Secretary determines necessary for ACOs to report to evaluate the quality of 

care furnished by ACOs. Section 1899(b)(3)(C) of the Act requires the Secretary to establish 

quality performance standards to assess the quality of care furnished by ACOs, and to seek to 

improve the quality of care furnished by ACOs over time by specifying higher standards, new 

measures, or both for the purposes of assessing the quality of care. Additionally, section 

1899(b)(3)(D) of the Act gives the Secretary authority to incorporate reporting requirements and 

incentive payments related to the PQRS, EHR Incentive Program and other similar initiatives 

under section 1848 of the Act. Finally, section 1899(d)(1)(A) of the Act states that an ACO is 

eligible to receive payment for shared savings, if they are generated, only after meeting the 

quality performance standards established by the Secretary. 
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In the November 2011 final rule establishing the Shared Savings Program, we established 

the quality performance standards that ACOs must meet to be eligible to share in savings that are 

generated (76 FR 67870 through 67904). Quality performance measures are submitted by ACOs 

through a CMS web interface, currently the group practice reporting (GPRO) web interface, 

calculated by CMS from internal and claims data, and collected through a patient and caregiver 

experience of care survey. 

Consistent with the directive under section 1899(b)(3)(C) of the Act, we believe the 

existing Shared Savings Program regulations incorporate a built in mechanism for encouraging 

ACOs to improve care over the course of their 3-year agreement period, and to reward quality 

improvement over time. During the first year of the agreement period, ACOs can qualify for the 

maximum sharing rate by completely and accurately reporting all quality measures. After that, 

ACOs must meet certain thresholds of performance, which are currently phased in, and are 

rewarded for improved performance on a sliding scale in which higher levels of quality 

performance translate to higher rates of shared savings (or, for ACOs subject to performancebased risk that demonstrate losses, lower rates of shared losses). In this way, the quality 

performance standard increases over the course of the ACO’s agreement period. 

Additionally, we have made an effort to align quality performance measures, submission 

methods, and incentives under the Shared Savings Program with the PQRS. Eligible 

professionals participating in an ACO may qualify for the PQRS incentive payment under the 

Shared Savings Program or avoid the downward PQRS payment adjustment when the ACO 

satisfactorily reports the ACO GPRO measures on their behalf using the GPRO web interface. 

Since the November 2011 final rule establishing the Shared Savings Program was issued, 

we have revisited certain aspects of the quality performance standard in the annual PFS 

rulemaking out of a desire to ensure thoughtful alignment with the agency’s other quality 
 391 

incentive programs that are addressed in that rule. Specifically, we have updated our rules to 

align with PQRS and the EHR Incentive Program, and addressed issues related to benchmarking 

and scoring ACO quality performance (77 FR 69301 through 69304; 78 FR 74757 through 

74764). We have identified several policies related to the quality performance standard that we 

would like to address in this rule at this time. Specifically, we are revisiting the current quality 

performance standard, proposing changes to the quality measures, and seeking comment on 

future quality performance measures. We are also proposing to modify the timeframe between 

updates to the quality performance benchmarks, to establish an additional incentive to reward 

ACO quality improvement, and to make several technical corrections to the regulations in 

subpart F of Part 425. 

1. Existing Quality Measures and Performance Standard 

 As discussed previously, section1899(b)(3) of the Act states that the Secretary may 

establish quality performance standards to assess the quality of care furnished by ACOs and 

“seek to improve the quality of care furnished by ACOs over time by specifying higher 

standards, new measures, or both....” In the November 2011 Shared Savings Program final rule, 

we established a quality performance standard that consists of 33 measures. These measures are 

submitted by the ACO through the GPRO web interface, calculated by CMS from administrative 

and claims data, and collected via a patient experience of care survey based on the Clinician and 

Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. 

Although the patient experience of care survey used for the Shared Savings Program includes the 

core CG-CAHPS modules, this patient experience of care survey also includes some additional 

modules. Therefore, we will refer to the patient experience of care survey that is used under the 

Shared Savings Program as CAHPS for ACOs. The measures span four domains, including 

patient experience of care, care coordination/patient safety, preventive health, and at-risk 
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population. The measures collected through the GPRO web interface are also used to determine 

whether eligible professionals participating in an ACO qualify for the 2013 and 2014 PQRS 

incentive payment or avoid the PQRS payment adjustment for 2015 and subsequent years. 

Eligible professionals in an ACO may qualify for the PQRS incentive payment or avoid the 

downward PQRS payment adjustment when the ACO satisfactorily reports all of the ACO 

GPRO measures on their behalf using the GPRO web interface. 

In selecting the 33 measure set, we balanced a wide variety of important considerations. 

Given that many ACOs were expected to be newly formed organizations, in the November 2011 

Shared Savings Program final rule (76 FR 67886), we concluded that ACO quality measures 

should focus on discrete processes and short-term measurable outcomes derived from 

administrative claims and limited medical record review facilitated by a CMS-provided web 

interface to lessen the burden of reporting. Because of the focus on Medicare FFS beneficiaries, 

our measure selection emphasized prevention and management of chronic diseases that have 

high impact on these beneficiaries such as heart disease, diabetes mellitus, and chronic 

obstructive pulmonary disease. We believed that the quality measures used in the Shared 

Savings Program should be tested, evidence-based, target conditions of high cost and high 

prevalence in the Medicare FFS population, reflect priorities of the National Quality Strategy, 

address the continuum of care to reflect the requirement that ACOs accept accountability for 

their patient populations, and align with existing quality programs and value-based purchasing 

initiatives. 

At this time, we continue to believe it is most appropriate to focus on quality measures 

that directly assess the overall quality of care furnished to FFS beneficiaries. The set of 33 

measures that we adopted in the November 2011 Shared Savings Program final rule includes 

measures addressing patient experience, outcomes, and evidence-based care processes. Thus far, 
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we have not included any specific measures addressing high cost services or utilization since we 

believe that the potential to earn shared savings offers an important and direct incentive for 

ACOs to address utilization issues in a way that is most appropriate for their organization, patient 

population, and local healthcare environment. We note that while the quality performance 

standard is limited to these 33 measures, the performance of ACOs is measured on many more 

metrics and ACOs are informed of their performance in these areas. For example, an assessment 

of an ACO’s utilization of certain resources is provided to the ACO via quarterly reports that 

contain information such as the utilization of emergency services or the utilization of CTs and 

MRIs. 

 As we have stated previously (76 FR 67872), our principal goal in selecting quality 

measures for ACOs was to identify measures of success in the delivery of high-quality health 

care at the individual and population levels. We believe endorsed measures have been tested, 

validated, and clinically accepted, and therefore, selected the 33 measures with a preference for 

NQF-endorsed measures. However, the statute does not limit us to using endorsed measures in 

the Shared Savings Program. As a result we also exercised our discretion to include certain 

measures that we believe to be high impact but that are not currently endorsed, for example, 

ACO#11, Percent of PCPs Who Successfully Qualify for an EHR Incentive Program Payment. 

In selecting the final set of 33 measures, we sought to include both process and outcome 

measures, including patient experience of care (76 FR 67873). Because ACOs are charged with 

improving and coordinating care and delivering high quality care, but also need time to form, 

acquire infrastructure and develop clinical care processes, we continue to believe it is important 

to have a combination of both process and outcomes measures. We note, however, that as other 

CMS quality reporting programs, such as PQRS, move to more outcomes-based measures and 
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fewer process measures over time, we may also revise the quality performance standard for the 

Shared Savings Program to incorporate more outcomes-based measures over time. 

Therefore, we viewed the 33 measures adopted in the November 2011 Shared Savings 

Program final rule as a starting point for ACO quality measurement. As we stated in that rule 

(67 FR 67891), we plan to modify the measures in future reporting cycles to reflect changes in 

practice and improvements in quality of care and to continue aligning with other quality 

reporting programs and will add and/or retire measures as appropriate through the rulemaking 

process. In addition, we are working with the measures community to ensure that the 

specifications for the measures used under the Shared Savings Program are up-to-date. We note 

that we must balance the timing of the release of specifications so they are as up-to-date as 

possible, while also giving ACOs sufficient time to review specifications. Our intention is to 

issue the specifications annually, prior to the start of the reporting period for which they will 

apply. For example, we issued the specifications for the 2014 reporting period in late 2013, prior 

to the start of the 2014 reporting period. 

In the November 2011 Shared Savings Program final rule (76 FR 67873), we combined 

care coordination and patient safety into a single domain to better align with the National Quality 

Strategy and to emphasize the importance of ambulatory patient safety and care coordination. 

We also intended to continue exploring ways to best capture ACO care coordination metrics and 

noted that we would consider adding new care coordination measures for future years (67 FR 

67877). 

2. Proposed Changes to the Quality Measures Used in Establishing Quality Performance 

Standards that ACOs must meet to be Eligible for Shared Savings 

Since the November 2011 Shared Savings Program final rule, we have continued to 

review the quality measures used for the Shared Savings Program to ensure that they are up to 
 395 

date with current clinical practice and are aligned with the GPRO web interface reporting for 

PQRS. Based on the reviews, we have identified a number of proposed measure additions, 

deletions and other revisions that we believe would be appropriate for the Shared Savings 

Program. Under the following proposed measure revisions, ACOs would be assessed on 37 

measures annually, an increase of 4 measures. However, as explained in more detail below, we 

believe the measures chosen are more outcome-oriented and would ultimately reduce the 

reporting burden on ACOs. 

The following is a description of the proposed changes that would be effective for the 

2015 reporting period and would be reported by ACOs to us in early 2016. Table 50 offers an 

overview of the proposed changes and is provided as a reference. (We note that the deletion and 

insertion of certain measures affects the composite measures, and we are proposing 

corresponding revisions to both the diabetes and coronary artery disease composite measures.) 

● CAHPS Stewardship of Patient Resources. This measure is one of the unscored 

survey measures currently collected in addition to the seven that are already part of the current 

set of 33 scored measures under the Shared Savings Program. Information on the unscored 

survey measure modules is currently shared with the ACOs for informational purposes only. 

The Stewardship of Patient Resources measure asks the patient whether the care team talked with 

the patient about prescription medicine costs. The measure exhibited high reliability during the 

first two administrations of the CAHPS survey, and during testing, the beneficiaries that 

participated in cognitive testing said that prescription drug costs was important to them. We are 

proposing to add Stewardship of Patient Resources as a scored measure in the patient experience 

domain because we believe, based on testing, that this is an important factor for measuring a 

beneficiary’s experience with healthcare providers. We are also proposing that the measure 

would be phased into pay for performance as we plan to do for other new measures, using a 
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similar process to the phase in that was used for the measure modules in the survey that are 

currently used to assess ACO quality performance. We seek comment on this proposal and on 

any other patient experience of care measures that might be considered in future rulemaking. 

● Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM). We 

propose to add a 30-day all cause SNF readmission measure. CMS is the measure steward for 

this claims based measure which is under review at NQF under NQF #2510. This measure 

estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients 

who have been admitted to a Skilled Nursing Facility within 30 days of discharge from a prior 

inpatient admission to a hospital, CAH, or a psychiatric hospital. The measure is based on data 

for 12 months of SNF admissions. We believe this measure would help fill a gap in the current 

Shared Savings Program measure set and would provide a focus on an area where ACOs are 

targeting care redesign. ACOs and their ACO providers/suppliers often include post-acute care 

(PAC) settings and the addition of this measure would enhance the participation and alignment 

with these facilities. Even when the ACO does not include post-acute facilities formally as part 

of its organization, ACO providers/suppliers furnish other services that have the potential to 

affect PAC outcomes. Thus, this measure would emphasize the importance of coordinating the 

care of beneficiaries across these sites of care. Additionally, because this measure is calculated 

from claims, there would not be a burden on ACOs to collect this information. 

● All-Cause Unplanned Admissions for Patients with Diabetes Mellitus (DM), Heart 

Failure (HF) and Multiple Chronic Conditions. We propose to add three new measures to the 

Care Coordination/Patient Safety domain. The three proposed new measures are for: all-cause 

unplanned Admissions for Patients with Diabetes Mellitus (DM), all-cause unplanned 

Admissions for Patients with Heart Failure (HF) and all-cause unplanned Admissions for 

Patients with Multiple Chronic Conditions. These three measures are under development though 
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a CMS contract with Yale New Haven Health Services Corporation/Center for Outcomes 

Research and Evaluation (CORE) to develop quality measures specifically for ACO patients with 

heart failure, diabetes, and multiple chronic conditions. We believe that these measures are 

important to promote and assess ACO quality as it relates to chronic condition inpatient 

admission because they are major causes for unplanned admissions and will support the ACOs’ 

efforts to improve care coordination for these chronic conditions. These measures are claims 

based, and therefore, we do not expect that they would impose any additional burden on ACOs. 

● Depression Remission at Twelve Months. We propose to add Depression Remission 

at Twelve Months (NQF #0710) to the Preventive Health domain. Depression is a serious health 

condition for the Medicare population and can decrease patient adherence to treatment for 

chronic conditions. This measure would enhance our measurement of health outcomes and 

depression is an important health condition that we believe is appropriate to be addressed by 

ACOs. The measure would be submitted through the GPRO web interface, and would be 

aligned with PQRS. We also seek comments on the inclusion of additional behavioral health 

measures, such as substance abuse or mental health measures, in future rulemaking cycles. 

● Diabetes Measures for Foot Exam and Eye Exam. Diabetes is one of the most serious, 

chronic health conditions for Medicare beneficiaries. It is critical that Medicare beneficiaries 

that have diabetes receive foot and eye exams to help prevent diabetes-related foot amputations 

and blindness. Both of the two new measures would be added to the Clinical Care for at Risk 

Population-Diabetes domain. They are endorsed by NQF (NQF #0055 and #0056). We also 

propose to include these two new measures as part of a new Diabetes Mellitus composite 

measure. These measures would also align with PQRS and the EHR Incentive Program. We 

believe these measures would be appropriate additional measures for assessing quality of care 

furnished in ACOs to help prevent diabetes- related foot amputations and blindness. 
 398 

● Coronary Artery Disease (CAD): Symptom Management. This new measure would be 

added to the Clinical Care for At Risk Population-Coronary Artery Disease domain and included 

in the CAD Composite Measure. The measure helps assess symptom management for CAD 

patients based on the percentage of adults with a diagnosis of coronary artery disease seen within 

a 12-month period with results of an evaluation of level of activity and an assessment of whether 

anginal symptoms are present or absent with appropriate management of anginal symptoms 

within a 12-month period. This new measure would be added to further enhance the CAD 

composite measure by adding an assessment of patient activity level and management of angina, 

which are important clinical factors for beneficiaries with CAD. The measure would align with 

PQRS (PQRS #0242) and the EHR Incentive Program. 

● Coronary Artery Disease (CAD): Beta Blocker Therapy—Prior Myocardial Infarction 

(MI) or Left Ventricular Systolic Dysfunction (LVEF<40%). This new measure would be added 

to the Clinical Care for At Risk Population-Coronary Artery Disease domain and included in the 

CAD Composite Measure. This new measure is endorsed by NQF as NQF #0070 and would be 

added to further enhance the CAD composite measure. This measure reflects the number of 

patients with CAD who have prior myocardial infarction or LVEF <40 percent who are 

prescribed beta-blocker therapy and thus is designed to support improvement in outcomes for 

these CAD patients. 

● Coronary Artery Disease (CAD): Antiplatelet Therapy. This new measure would be 

added to the Clinical Care for At Risk Population-Coronary Artery Disease domain and included 

in the CAD Composite Measure. The measure is defined as the percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12-month period that 

were prescribed aspirin or clopidogrel. This new measure is endorsed by NQF as NQF #0067 

and would be added to update the CAD composite measure to reflect updated clinical guidelines 
 399 

for lipid control. This new measure would replace the existing measure at ACO #30, Ischemic 

Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic, which we are proposing to 

remove because it no longer reflects current clinical guidelines. 

● Documentation of Current Medications in the Medical Record (NQF #0419). This 

new measure would replace ACO #12 (NQF #0097) Medication Reconciliation measure. The 

current measure is designed to determine whether medication reconciliation was done 

immediately following a hospital discharge whereas the medical community has indicated to us 

that it is better clinical practice to perform medication reconciliation at every office visit, which 

NQF #0419 is designed to measure. In addition, this new replacement measure aligns with both 

PQRS and the EHR Incentive Program. 

● Percent of PCPs who Successfully Meet Meaningful Use Requirements. Because the 

EHR Incentive Program begins its transition to a payment adjustment effective in 2015, we 

propose to modify the name and specifications for ACO #11 Percent of PCPs who Successfully 

Qualify for an EHR Incentive Program Payment so that it more accurately depicts successful use 

and adoption of EHR technology in the coming years. We note this measure would continue to 

be doubly weighted. 

We seek comment on these proposed new measures. 

Additionally, we have identified a number of the existing measures that have not kept up 

with clinical best practice, are redundant with other measures that make up the quality reporting 

standard, or that could be replaced by similar measures that are more appropriate for ACO 

quality reporting. We propose to no longer collect data on the following measures, and these 

measures would no longer be used for establishing the quality performance standards that ACOs 

must meet to qualify to share in savings: 
 400 

● ACO #12, Medication Reconciliation after Discharge from an Inpatient Facility: As 

explained above, we would replace this measure with a new measure for documentation of 

current medications in the medical record since the medical community has indicated the 

importance of medication reconciliation at each office visit rather than only after an inpatient 

discharge. 

● ACO #22, Diabetes Composite measure: hemoglobin A1c control (<8 percent). The 

Hemoglobin A1c Control (<8%) component is being proposed for removal as we have concerns 

that the HbA1c level monitored in this measure is considered too low to comprehensively 

evaluate HbA1c control for the frail elderly population. 

● ACO #24, Diabetes Composite: Blood Pressure (<140/90) (NQF #0729). In an effort 

to reduce redundant and burdensome ACO reporting of quality measures, we are proposing to no 

longer collect data for this measure. Although we recognize that the sample patient populations 

for the measures are different, we believe that there is clinical overlap between ACO #24 and 

ACO #28, Hypertension (HTN): Blood Pressure Control (NQF #0018). We propose to retain 

ACO #28, rather than ACO #24, because ACO #28 represents a more comprehensive assessment 

of an ACO’s performance in controlling its population’s high blood pressure, whereas the 

diabetes measure assesses a subpopulation of the broader blood pressure measure. 

● ACO #25, Diabetes Composite: Tobacco Non-use (NQF #0729). We believe this 

measure is somewhat duplicative of the separate measure ACO #17, Tobacco Use Assessment 

and Tobacco Cessation Intervention (NQF #0028) and that the diabetes measure may capture a 

subpopulation of the broader measure. We prefer to use NQF #0028 as a measure of tobacco use 

for the Shared Savings Program because this measure has been identified as a cross-cutting 

measure as it represents a screening assessment that most eligible professionals may perform and 

is applicable to most adult patients. This measure is applicable in various outpatient settings. 
 401 

● ACO #23, Diabetes Composite: Low Density Lipoprotein (<100) (NQF #0729). We 

propose to retire this and the two other lipid control measures listed below as a result of new 

clinical guidelines released in 2013 by the American College of Cardiology and American Heart 

Association (see 

https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf). The 

new guidelines recommend treating individuals with moderate-to-high dose statin therapy based 

on cardiac risk rather than only treating high cholesterol to specific targets. . 

● ACO #29, Ischemic Vascular Disease: Complete Lipid Profile and LDL Control (<100 

mg/dl) (NQF #0075). We propose to retire this lipid control related measure because of the new 

clinical guidelines for statin treatment as noted in the previous bullet. 

● ACO #30, Ischemic Vascular Disease: Use of Aspirin or another Antithrombotic (NQF 

#0068). This measure would be replaced by the proposed new CAD measure for antiplatelet 

therapy (NQF #67), which reflects current clinical guidelines. 

● ACO #32, Coronary Artery Disease (CAD) Composite: Drug Therapy for Lowering 

LDL Cholesterol (NQF #74). We propose to retire this lipid control related measure because of 

the new clinical guidelines for statin treatment as noted above. 

We seek comment on our proposal to remove these measures from the quality 

performance standards. 

Finally, given these proposed changes, we propose updates and revisions to the Diabetes 

and CAD Composites. We propose that the Diabetes Composite would include the following 

measures: 

● ACO #26: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for 

Patients with Diabetes Mellitus and Ischemic Vascular Disease. 

● ACO #27: Diabetes: Hemoglobin A1c Poor Control. 
 402 

● ACO #41: Diabetes: Foot Exam. 

● ACO #42: Diabetes: Eye Exam. 

We further propose that the CAD Composite would include the following measures: 

● ACO #33: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor 

Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%). 

● ACO #43: Antiplatelet Therapy. 

● ACO #44: Symptom Management. 

● ACO #45: Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left 

Ventricular Systolic Dysfunction (LVEF<40%). 

We seek comment on these proposed composites and whether there are any concerns 

regarding calculation of a composite score. There has been increased interest in the use of 

composite performance measures over the past few years and stakeholders have raised general 

concerns regarding composite measures and their purpose for quality improvement. CMS 

worked with the National Quality Forum (NQF) and their technical expert panel in 2013 to 

update NQF’s composite measure evaluation guidance, which in turn may also be used by 

developers for composite measure development. Given the general concerns around composite 

measures and their use, we seek comment on how we combine and incorporate component 

measure scoring for the composite. In particular, we are interested in whether stakeholders have 

any concerns about including ACO #27, reverse-scored measure, in the Diabetes Composite, and 

whether there are any methodological considerations we should consider when including a 

reverse-scored measures in composites. 

To summarize, under these proposed changes, we would add 12 new measures and retire 

eight measures. We are also proposing to rename the EHR measure in order to reflect the 

transition from an incentive payment to a payment adjustment under the EHR Incentive Program 
 403 

and to revise the component measures within the Diabetes and CAD composites. In total, we 

propose to use 37 measures for establishing the quality performance standards that ACOs must 

meet to achieve shared savings. Although the total number of measures would increase from the 

current 33 measures to 37 measures, we do not anticipate that this would increase the reporting 

burden on ACOs. The increased number of measures is accounted for by measures that would 

be calculated by CMS using administrative claims data or from a patient survey. The total 

number of measures that the ACO would need to directly report through the CMS website 

interface would actually decrease by one, in addition to removing redundancy in measures 

reported. 

As part of these proposed changes, we would replace the current five component diabetes 

composite measure with a new four component diabetes composite measure. In addition, we 

would replace the current two component coronary artery disease composite measure with a new 

four component coronary artery disease composite measure. Twenty-one of the measures would 

be reported by ACOs through the GPRO web interface and scored as 15 measures. 

An overview of the proposed changes is provided in Table 50 which demonstrates what 

measures would be used to assess ACO quality under the Shared Savings Program if our 

proposals are finalized. 
 404 

TABLE 50: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for S

Domain ACO Measure # Measure Title Proposed New Measure NQF #/Measure Steward Method of Data Submission 

Pay 

PY

AIM: Better Care for Individuals 

Patient/Caregiver 

Experience 

ACO - 1 CAHPS: Getting Timely Care, Appointments, and Information NQF #0005, AHRQ Survey R 

ACO - 2 CAHPS: How Well Your Doctors Communicate NQF #0005 AHRQ Survey R ACO - 3 CAHPS: Patients' Rating of Doctor NQF #0005 AHRQ Survey R ACO - 4 CAHPS: Access to Specialists NQF #N/A CMS/AHRQ Survey R ACO - 5 CAHPS: Health Promotion and Education NQF #N/A CMS/AHRQ Survey R 

ACO – 6 CAHPS: Shared Decision Making NQF #N/A CMS/AHRQ Survey R ACO – 7 CAHPS: Health Status/Functional Status NQF #N/A CMS/AHRQ Survey R 

ACO - 34 CAHPS: Stewardship of Patient Resources X NQF #N/A CMS/AHRQ Survey R 

Care Coordination/ 

Safety 

ACO - 8 

Risk-Standardized, All Condition Readmission Adapted NQF 

#1789 CMS 

Claims R 

ACO - 35 

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) X 

NQF #TBD CMS Claims R 

ACO - 36 All-Cause Unplanned Admissions for Patients with Diabetes X NQF#TBD CMS Claims R 

ACO -37 All-Cause Unplanned Admissions for Patients with Heart Failure X NQF#TBD CMS Claims R ACO -38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions X NQF#TBD CMS Claims R 

ACO - 9 

Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) 

Adapted NQF #0275 AHRQ Claims R 

ACO - 10 

Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) 

Adapted NQF #0277 AHRQ 

Claims R 

ACO - 11 

Percent of PCPs who Successfully Meet Meaningful Use Requirements 

NQF #N/A CMS 

EHR Incentive 

Program 

Reporting 

R 
 405 

Domain ACO Measure # Measure Title Proposed New Measure NQF #/Measure Steward Method of Data Submission 

Pay 

PY

ACO -39 Documentation of Current Medications in the Medical Record X NQF #0419 CMS CMS Web Interface R 

ACO - 13 Falls: Screening for Future Fall Risk NQF #0101 NCQA CMS Web Interface R 

AIM: Better Health for Populations 

Preventive Health 

ACO - 14 Preventive Care and Screening: Influenza Immunization NQF #0041 AMA-PCPI CMS Web Interface R 

ACO – 15 Pneumonia Vaccination Status for Older Adults NQF #0043 NCQA CMS Web Interface R ACO – 16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up NQF #0421 CMS CMS Web Interface R ACO – 17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention NQF #0028 AMA-PCPI CMS Web Interface R ACO – 18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan NQF #0418 CMS CMS Web Interface R ACO – 19 Colorectal Cancer Screening NQF #0034 NCQA CMS Web Interface R ACO – 20 Breast Cancer Screening NQF #NA NCQA CMS Web Interface R 

ACO - 21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented CMS CMS Web Interface R 

Clinical Care for At Risk 

Population - Depression ACO – 40 Depression Remission at Twelve Months X NQF #0710 MNCM CMS Web Interface R 

Clinical Care for At Risk 

Population - Diabetes 

ACO – 26 

Diabetes Composite (All or Nothing Scoring): 

ACO - 26: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes Mellitus and Ischemic Vascular Disease ACO - 27: Diabetes Mellitus: Hemoglobin A1c Poor Control ACO - 41: Diabetes: Foot Exam ACO - 42: Diabetes: Eye Exam 

CMS composite NQF #0729 MNCM (individual measure) 

CMS Web 

Interface 

R 

ACO -27 

NQF #0059 NCQA (individual component) 

CMS Web 

Interface R 

ACO - 41 X 

NQF #0056 NCQA (individual component) 

CMS Web 

Interface R 

ACO - 42 X 

NQF #0055 NCQA (individual component) 

CMS Web 

Interface R 

Clinical Care for At Risk 

Population - Hypertension ACO - 28 Hypertension (HTN): Controlling High Blood Pressure NQF #0018 NCQA CMS Web Interface R 

Clinical Care for At Risk ACO - 31 Heart Failure (HF): Beta-Blocker Therapy for Left NQF #0083 CMS Web R 
 406 

Domain ACO Measure # Measure Title Proposed New Measure NQF #/Measure Steward Method of Data Submission 

Pay 

PY

Population - 

Heart Failure 

Ventricular Systolic Dysfunction (LVSD) AMA-PCPI Interface 

Clinical Care for At Risk 

Population – Coronary 

Artery Disease 

ACO - 33 

Coronary Artery Disease (CAD) Composite (All or Nothing Scoring): 

ACO – 33: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) ACO - 43:Antiplatelet Therapy ACO - 44: Symptom Management ACO - 45: Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF<40%) 

CMS composite NQF # 0066 ACC (individual component) 

CMS Web 

Interface 

R 

ACO - 43 X 

NQF #0067 ACC (individual component) 

CMS Web 

Interface R 

ACO - 44 X 

NQF #N/A AMA-PCPI (individual component) 

CMS Web 

Interface R 

ACO - 45 X 

NQF #0070 ACC (individual component) 

CMS Web 

Interface R 
 407 

Table 51 provides the current number of measures by domain and displays the total 

points and domain weights used for scoring purposes. The current scoring methodology is 

explained in the regulations at §425.502 and in the preamble to the November 2011 final rule (76 

FR 67895 through 67900). Table 52 provides a summary of the proposed number of measures 

by domain and the resulting total points and domain weights that would be used for scoring 

purposes under these proposed changes. Otherwise, the current quality scoring points 

methodology for calculating an ACO’s overall quality performance score would continue to 

apply. Table 53 provides the measures that are retired/replaced. 

TABLE 51: Current Number of Measures and Total Points for Each Domain within the 

Quality Performance Standard 

 Domain Number of 

Individual Measures

Total Measures for 

Scoring Purposes

Total Possible Points Domain Weight

Patient/Caregiver 

Experience 

7 7 individual survey 

module measures 

14 25% 

Care Coordination/ 

Patient Safety 

6 6 measures, including 

the EHR measure 

double-weighted (4 

points) 

14 25% 

Preventive Health 8 8 measures 16 25% 

At-Risk Population 12 7 measures, including 

5-component diabetes 

composite measure 

and 2-component 

coronary artery 

disease composite 

measure 

14 25% 

Total in all Domains 33 28 58 100% 

TABLE 52: Proposed Number of Measures and Total Points for Each Domain within the 

Quality Performance Standard 

 Domain Number of 

Individual Measures

Total Measures for 

Scoring Purposes

Total Possible Points Domain Weight

Patient/Caregiver 

Experience 

8 8 individual survey 

module measures 

16 25% 

Care Coordination/ 

Patient Safety 

10 9 measures, plus the 

EHR measure doubleweighted (4 points) 

22 25% 

Preventive Health 8 8 measures 16 25% 
 408 

Domain Number of 

Individual Measures

Total Measures for 

Scoring Purposes

Total Possible Points Domain Weight

At-Risk Population 11 5 measures, including 

3 individual measures 

plus a 4-component 

diabetes composite 

measure and a 4-

component coronary 

artery disease 

composite measure 

10 25% 

Total in all Domains 37 31 64 100% 

TABLE 53: Shared Savings Program Measures Retired/Replaced 

Notes Domain Measure Title NQF 

Measure #/ 

Measure 

Steward 

Method of 

Data 

Submission 

Pay for Performance Phase In 

R = Reporting P=Performance 

Performance Performance Performance 

 Year 1 Year 2 Year 3

ACO #12 

Replaced 

Care 

Coordination/ 

Patient Safety 

Medication 

Reconciliation: 

Reconciliation After 

Discharge from an 

Inpatient Facility 

NQF #97

AMAPCPI/NCQA 

GPRO Web 

Interface 

R P P 

ACO #22 

Retired 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Hemoglobin A1c Control 

(<8 percent) 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P 

ACO #23 

Retired 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Low Density Lipoprotein 

(<100) 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P 

ACO #24 

Retired -

Redunda

nt 

Measure 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Blood Pressure <140/90 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P

ACO #25 

Retired - 

Redunda

nt 

measure 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Tobacco Non Use 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P

ACO #29 

Retired 

At Risk 

Population – 

Ischemic 

Vascular 

Disease 

Ischemic Vascular 

Disease (IVD): Complete 

Lipid Profile and LDL 

Control <100 mg/dl

NQF #75 

NCQA 

GPRO Web 

Interface 

R P P

ACO #30 

Replaced 

At Risk 

Population – 

Ischemic 

Vascular 

Disease 

Ischemic Vascular 

Disease (IVD): Use of 

Aspirin or Another 

Antithrombotic 

NQF #68 

NCQA 

GPRO Web 

Interface 

R P P
 409 

Notes Domain Measure Title NQF 

Measure #/ 

Measure 

Steward 

Method of 

Data 

Submission 

Pay for Performance Phase In 

R = Reporting P=Performance 

Performance Performance Performance 

 Year 1 Year 2 Year 3

ACO #32 

Retired 

At Risk 

Population – 

Coronary 

Artery 

Disease 

Coronary Artery Disease 

(CAD) Composite: All or 

Nothing Scoring:

Drug Therapy for 

Lowering LDLCholesterol 

NQF #74 

CMS 

(composite) / 

AMA-PCPI 

(individual 

component) 

GPRO Web 

Interface 

R R P

We believe that these modifications will enhance ACO quality reporting, better reflect 

clinical practice guidelines, streamline measures reporting, and enhance alignment with PQRS 

and the EHR Incentive Program. Finally, we are proposing that these measures would become 

effective beginning with the 2015 reporting period, and 2015 performance year (PY). All 37 

measures would be phased in for ACOs with 2015 start dates according to the phase-in schedule 

in Table 50. ACOs with start dates before 2015 would be responsible only for complete and 

accurate reporting of the new measures for the 2015 performance year, and then responsible for 

either reporting or performance on the measures according to the phase in schedule. For 

example, assume a new measure is scheduled to phase in with reporting in PY1, reporting in 

PY2, and performance in PY3. Further assume that an ACO with a 2014 start date will be in its 

second performance year (PY2) when the measure becomes effective. In this example, the ACO 

would be responsible for complete and accurate reporting of the new measure in PY2 and for 

performance on the measure in PY3. If we change the assumptions in the example to say that the 

new measure is scheduled to phase in with reporting in PY1, performance in PY2, and 

performance in PY3, then the ACO would be responsible for complete and accurate reporting of 

the new measure in PY2 and for performance on the measure in PY3. Finally, we note that 

consistent with our proposed revisions to §425.502(a) regarding quality reporting in a second and 

subsequent agreement period, an ACO that transitions to a new agreement period would continue 
 410 

to be assessed on the quality performance standard that would otherwise apply to an ACO in the 

third performance year of its first agreement period. Take the example of an ACO with a 2013 

start date that will be responsible for reporting the new measure in the 2015 reporting period, its 

third performance year. Assume the measure is scheduled to phase in from reporting in PY1, 

reporting in PY2, and performance in PY3. In this case, the ACO would be responsible for 

complete and accurate reporting of the new measure in 2015 (PY3 of its first agreement period). 

If the ACO renews its participation agreement for another 3 years, the ACO would be 

responsible for performance on that measure for each year of its new agreement period because 

the measure is designated as a pay for performance measure in PY3 of the preceding agreement 

period. 

Additionally, as noted in the November 2011 Shared Savings Program final rule (76 FR 

67900), the Shared Savings Program uses the same sampling method used by PQRS GPRO. 

Specifically, the sample for the ACO GPRO must consist of at least 411 assigned beneficiaries 

per measure set/domain. If the pool of eligible, assigned beneficiaries is less than 411, the ACO 

must report on 100 percent, or all, of the assigned beneficiaries sampled. To the extent that 

PQRS modifies and finalizes changes in the reporting requirements for group practices reporting 

via the GPRO web interface, we propose to make similar modifications to ACO reporting 

through the GPRO web interface. Specifically, as discussed in section III.K.4.a. of this proposed 

rule, we are proposing to reduce the GPRO web interface minimum reporting requirements for 

PQRS reporting from 411 to 248 consecutively ranked and assigned patients for each measure or 

100 percent of the sample for each measure if there are less than 248 patients in a given sample. 

We propose that the reduced sample for each measure for reporting through the GPRO web 

interface would also apply to ACOs. We believe that a reduction in the number of sampled 
 411 

beneficiaries would reduce reporting burden for ACOs while maintaining high statistical validity 

and reliability in results. 

3. Request for Comments for Future Quality Measures 

In addition to the proposed changes to the current set of 33 quality measures for the 

Shared Savings Program discussed above, we are interested in public comment on additional 

measures that we may consider in future rulemaking. We particularly welcome comments 

regarding the following issues: 

● Gaps in measures and additional specific measures: We recognize that there may be 

gaps in the ACO quality performance standard. For example, ACOs are charged with improving 

care coordination for FFS beneficiaries. While above we propose to add a measure for SNF 30-

day all-cause readmission to address current gaps in SNF settings, we seek comment on whether 

there are additional measures that might be used to assess the ACO’s performance with respect 

to care coordination in post-acute care and other settings. We also recognize the need to balance 

filling gaps in the quality performance standard with the reporting burden on ACOs. To the 

extent possible, we wish to identify measures for filling any gaps in the quality performance 

standard that would not increase the reporting burden on ACOs unduly. We welcome comments 

on specific measures or measure groups that may be considered in future rulemaking to fill in 

gaps that may exist for assessing ACO quality performance. For example, we seek input on 

measures that address the quality of care in the various different settings that may be part of an 

ACO, such as post-acute care settings including SNF or home health. We note that any 

suggestions for new measures would be more thoroughly discussed in a future rulemaking cycle 

prior to being adopted as part of the quality performance standard under the Shared Savings 

Program and if we deem it appropriate we would also submit them to the NQF Measures 

Application Partnership (MAP) via the list of Measures Under Consideration that the Secretary 
 412 

annually makes available to the public as part of the pre-rulemaking process under section 

1890A(a)(2) of the Act for the purpose of seeking multi-stakeholder group input, consistent with 

the requirements of section 3014 of the Affordable Care Act, if the measures have not already 

been reviewed by the MAP. 

● Caregiver experience of care: While we recognize there is a concern about patient 

subjectivity to surveys, we include measures based on data collected via the patient experience of 

care survey in the quality performance standard because we believe patients' perception of their 

care experience reflects important aspects of the quality of the care they receive, such as 

communication and patient engagement in decision-making, that are not adequately captured by 

other measures. As such, patient surveys are important complements to the other process of care 

and outcomes measures. For this reason, we stated in November 2011 Shared Savings Program 

final rule (76 FR 67874) that we intended to expand the quality measures over time to include 

more caregiver experience measures. Therefore, we seek comment on additional specific 

caregiver experience of care measures that might be considered in future rulemaking. 

● Alignment with Value-Based Payment Modifier (VM) measures: We desire to 

continue to align with other Medicare quality initiatives in order to reduce ACO burden and 

streamline quality reporting and indicators. In the CY 2013 PFS final rule with comment period 

(77 FR 69313) we established a policy not to apply the VM in CY 2015 and CY 2016 to groups 

of physicians that participate in ACOs under the Shared Savings Program. Although section 

1848(p)(4)(B)(iii)(I) of the Act gives the Secretary discretion to apply the VM to specific 

physicians and groups of physicians as the Secretary determines appropriate for 2015 and 2016, 

consistent with section 1848(p)(4)(B)(iii)(II), which requires application of the VM to all 

physicians and groups of physicians beginning not later than January 1, 2017, we are proposing 

to start applying the VM to physicians participating in ACOs beginning in 2017. In addition, in 
 413 

section III.K.4.b of this proposed rule, we discuss our proposal to also apply the VM to all 

nonphysician eligible professionals in groups with 2 or more eligible professionals and to solo 

practitioners who are nonphysician eligible professionals, including eligible professionals 

participating in ACOs, starting in CY 2017. To that end, we are seeking comment on whether 

there are synergies that can be created by aligning the ACO quality measures set with the 

measures used under the VM. For example, in the Value-based Modifier program, there are two 

claims-based composite outcomes measures, namely, the Composite of Acute Prevention Quality 

Indicators (PQIs) comprised by 3 measures (NQF #279 Bacterial Pneumonia Admission Rate, 

NQF #280, Dehydration Admission Rate, and NQF #281, Urinary Tract Infection Admission 

Rate) and the Composite of Chronic Prevention Quality Indicators (PQIs) comprised by 6 

measures (NQF #638 Uncontrolled Diabetes, NQF #272 Short Term Diabetes complications, 

NQF #274 Long Term Diabetes Complications, NQF #285 Lower Extremity Amputation for 

Diabetes, NQF #275 COPD, and NQF #277 Congestive Heart Failure). (See 

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/2012-ACSC-Outcomes-Msrs.pdf ). Because 

these VM measures are claims based measures, no additional reporting burden would be added 

to ACOs. In addition, we note that two of these measures are currently a part of the ACO quality 

measures set, specifically, NQF #275, “Ambulatory Sensitive Conditions Admissions: Chronic 

Obstructive Pulmonary Disease,” and NQF #277: “Ambulatory Sensitive Conditions 

Admissions: Congestive Heart Failure.” Although we are not proposing changes at this time to 

align with the measures used under the VM, we are seeking comment on whether the VM 

composites should be considered in the future as a replacement for the two ACO claims based 

ambulatory sensitive conditions admissions (ASCA) measures. 
 414 

● Specific measures to assess care in the frail elderly population: We recognize 

providers face challenges in caring for the health needs of the frail elderly. There are, however, 

many challenges in defining and measuring the quality of care for this population. In the 

November 2011 Shared Savings Program final rule, we incorporated a measure focused on the 

frail elderly population -- ACO#13 Screening for Fall Risk, which rewards ACOs for 

incorporating fall risk assessments in the redesign of their care processes. Our expectation was 

that practitioners would use the results of the fall risk assessments to promote meaningful 

conversations with their frail elderly patients about fall risks and ways to prevent or reduce these 

events. We also stated that as ACOs gain more experience integrating the fall risk screening into 

their day-to-day practices, we planned to revisit the frail elderly measures in future rulemaking to 

build upon these achievements and to address additional issues for the frail elderly (76 FR 

67886). We welcome comments with suggestions of new measures of the quality of care 

furnished to the frail elderly population that we may consider adopting in future rulemaking. 

● Utilization: We did not include utilization measures in the quality performance 

standards adopted in the November 2011 final rule establishing the Shared Savings Program 

because we believed that ACOs have an intrinsic motivation to reduce inappropriate utilization 

of services in order to achieve shared savings. However, in recognition of the value of feedback 

on utilization, we include utilization data as part of the quarterly aggregate reports provided to 

ACOs. We welcome comments on whether it is sufficient for such utilization information to be 

included in the aggregate quarterly reports to ACOs or whether utilization measures should also 

be used to assess the ACO’s quality performance as an added incentive to provide more efficient 

care. If commenters are interested in having such utilization measures included in the quality 

performance standard, we welcome specific comments on what measures would be most 

appropriate and suggestions for how to risk adjust these measures. 
 415 

● Health outcomes: Currently, the quality performance standard includes a self-reported 

health and functional status measure as part of the patient experience of care survey. We 

finalized this measure as pay for reporting for all 3-years of the agreement period to allow ACOs 

to gain experience with the measure (which had not previously been used for accountability 

purposes in any pay-for-performance initiative) and to provide important information to them on 

improving the health outcomes of the population they serve (76 FR 67876). Patient-reported 

outcomes, although subjective, provide valuable information not captured by other means. We 

continue to believe that it is appropriate to require ACOs to report this measure and to maintain 

the performance standard at full and accurate reporting in order to allow ACOs to gain 

experience with the measure. We welcome suggestions as to whether and when it would be 

appropriate to include a self-reported health and functional status measure in the quality 

performance standard. We specifically welcome comments on the appropriateness of using a 

tool such the Health Outcomes Survey for health plans which assesses changes in the physical 

and mental health of individual beneficiaries over time. This survey would require at least 2 

years of reporting by the same beneficiary and assesses function over time rather than function at 

a particular point in time. We also welcome suggestions for alternatives to self-reported 

measures that may be considered in the future. 

● Measures for retirement: Some measures may not provide sufficiently useful 

information for assessing ACO quality performance since they are “topped out”, meaning that all 

but a very few of organizations achieve near perfect performance on the measure. As a result, 

such measures may no longer provide meaningful information regarding an ACO’s quality 

performance. Other examples of candidates for retirement could be measures that do not drive 

quality improvement. We seek input from commenters on any measures that should be 

considered for retirement in future rulemaking. We welcome comments on whether to continue 
 416 

to require ‘topped out” measures be included as pay for reporting measures. For example, it 

could be important to require ACOs to continue to report such measures so that we can assess 

performance to ensure quality of care does not decline or for other reasons. In addition, we note 

that as discussed below we are proposing changes to the benchmarking methodology for topped 

out measures. 

● Additional public health measures: We may propose to include an additional 

preventive health measure in the quality measure set under the Shared Savings Program in future 

rulemaking. Specifically, we are considering adding “Preventive Care and Screening: 

Unhealthy Alcohol Use: Screening and Brief Counseling” (NQF #2152). This measure would 

reflect screening of Medicare beneficiaries covered under the existing Medicare benefit referred 

to as the “Screening and Behavioral Counseling Interventions in Primary Care to Reduce 

Alcohol Misuse” benefit. We welcome comments on the potential addition of this measure and 

would consider any comments received in developing any future proposal with respect to this 

measure. 

4. Accelerating Health Information Technology 

a. Overview. 

 HHS believes all patients, their families, and their healthcare providers should have 

consistent and timely access to their health information in a standardized format that can be 

securely exchanged between the patient, providers, and others involved in the patient’s care. 

(HHS August 2013 Statement, “Principles and Strategies for Accelerating Health Information 

Exchange.” http://www.healthit.gov/policy-researchers-implementers/accelerating-healthinformation-exchange-hie). The Department is committed to accelerating health information 

exchange (HIE) through the use of electronic health records (EHRs) and other types of health 

information technology (HIT) across the broader care continuum through a number of initiatives 
 417 

including: (1) alignment of incentives and payment adjustments to encourage provider adoption 

and optimization of HIT and HIE services through Medicare and Medicaid payment policies; (2) 

adoption of common standards and certification requirements for interoperable HIT; (3) support 

for privacy and security of patient information across all HIE-focused initiatives; and (4) 

governance of health information networks. These initiatives are designed to encourage HIE 

among health care providers, including professionals and hospitals eligible for the Medicare and 

Medicaid EHR Incentive Programs and those who are not eligible for the EHR Incentive 

Programs, as well as those providers that are participating in the Medicare Shared Savings 

Program in an ACO and those that are not, and are designed to improve care delivery and 

coordination across the entire care continuum. For example, the Transition of Care Measure #2 

in Stage 2 of the Medicare and Medicaid EHR Incentive Programs requires HIE to share 

summary records for more than 10 percent of care transitions. In addition, to increase flexibility 

in the Office of the National Coordinator for Health IT’s (ONC's) HIT Certification Program and 

expand HIT certification, ONC has issued a proposed rule concerning a voluntary 2015 Edition 

of EHR certification criteria, which would more easily accommodate certification of HIT for 

technology used in health care settings where health care providers are not typically eligible for 

incentive payments under the EHR Incentive Programs, to facilitate greater HIE across the entire 

care continuum. 

 We believe that HIE and the use of certified EHRs can effectively and efficiently help 

ACOs and participating providers improve internal care delivery practices, support management 

of patient care across the continuum, and support the reporting of eCQMs. More information on 

the Voluntary 2015 Edition EHR Certification Criteria Proposed Rule is available at 

http://healthit.gov/policy-researchers-implementers/standards-and-certification-regulations. 

b. Electronic Reporting of Quality Measure Data 
 418 

We believe that certified EHR technology used in a meaningful way is one piece of a 

broader health information technology infrastructure needed to reform the health care system and 

improve health care quality, efficiency, and patient safety. Through our programs such as the 

Medicare and Medicaid EHR Incentive Programs and the Stage 2 meaningful use (MU) 

requirements we seek to expand the meaningful use of certified EHR technology. Adoption of 

certified EHR technology (CEHRT) by ACO participants and ACO providers/suppliers may help 

support efforts to achieve improvements in patient care and quality, including reductions in 

medical errors, increased access to and availability of records and data, improved clinical 

decision support, and the convenience of electronic prescribing. Additionally, we believe that 

the potential for the Shared Savings Program to achieve its goals could be further advanced by 

direct EHR-based quality data reporting by ACOs and their ACO participants and ACO 

providers/suppliers. This could help reinforce the use of CEHRT, reduce errors in quality 

measure submission, and achieve data submission efficiencies. We believe ACOs and their 

providers should be leaders in encouraging EHR adoption and should be using CEHRT to 

improve quality of care and patient safety and to reduce errors. 

 Furthermore, beginning in 2015, eligible professionals that do not successfully 

demonstrate meaningful use of certified EHR technology will be subject to a downward 

payment adjustment under Medicare that starts at -1 percent and increases each year that an 

eligible professional does not demonstrate meaningful use, to a maximum of -5 percent. A final 

rule establishing the requirements of Stage 2 of the Medicare EHR Incentive Program appeared 

in the September 4, 2012 Federal Register (Medicare and Medicaid Programs; Electronic 

Health Record Incentive Program—Stage 2 Final Rule) (77 FR 53968). Included in this final 

rule are the meaningful use and other requirements that apply for the payment adjustments under 

Medicare for covered professional services provided by eligible professionals failing to 
 419 

demonstrate meaningful use of CEHRT, including the CQM reporting component of meaningful 

use. As previously discussed in section III.M.2, we are proposing to revise the name and the 

specifications for the quality measure regarding EHR adoption to take the changing incentives 

into account. Specifically, we are proposing to change the name of ACO #11 from “Percent of 

PCPs Who Successfully Qualify for an EHR Incentive Program Payment” to “Percent of PCPs 

Who Successfully Meet Meaningful Use Requirements” to more accurately reflect what is being 

measured. 

 Additionally, under a group reporting option established for the Medicare EHR Incentive 

Program (77 FR 54076 through 54078), EPs participating in an ACO under the Shared Savings 

Program who extract the data necessary for the ACO to satisfy the quality reporting requirements 

of the Shared Savings Program from CEHRT would satisfy the CQM reporting component of 

meaningful use as a group for the Medicare EHR Incentive Program. In addition to submitting 

CQMs as part of an ACO, EPs have to individually satisfy the other objectives and associated 

measures for their respective stage of meaningful use. 

 However, we clarify that if an EP intends to use this group reporting option to meet the 

CQM reporting component of meaningful use, then the EP would have to extract all its CQM 

data from a CEHRT and report it to the ACO (in a form and manner specified by the ACO) in 

order for the EP to potentially qualify for the Medicare EHR Incentive Program. The ACO must 

also report the GPRO web interface measures and satisfy the reporting requirements under the 

Shared Savings Program in order for its EPs to satisfy the CQM reporting component of 

meaningful use for the Medicare EHR Incentive Program. 

 Although these group reporting requirements were established under the Medicare EHR 

Incentive Program, the Shared Savings Program regulations were not amended to reflect these 

reporting requirements. Therefore, we propose to amend the regulations governing the Shared 
 420 

Savings Program to align with the requirements previously adopted under the Medicare EHR 

Incentive Program in order to provide that EPs participating in an ACO under the Shared 

Savings Program can satisfy the CQM reporting component of meaningful use for the Medicare 

EHR Incentive Program when the ACO reports GPRO web interface measures by adding new 

paragraph (d) to §425.506. This new paragraph will provide that EPs participating in an ACO 

under the Shared Savings Program satisfy the CQM reporting component of meaningful use for 

the Medicare EHR Incentive Program when: (1) the eligible professional extracts data necessary 

for the ACO to satisfy its GPRO quality reporting requirements from CEHRT; and (2) the ACO 

satisfactorily reports the ACO GPRO measures through a CMS web interface. 

Although this proposal will align the Medicare Shared Savings Program regulations with the 

existing requirements under the Medicare EHR Incentive Program, we intend to take steps in the 

future to better align and integrate EHR use into quality reporting under the Shared Savings 

Program. 

We recognize there are operational constraints that must be considered when developing 

policies related to electronic reporting of quality measures under the Shared Savings Program. 

First, many ACO legal entities are conveners of Medicare enrolled entities, but are not Medicareenrolled themselves, that is, many ACO legal entities do not provide direct health care services, 

and therefore, may not thus far have had a need for an EHR. Further, ACO participants and 

ACO providers/suppliers may be at different levels of EHR adoption. For example, an ACO 

may have ACO participants that do not own an EHR. Other ACOs may have ACO participants 

that have and use EHR platforms, but have chosen different platforms, each requiring different 

modifications to make them uniformly extract required quality data. In addition, ACOs have told 

us that different EHR platforms may not yet be seamlessly interoperable. Finally, within each 

ACO participant, there may be differing levels of EHR use among the ACO providers/suppliers 
 421 

that are EPs. Operationally, a few options could be considered for implementing the eCQM 

portion of the meaningful use requirements in the future. For example, we could consider 

whether it would be preferable for the EPs within each ACO participant to individually submit 

EHR data to CMS, whether each ACO participant should report as a group; whether the ACO 

itself should aggregate EHR data from its ACO participants and then submit the quality measures 

to CMS; or whether the ACO could submit quality measure data via a data submission vendor 

that would be responsible for aggregating and submitting the data on the ACO’s behalf. 

Although we are not proposing any new requirements regarding EHR based reporting 

under the Shared Savings Program at this time, we welcome suggestions and comments about 

these issues which we would consider in developing any future proposals. We especially seek 

comment on the feasibility of an ACO to be a convener and submitter of quality measures 

through an EHR or alternative method of electronically reporting quality measures to us. We are 

interested in the opportunities and barriers to ACO EHR quality measure reporting, as well as 

ways to overcome any barriers. We also welcome suggestions on alternative ways that we might 

implement EHR-based reporting of quality measures in the Shared Savings Program, such as 

directly from EHRs or via data submission vendors. We seek comment on whether EHR 

reporting should be a requirement for all Shared Savings Program ACOs or if the requirement 

for EHR reporting should be phased in gradually, for instance through a separate risk track or by 

the establishment of a “core and menu” quality measure set approach in which we would 

establish a core set of required quality measures and then supplement these required measures 

with a menu of additional measures (such as EHR-based reporting) from which an ACO could 

choose. This approach could provide ACOs with additional flexibility and allow them to report 

on quality measures that better reflect any special services they provide. As an alternative, we 

also seek comment on whether ACO providers/suppliers could use a local registry-like version of 
 422 

the GPRO web interface to capture relevant clinical information and to monitor performance on 

all Medicare patients throughout the year and to more easily report quality data to CMS annually. 

3. Quality Performance Benchmarks 

a. Overview of Current Requirements 

Section 1899(b)(3)(C) of the Act directs the Secretary to “establish quality performance 

standards to assess the quality of care furnished by ACOs” and to “seek to improve the quality of 

care furnished by ACOs over time by specifying higher standards, new measures, or both for 

purposes of assessing such quality of care.” Under the current Shared Savings Program 

regulations at §425.502, the following requirements with regard to establishing a quality 

performance benchmark for measures apply: (1) during the first performance year of an ACO’s 

agreement period, the quality performance standard is set at the level of complete and accurate 

reporting; (2) during subsequent performance years, the quality performance standard will be 

phased in such that ACOs will be assessed on their performance on certain measures (see Table 1 

of the November 2011 Shared Savings Program final rule (76 FR 67889 through 67890), for 

details of the transition for each of the 33 measures); (3) we designate a quality performance 

benchmark and minimum attainment level for each measure, and establish a point scale for the 

level of achievement on each measure; and (4) we define quality performance benchmarks using 

FFS Medicare data or using flat percentages when the 60th percentile is equal to or greater than 

80.00 percent. 

Section 425.502(b)(2) governs the data that CMS uses to establish the quality 

performance benchmarks for quality performance measures under the Shared Savings Program. 

Consistent with section 1899(b)(3)(C) of the Act, which requires CMS to seek to improve the 

quality of care furnished by ACOs participating in the Shared Savings Program over time, 

§425.500(b)(3) states that in establishing the measures to assess the quality of care furnished by 
 423 

an ACO, CMS seeks to improve the quality of care furnished by ACOs over time by specifying 

higher standards, new measures, or both. 

Subsequently, we discussed several issues related to the establishment of quality 

performance benchmarks in the CY 2014 PFS final rule with comment period 

(78 FR 74759 through 74764). In that rule (78 FR 74760), we finalized a proposal to combine 

all available Medicare FFS quality data, including data gathered under PQRS (through both the 

GPRO web interface tool and other quality reporting mechanisms) and other relevant FFS 

quality data reported to CMS (including data submitted by Shared Savings Program and Pioneer 

ACOs) to set the quality performance benchmarks for 2014 and subsequent reporting periods. In 

establishing this policy, we determined that it was appropriate to use all FFS data rather than 

only ACO data, at least in the early years of the program, to avoid the possibility of punishing 

high performers where performance is generally high among all ACOs. We did not finalize a 

proposal to use Medicare Advantage (MA) data alone or in combination with FFS data in the 

short-term. Instead, we stated in the CY 2014 PFS final rule with comment period 

(78 FR 74760) that we intended to revisit the policy of using MA data in future rulemaking when 

we have more experience setting benchmarks for ACOs. 

Additionally, in the CY 2014 PFS final rule with comment period, we retained the ability 

to use flat percentages to set benchmarks when many reporters demonstrate high achievement on 

a measure, so that ACOs with high performance on a measure are not penalized (78 FR 74760). 

More specifically, we will now use all available FFS data to calculate benchmarks, including 

ACO data, except where performance at the 60th percentile is equal to or greater than 80 percent 

for individual measures. In these cases, a flat percentage will be used to set the benchmark for 

the measure. This policy allows ACOs with high scores to earn maximum or near maximum 
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quality points while still allowing room for improvement and rewarding that improvement in 

subsequent years. 

As previously discussed, the first year of an ACO’s agreement period is pay for reporting 

only, so ACOs earn their maximum sharing rate for completely and accurately reporting all 33 

quality measures. Quality performance benchmarks are released in subregulatory guidance prior 

to the start of the quality reporting period for which they apply so that as we phase in measures 

to pay for performance ACOs are aware of the actual performance rates they will need to achieve 

to earn the maximum quality points under each domain. In the November 2011 Shared Savings 

Program final rule, we indicated our intent to gradually raise the minimum attainment level to 

continue to incentivize quality improvement over time and noted that we would do so through 

future rulemaking after providing sufficient advance notice with a comment period to allow for 

industry input (76 FR 67898). In the CY 2014 PFS final rule with comment period, we reiterated 

our policy of setting quality performance benchmarks prior to the reporting year for which they 

would apply (78 FR 74759). Specifically, we use data submitted in 2013 for the 2012 reporting 

period to set the quality performance benchmarks for the 2014 reporting period. However, we 

recognize that in the first few years of the Shared Savings Program, we will only have a limited 

amount of data for some measures, which may cause the benchmarks for these measures to 

fluctuate, possibly making it difficult for ACOs to improve upon their previous year’s 

performance. Stakeholders have also told us that they prefer to have a stable benchmark target 

so that they can be rewarded for quality improvement from one year to the next. Therefore, 

instead of modifying quality performance benchmarks annually, in the CY 2014 PFS final rule 

with comment period (78 FR 74761) we stated that we would set the benchmarks for the 2014 

reporting year in advance using data submitted during 2013 for the 2012 reporting year, and 

continue to use that benchmark for 2 reporting years (specifically, the 2014 and 2015 reporting 
 425 

years). We further indicated our intention to revisit this issue in future rulemaking to allow for 

public comment on the appropriate number of years that a benchmark should apply before it is 

updated. 

b. Proposed Revisions for Benchmarking Measures That Are “Topped Out” 

 In the discussion of measures above, we indicated that some measures may be topped out, 

meaning that all but a very few of organizations achieve near perfect performance on the 

measure. Since publication of the quality performance benchmarks for the 2014 and 2015 

quality reporting years, a number of ACOs have noted that using available national FFS data has 

resulted in some benchmarks where the 80th or 90th percentiles approach 100 percent 

performance on the measure. Stakeholders have suggested it is unreasonable to hold 

organizations, especially very large organizations such as ACOs to this high standard and that it 

may be easier for smaller and medium size physician practices to achieve higher levels of 

performance given their smaller patient populations. We believe these concerns have merit 

because we have looked at the FFS data submitted to CMS and agree it is possible that smaller 

practices or practices with smaller populations may be able achieve these higher levels of 

performance more easily than larger practices or organizations with larger patient populations. 

Therefore, we are proposing certain modifications to our benchmarking methodology to address 

the way that such “topped out” measures are treated for purposes of evaluating an ACO’s 

performance. Specifically, when the national FFS data results in the 90th percentile for a 

measure are greater than or equal to 95 percent, we would use flat percentages for the measure, 

similar to our policy under §425.502(b)(2)(ii) of using flat percentages when the 60th percentile 

is greater than 80 percent to address clustered measures. We believe this approach would 

address concerns about how topped out measures affect the quality performance standard while 

continuing to reward high performance, and being readily understandable to all. We propose to 
 426 

revise §425.502(b)(2)(ii) to reflect this proposed policy. We invite comments on this proposal. 

We also invite comments on other potential approaches for addressing topped out measures. We 

would use any comments received to help develop any future proposals regarding topped out 

measures. For example, we welcome comments on whether we should drop topped out measures 

from the measures set, fold them into composites, or retain them but make them pay for reporting 

only. 

c. Proposed Quality Performance Standard for Measures that Apply to ACOs that Enter a Second 

or Subsequent Participation Agreement 

 As discussed previously, during an ACO’s first participation agreement period, the 

quality performance standard during the first performance year is initially set at the level of 

complete and accurate reporting, and then, during performance years 2 and 3 within the ACO’s 

first agreement period, the quality performance standard is phased in such that the ACO is 

assessed on its performance on selected measures. We did not directly indicate the quality 

performance standard that would apply if an ACO were to subsequently enter into a second or 

subsequent participation agreement. However, §425.502(a)(1) provides that during the first 

performance year of an ACO’s agreement period, CMS will define the quality performance 

standard at the level of complete and accurate reporting of all quality measures. As drafted, this 

regulation could be read to imply that the quality performance standard for ACOs in the first 

performance year of a subsequent agreement period would also be set at the standard of full and 

accurate reporting. We do not believe it is appropriate for an ACO in a second or subsequent 

agreement period to report quality measures on a pay-for-reporting basis if they have previously 

reported these measures in a prior agreement period. The ACO would have gained experience 

reporting the quality measures during the earlier agreement period, and as a result, we do not 

believe it would be necessary to provide any further transition period. Rather, we believe it 
 427 

would be appropriate to assess the ACO’s actual performance on measures that have been 

designated as pay for performance during all 3 years of the second or subsequent participation 

agreement period. 

 Accordingly, we propose to revise our regulations to expressly provide that during a 

second or subsequent participation agreement period, the ACO would continue to be assessed on 

its performance on each measure that has been designated as pay for performance. That is, the 

ACO would continue to be assessed on the quality performance standard that would otherwise 

apply to an ACO if it were in the third performance year of the first agreement period. We will 

do this by modifying §425.502(a)(1) and (a)(2) to indicate that the performance standard will be 

set at the level of complete and accurate reporting of all quality measures only for the first 

performance year of an ACO’s first agreement period, and that during subsequent agreement 

periods, pay for performance will apply for all three performance years. As proposed earlier in 

this section, new measures that are added to the quality performance standard would be phased in 

along the timeline indicated when the measure is added and in operational documents. 

d. Proposed Timing for Updating Benchmarks 

 As discussed in the CY 2014 PFS final rule with comment (78 FR 74761), we have 

further considered suggestions from ACOs regarding the appropriate number of years that a 

benchmark should apply before it is updated. ACOs suggested that there be a longer period of 

time to gain experience with the performance measure, before benchmarks are further updated. 

ACOs also indicated that it would be desirable to set and leave benchmarks static for additional 

performance years so that they have a quality improvement target to strive for that does not 

change frequently. ACOs believe that a stable benchmark would enhance their ability to be 

rewarded for quality improvement, as well as quality achievement, from one year to the next. 

We recognize, however, that there could be some concerns about lengthening the period between 
 428 

updates to the quality performance benchmarks. The current benchmarks as discussed 

previously, for example, are based on a combination of all available Medicare FFS quality data, 

including data gathered under PQRS, the Shared Savings Program and Pioneer ACO Model, but 

not MA quality data. To the extent that the benchmarks are based on quality data reported by a 

large number of ACOs and other FFS entities, we believe it is reasonable to use them to assess 

the quality performance of ACOs. Furthermore, as discussed in the 2014 PFS final rule with 

comment period (78 FR 74761), we are also persuaded that we should establish a longer period 

between updates to the benchmarks in order to provide ACOs with a more stable target for 

measuring quality improvement. In the absence of this stability, it could be very difficult to 

assess quality improvement from year to year. 

 In the 2014 PFS final rule with comment period, we noted that we intended to address the 

number of years between updates to the benchmarks again in future rulemaking in order to allow 

for public comment. Therefore, we considered how long benchmarks should be in place before 

they are updated. We considered a range of options, from setting benchmarks every 2 years to 

setting benchmarks every 5 years. For example, we considered the option of setting benchmarks 

every 3 years. However, we note that ACO agreement periods are 3 years long and a new cohort 

of ACOs enters the program each year. As a result, setting benchmarks every 3 years might 

advantage some ACOs over others, particularly ACOs that have an agreement period during 

which benchmarks are not updated. Therefore, we propose to update benchmarks every 2 years. 

We believe 2 years is an appropriate amount of time because the Shared Savings Program is 

relatively new and we do not have extensive experience in setting benchmarks under the Shared 

Savings Program. Updating the benchmarks every 2 years would enable us to be more flexible 

and give us the ability to make adjustments more frequently if appropriate. We note, however, 

that we may revisit this policy as more ACOs enter the program, more FFS data is collected 
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which could help us better understand to what extent benchmarks should vary from year to year, 

or if we make any future proposals regarding the use of MA quality data for setting benchmarks. 

 Accordingly, we propose to revise §425.502(b) to add a new paragraph (b)(4)(i), which 

will provide that CMS will update benchmarks every 2 years. To illustrate this proposed policy, 

the existing quality performance benchmarks, which are based on data submitted in 2013 for the 

2012 reporting period would apply for a total of 2 performance years (the 2014 and 2015 

performance years) after which we would reset the benchmarks for all ACOs based on data for 

the 2014 reporting period that is reported during 2015. These updated benchmarks would apply 

for the 2016 and 2017 performance years. This timeline is summarized in Table 54. Under this 

proposal, ACOs would have a stable target for quality achievement for 2 years, which should 

improve the opportunity for ACOs to be rewarded for improvement from year to year compared 

to that benchmark. We also propose to revise §425.502(b) to add a new paragraph (b)(4)(ii), 

which will provide that for measures introduced in the first year of the 2-year benchmarking 

cycle, the benchmark will be established in the second year and updated along with the other 

measures at the start of the next 2-year benchmarking cycle. 

 We seek comment on this proposal. We specifically seek comment on the appropriate 

number of years that a benchmark should remain stable before it is updated. We also welcome 

comments about when annual updates might be appropriate such as when there is a substantive 

specification change to a measure between years. For instance, the age range used for the breast 

cancer screening measure is different in 2014 than in 2013, or when the measure owner modifies 

or retires a measure. Additionally, although we are proposing to retain our current policy of 

using the most recent available data to set the quality performance benchmarks, we also seek 

comment on whether data from other reporting periods should also be considered in establishing 

benchmarks that will apply for 2 performance years. Specifically, we seek input on whether data 
 430 

from multiple years should be used to help provide more stable benchmarks. For example, 

should data submitted for the 2013 and 2014 reporting periods be combined to set benchmarks 

for the 2016 and 2017 performance years? 

TABLE 54: Proposed Timeline for Setting and Updating Quality Performance 

Benchmarks 

Reporting period for data 

used to set benchmark 

Year data is collected, 

analyzed, and benchmark is 

published 

Performance year and reporting period to 

which benchmark applies 

2012 2013 2014 & 2015 

2014 2015 2016 & 2017 

2016 2017 2018 & 2019 

 

4. Rewarding Quality Improvement 

a. Current Approach to Rewarding ACOs for Both Quality Attainment and Quality 

Improvement 

 ACOs must meet a CMS-specified quality performance standard in order to be eligible to 

share in savings. The Shared Savings Program quality performance standard currently consists 

of a set of quality measures spanning four domains that are collected via the patient and 

caregiver experience of care survey, calculated by CMS from internal administrative and claims 

data, and submitted by the ACO through the CMS web interface. The four domains include 

patient/caregiver experience of care, care coordination/patient safety, preventive health, and atrisk populations. The measures collected through the CMS web interface are also used to 

determine whether eligible professionals that bill through the TIN of an ACO participant qualify 

for the PQRS incentive payment or avoid the downward PQRS payment adjustment. Eligible 

professionals that bill through the TIN of an ACO participant may qualify for the PQRS 

incentive payment or avoid the downward PQRS payment adjustment when the ACO 

satisfactorily reports the ACO GPRO quality measures on their behalf. 
 431 

 Under current policy, the quality performance standard is defined at the level of full and 

complete reporting for the first performance year of an ACO’s agreement period. After that, an 

ACO must meet certain thresholds of performance and is rewarded on a sliding scale in which 

higher levels of quality performance translate to higher rates of shared savings. This scale, 

therefore, rewards improvement over time, since higher performance translates to higher shared 

savings. For example, an ACO that performs at the 80th percentile one year and then at the 90th

percentile the next year would receive a higher level of shared savings in its second year than its 

first year, based on its improved quality performance. In this way, ACOs are rewarded for both 

attainment and improvement. This is particularly true when benchmarks are stable for more than 

one year, as proposed previously. 

We recognize that rewards for both quality attainment, as well as quality improvement 

are not always built in to pay-for-performance initiatives. For example, in HVBP (Hospital 

Value-Based Purchasing) hospitals are scored based on the higher of their achievement or 

improvement on specified quality measures, with some hospitals receiving incentive payments if 

their overall performance is high enough relative to their peers. In the November 2011 final rule 

establishing the Shared Savings Program (76 FR 67897), we indicated in response to comments 

that we believe the approach of offering more points for better quality performance also offers an 

implicit incentive for continuous quality improvements, since it incorporates a sliding scale in 

which higher levels of quality performance translate to higher sharing rates. We believed that 

high performing ACOs should do well under this approach since it recognizes and provides 

incentives for ACOs to maintain high quality performance in order to maximize their share of 

savings and minimize their share of losses. 
 432 

b. Additional Rewards for Quality Improvement 

 ACOs and other stakeholders have suggested that the current quality points scale 

described above does not adequately reward ACOs for both quality attainment and improvement. 

They request that we further strengthen the incentives for quality improvement by including an 

additional explicit reward for those ACOs that improve from one year to the next. 

 As discussed previously, the existing quality performance standard includes a sliding 

point scale that rewards ACOs for certain levels of attainment. In addition, we note that under 

the proposal discussed above in which we propose to establish a stable quality performance 

benchmark for a period of 2 years, there should be an even greater opportunity for every ACO to 

demonstrate improvement and be rewarded for that improvement from year to year. However, 

we are persuaded by suggestions from stakeholders that an additional, more explicit reward 

should be included for ACOs that improve their quality scores from year to year. The success of 

the Shared Savings Program is partially dependent on ACOs further improving the quality of the 

care they provide, not merely maintaining current levels of quality. Therefore, we are proposing 

to revise our existing quality scoring strategy to explicitly recognize and reward ACOs that make 

year-to-year improvements in their quality performance scores on individual measures. We 

believe that offering an additional and explicit reward for improving quality performance would 

complement and reinforce our current quality performance scoring system that implicitly takes 

into account improvements over prior performance and rewards ACOs with a greater share in 

savings for greater quality performance. We believe that adding an explicit incentive places 

even greater emphasis on quality improvement, encouraging all ACOs to continue to improve 

quality for their patient populations over time, in addition to maintaining existing high quality 

levels. 
 433 

 To develop such an approach, we looked to the MA program, which has already 

successfully developed and implemented a formula for measuring quality improvement. The 

MA five star rating program computes an improvement change score which is defined as the 

score for a measure in performance year minus the score in previous performance year. The MA 

five star rating program then measures each plan’s net quality improvement by calculating the 

total number of significantly improved quality measures and subtracting the total number of 

significantly declined quality measures. This is an approach that we believe is also appropriate 

for measuring quality improvement for ACOs. (For more details on the formula for calculating 

the MA quality improvement measure, see the discussion in “Medicare 2014 Part C & D Star 

Rating Technical Notes”, Attachment I, page 80, which can be downloaded from the CMS 

website at http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html.) 

 We continue to believe it is important to recognize that the Shared Savings Program is 

not a managed care program. Unlike MA, this program’s design retains FFS flexibility and the 

freedom of choice available to beneficiaries under Medicare Parts A and B which generally 

necessitates different program requirements. However, in this case we believe there would be 

significant advantages for the Shared Savings Program to adopt the formula for a quality 

improvement measure that MA has already developed and implemented rather than attempt to 

develop a new formula for a quality improvement measure. In particular, the MA measure 

formula has already been fully developed and vetted with stakeholders, in the context of the MA 

program, with detailed operational specifications and previously shared with the public. 

 In addition, we believe it is important to add a quality improvement measure to the 

Shared Savings Program in a manner that would minimize disruption for ACOs. We believe it 

would be undesirable for both ACOs and the program if the quality improvement measure were 
 434 

added in a way that required extensive revisions to the current quality measurement 

methodology, for example, reweighting of the four quality measure domains. Therefore, we 

propose to add a quality improvement measure to award bonus points for quality improvement to 

each of the existing four quality measure domains. For each quality measure domain, we would 

award an ACO up to two additional bonus points for quality performance improvement on the 

quality measures within the domain. These bonus points would be added to the total points that 

the ACO achieved within each of the four domains. Under this proposal, the total possible points 

that can be achieved in a domain, including up to 2 bonus points, could not exceed the current 

maximum total points achievable within the domain. For example, as shown in Table 51, 

currently the total possible points for the patient/caregiver experience domain, which has seven 

individual measures, is 14 total possible points. Under this proposal to provide for quality 

improvement bonus points, the maximum possible points within this domain would continue to 

be 14. If an ACO scored 12 points and was awarded two additional bonus points for quality 

improvement then the ACO’s total points for this domain would be 14. However, if instead this 

same ACO had scored 13 points, then this ACO’s total points after adding the bonus points could 

still not exceed 14. 

 ACOs would achieve bonus points for this quality improvement measure in a domain if 

they achieve statistically significant levels of quality improvement for measures within the 

domain, as discussed below. Otherwise, the current methodology for calculating the ACO’s 

overall quality performance score would continue to apply (see §425.502(e) and 76 FR 67895 

through 67900). Additional details about the proposal to incorporate bonus points into the 

quality performance scoring methodology follow: 

 Table 51 shows the maximum possible points that currently may be earned by an ACO in 

each domain and for all domains. Table 52 shows the maximum possible points that may be 
 435 

earned under the proposed quality measures changes. The data in Tables 51 and 52 are not 

affected by this proposal to provide for bonus points for quality improvement and do not include 

the proposed maximum of two bonus points in each domain. The quality improvement measure 

scoring for a domain would be based on the ACO’s net improvement in quality for the other 

measures in the domain. The calculation of the quality improvement measure for each domain 

would generally be based on the formula used for the MA five star rating program, as follows: 

Improvement Change Score = score for a measure in performance year minus score in 

previous performance year. 

In general, for a measure to be eligible to be included for purposes of determining quality 

improvement and awarding bonus points in a domain for a performance year, the measure must 

be a measure for which an ACO was scored in both the performance year and the immediately 

preceding performance year. Measures that were not scored in both the performance year and 

the immediately preceding performance year, for example, new measures, would not be included 

in the assessment of improvement. Otherwise, for purposes of determining quality improvement 

and awarding bonus points, we would include all of the individual measures within the domain, 

including both pay-for-reporting measures and pay-for-performance measures. We believe it 

would be appropriate to include pay-for-reporting measures for purposes of determining quality 

improvement and awarding bonus points since under §425.500(f) ACOs that fail to report all 

quality measures, including pay-for-reporting measures completely, accurately, and timely may 

be subject to termination or other corrective action. As an example, pay for reporting applies to 

the CAHPS health status/functional status measure for all three performance years. However, 

the ACO’s performance on the health status/functional status measure would still be considered 

in performance years two and three when we evaluate whether an ACO should be awarded bonus 

points. 
 436 

In determining improvement, the actual performance score achieved by the ACO on the 

measure would be used, not the score used to determine shared savings. In other words, we 

calculate a performance score for each measure, regardless of whether it is pay for reporting or 

pay for performance, and include the score in the report we provide to the ACO. For example, 

all measures are pay for reporting in the first year of an ACO’s first agreement period, but even 

though the ACO will receive full credit for all reported measures, its actual performance on those 

measures will also be scored and provided to the ACO for informational purposes. We believe it 

is appropriate to use these actual performance scores to assess improvement on a measure from 

year to year, regardless of whether the measure is designated as a pay for reporting or a pay for 

performance measure in that performance year because the performance scores achieved by the 

ACO provide the best indication of the actual change in quality performance by the ACO. 

If the ACO is in its first performance year of its first agreement period, then it would not 

be possible, of course, to measure quality improvement. Therefore, for these ACOs the existing 

scoring methodology would continue to apply and no bonus points would be awarded. If an 

ACO in its second or subsequent performance year does not experience an improvement nor a 

decline in quality performance for any of the selected measures compared to its previous 

reporting period, or it experiences an improvement for some measures but has an equal or greater 

number of measures where quality performance has declined, then the ACO would likewise not 

be awarded any bonus points. If an ACO renews a participation agreement, then the 

measurement of quality improvement would be based on a comparison between performance in 

the first year of the new agreement period and performance in the 3rd year of the previous 

agreement period. 

 For each qualifying measure, we would determine whether there was a significant 

improvement or decline between the two performance years by applying a common standard 
 437 

statistical test. (See the discussion of the t-test for calculating the MA quality improvement 

measure in “Medicare 2014 Part C & D Star Rating Technical Notes”, Attachment I, page 80, 

which can be downloaded from the CMS website at http://www.cms.gov/Medicare/PrescriptionDrug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html). Statistical significance 

testing in this case assesses how unlikely it is that differences as big as those observed would be 

due to chance when the performance is actually the same. Under this methodology, we can be 

reasonably certain, at a 95 percent level of confidence, that statistically significant differences in 

an ACO’s quality measure performance for a year compared to the previous year are real and not 

simply due to random variation in measure sampling. 

 The awarding of bonus points would be based on an ACO’s net improvement within a 

domain, and would be calculated by determining the total number of significantly improved 

measures and subtracting the total number of significantly declined measures. Up to two bonus 

points would be awarded on a sliding scale based on the ACO’s net improvement for the domain 

to the total number of individual measures in the domain. Specifically, the bonus points, up to a 

maximum of 2 points, would be awarded in direct proportion to the ACO’s net improvement for 

the domain to the total number of individual measures in the domain. For example, there are 

seven individual measures for the patient/caregiver experience of care domain. If the ACO 

achieved a significant quality increase in all seven measures then the ACO would be awarded the 

maximum of two bonus points for this domain. However, if the ACO achieved a significant 

quality increase in only one of the seven measures in this domain and no significant quality 

decline on any of the measures then the ACO would be awarded 0.29 bonus points for quality 

improvement in the domain that is 1/7 times 2 = 0.29. The total points that the ACO could 

achieve in this domain could still not exceed the current maximum of 14 points shown in Table 

51. 
 438 

 Tables 51 and 52 reflect the current quality measure scoring methodology which would 

continue under this proposal. These tables show the number of points available per domain 

under both the current quality performance standard and the proposed revisions to the quality 

performance standard. 

 Consistent with our current quality scoring methodology, the total points earned for 

measures in each domain, including any quality improvement bonus points up to the total 

possible points, would be summed and divided by the total points available for that domain to 

produce an overall domain score of the percentage of points earned versus points available. The 

percentage score for each domain will be averaged together to generate a final overall quality 

performance score and sharing rate for each ACO that will be used to determine the amount of 

savings it shares or, if applicable, the amount of losses it owes, consistent with the requirements 

under §425.502(e). 

 In developing this proposal to award bonus points for quality improvement, we 

considered several alternative options. Specifically, we considered whether it would be more 

appropriate not to award bonus points but instead to include a computed quality improvement 

measure that would be incorporated into the current scoring methodology just as any other 

measure would be added. Under this alternative approach, we would increase the total possible 

points that could be awarded in a domain. However, we did not propose that approach because 

we believe that awarding bonus points would provide the desired incentive, would be more 

understandable and less disruptive, and would not require extensive changes to the quality 

performance standard. By awarding bonus points we also avoid the need to develop ways to 

avoid unfairly penalizing new ACOs. Similarly, ACOs that have already achieved a very high 

level of quality for an individual measure may not be able to achieve further statistically 

significant improvement for the measure. Such ACOs could otherwise be disadvantaged if they 
 439 

were not able to earn performance points for a new quality improvement measure added to the 

total measures in the domain. We believe our quality improvement proposal mitigates these 

concerns because the measure recognizes incremental improvement at higher levels of 

performance and does not impose any penalty on ACOs that have already achieved a high level 

of performance. 

 We also considered whether we should provide an even greater additional incentive by 

increasing the total possible bonus points, perhaps up to 4 points to provide a higher incentive for 

greater levels of quality improvement. However, we are not proposing that option because we 

are concerned that awarding 4 points for the quality improvement measure could overweight the 

additional incentive for quality improvement given that the program already rewards higher 

performance with a greater share of any savings. 

 In addition, we have some concerns about whether it would be appropriate to use the 

“pay for reporting” data reported to us, given that the accuracy does not affect an ACO’s quality 

performance score in the first performance year. Therefore, we considered whether the proposed 

quality improvement score should apply only to those ACOs that have completed at least two 

performance years. Under this alternative approach, ACOs would have an opportunity to be 

assessed based on their actual quality measure performance before being assessed on their 

quality improvement scores. We did not select this approach because we wanted to provide an 

incentive that would apply as soon as possible in the agreement period. Furthermore, as noted 

earlier, we believe it would be appropriate to include pay-for-reporting measures for purposes of 

awarding bonus points since under §425.500(f) ACOs are required to report pay-for-reporting 

measures completely, accurately, and timely. 

 We are proposing to add a new paragraph (e)(4) to §425.502 to incorporate this proposed 

process for calculating bonus points for quality improvement into the quality performance 
 440 

scoring methodology. We seek comments on this proposal and welcome comments on the 

alternative approaches discussed above. We also seek comments on whether there are other 

alternative approaches to explicitly rewarding quality improvement for ACOs, and whether the 

implicit reward for quality improvement provided under the current regulations is sufficient. 

 We also welcome any suggestions on how the Shared Savings Program might integrate 

elements of other quality improvement methodologies such as those employed by HVBP or MA. 

Such comments would be considered in developing possible future proposals to further align 

with other Medicare quality improvement programs. 

5. Technical Corrections 

 Currently §425.502(d)(2)(ii) states that ACOs must score above the minimum attainment 

level determined by CMS on 70 percent of the measures in each domain. If an ACO fails to 

achieve the minimum attainment level on at least 70 percent of the measures in a domain, CMS 

will take the actions described in §425.216(c). We note that §425.216, which addresses the 

actions we may take prior to termination of an ACO from the Shared Savings Program does not 

include a paragraph (c). To encompass all of the actions we may take prior to termination, we 

believe the correct reference should be to §425.216 generally, and therefore, propose to make a 

technical correction to §425.502(d)(2)(ii) to eliminate the specific reference to paragraph (c) of 

§425.216. We also propose to correct a typographical error in this provision by revising “actions 

describe” to read “actions described.” 

 In addition, we are also proposing to make a technical correction to §425.502(a)(2). This 

provision currently states that ACOs will be assessed on performance based on the minimum 

attainment level for certain measures. However, as explained above and in the November 2011 

Shared Savings Program final rule (76 FR 67895 through 67896), ACO performance on a 

measure is assessed not only based on the minimum attainment level for the measure but also 
 441 

based upon the quality performance benchmark that has been established for that measure. This 

methodology for calculating the performance score for a measure is codified in the regulations at 

§425.502(c). Accordingly, we propose to amend §425.502(a)(2) to state that ACO performance 

will be assessed based on the quality performance benchmark and minimum attainment level for 

certain measures. 

 We request comments on these proposed technical corrections. 
 442 

N. Value-Based Payment Modifier and Physician Feedback Program 

1. Overview 

Section 1848(p) of the Act requires that we establish a value-based payment modifier 

(VM) and apply it to specific physicians and groups of physicians the Secretary determines 

appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, 

2017. On or after January 1, 2017, section 1848(p)(7) of the Act provides the Secretary 

discretion to apply the VM to eligible professionals as defined in section 1848(k)(3)(B) of the 

Act. Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral. 

In this rule, we are proposing policies to apply the VM to all physicians and groups of 

physicians and also nonphysician eligible professionals and to increase the amount of payment at 

risk. We also are proposing to refine the methodologies used to determine our quality and cost 

composites and also to establish a corrections process for 2015. 

2. Governing Principles for VM Implementation. 

In the CY 2013 PFS final rule with comment period, we discussed the goals of the VM 

and also established that specific principles should govern the implementation of the VM (77 FR 

69307). We refer readers to that rule for a detailed discussion and list those principles here for 

reference. 

● A focus on measurement and alignment. Measures for the VM should consistently 

reflect differences in performance among groups or solo practitioners, reflect the diversity of 

services furnished, and be consistent with the National Quality Strategy and other CMS quality 

initiatives, including the PQRS, the Shared Savings Program, and the Medicare EHR Incentive 

Program. 

● A focus on physician and eligible professional choice. Physicians and other 

nonphysician eligible professionals should be able to choose the level (individual or group) at 
 443 

which their quality performance will be assessed, reflecting eligible professionals’ choice over 

their practice configurations. The choice of level should align with the requirements of other 

physician quality reporting programs. 

● A focus on shared accountability. The VM can facilitate shared accountability by 

assessing performance at the group level and by focusing on the total costs of care, not just the 

costs of care furnished by an individual professional. 

● A focus on actionable information. The Quality and Resource Use Reports (QRURs) 

should provide meaningful and actionable information to help groups and solo practitioners 

identify clinical areas where they are doing well, as well as areas in which performance could be 

improved by providing groups and solo practitioners with QRURs on the quality and cost of care 

they furnish to their patients. 

● A focus on a gradual implementation. The VM should focus initially on identifying 

high and low performing groups and solo practitioners. As we gain more experience with 

physician measurement tools and methodologies, we can broaden the scope of measures 

assessed, refine physician peer groups, create finer payment distinctions, and provide greater 

payment incentives for high performance. 

3. Overview of Existing Policies for the Physician VM. 

In the CY 2013 PFS final rule with comment period (77 FR 69310), we finalized policies 

to phase-in the VM by applying it starting January 1, 2015, to payments under the Medicare PFS 

for physicians in groups of 100 or more eligible professionals. A summary of the existing 

policies that we finalized for the CY 2015 VM can be found in the CY 2013 PFS proposed rule 

(77 FR 44991 through 45021). Similarly, in the CY 2014 PFS final rule with comment period, 

we finalized policies to phase-in the VM by applying it starting January 1, 2016 to payments 

under the Medicare PFS for physicians in groups of 10 or more eligible professionals. The 
 444 

policies that we finalized for the CY 2016 VM can be found in the CY 2014 final rule with 

comment period (78 FR 74765 through 74787) 

4. Provisions of this Proposed Rule 

We are making the following proposals regarding the VM policies: 

● To apply the VM to all physicians and nonphysician eligible professionals in groups 

with 2 or more eligible professionals and to solo practitioners starting in CY 2017. 

● To make quality–tiering mandatory for groups and solo practitioners within Category 

1 for the CY 2017 VM. Category 1 includes: (1) groups that meet the criteria for satisfactory 

reporting of data on PQRS quality measures via the group practice reporting option (GPRO) for 

the CY 2017 PQRS payment adjustment; (2) groups that do not register to participate in the 

PQRS as a group practice participating in the PQRS GPRO in CY 2015 and that have at least 50 

percent of the group’s eligible professionals meet the criteria for satisfactory reporting of data on 

PQRS quality measures as individuals for the CY 2017 PQRS payment adjustment, or in lieu of 

satisfactory reporting, satisfactorily participate in a PQRS-qualified clinical data registry for the 

CY 2017 PQRS payment adjustment; and (3) solo practitioners that meet the criteria for 

satisfactory reporting of data on PQRS quality measures as individuals for the CY 2017 PQRS 

payment adjustment, or in lieu of satisfactory reporting, satisfactorily participate in a PQRSqualified clinical data registry for the CY 2017 PQRS payment adjustment. However, groups 

with between 2 and 9 eligible professionals and solo practitioners would be subject only to any 

upward or neutral adjustment determined under the quality-tiering methodology, and groups with 

10 or more eligible professionals would be subject to upward, neutral, or downward adjustments 

determined under the quality-tiering methodology 
 445 

● To apply the VM to physicians and nonphysician eligible professionals participating in 

the Shared Savings Program, the Pioneer ACO Model, the CPC Initiative, or other similar 

Innovation Center models or CMS initiatives starting in CY 2017. 

● To clarify the exclusion of non-assigned claims for non-participating providers from 

the VM. 

● To increase the amount of payment at risk under the VM from 2.0 percent in CY 2016 

to 4.0 percent in CY 2017. 

● To align the quality measures and quality reporting mechanisms for the VM with those 

available to groups and individuals under the PQRS during the CY 2015 performance period. 

● To expand the current informal inquiry process to allow additional corrections for the 

CY 2015 payment adjustment period. 

● To address the concerns raised by NQF regarding the per capita cost measures in the 

cost composite. 

We also seek comment on, but make no proposals regarding 

the treatment of hospital-based physicians with regard to the VM. 

a. Group Size 

Section 1848(p)(4)(B)(iii) of the Act requires the Secretary to apply the VM to items and 

services furnished under the PFS beginning on January 1, 2015, for specific physicians and 

groups of physicians the Secretary determines appropriate, and beginning not later than January 

1, 2017, for all physicians and groups of physicians. 

In the CY 2013 PFS final rule with comment period, we stated that we would gradually 

phase in the VM in CY 2015 by first applying it to large groups (77 FR 69308), which we 

defined as groups of physicians with 100 or more eligible professionals. In the CY 2014 PFS 

final rule with comment period, we continued our phase-in of the VM and adopted a policy to 
 446 

apply the VM in CY 2016 to groups of physicians with 10 or more eligible professionals (78 FR 

74765-74767). 

As mentioned above, section 1848(p)(4)(B)(iii)(II) of the Act requires the Secretary to 

apply the VM to items and services furnished under the PFS beginning not later than January 1, 

2017, for all physicians and groups of physicians. Therefore, we propose to apply the VM in CY 

2017 and each subsequent calendar year payment adjustment period to physicians in groups of 

physicians with 2 or more eligible professionals and to physicians who are solo practitioners. 

For purposes of the VM, we defined a physician, a group of physicians, and an eligible 

professional in the CY 2013 PFS final rule with comment period (77 FR 69307-69310). We 

propose to define a “solo practitioner” at §414.1205 as a single Tax Identification Number (TIN) 

with 1 eligible professional who is identified by an individual National Provider Identifier (NPI) 

billing under the TIN. This proposal completes our phase in of the VM as required by the Act. 

Please note that in section III.N.4.b of this proposed rule, we discuss our proposal to also apply 

the VM to nonphysician eligible professionals in groups subject to the VM and to nonphysician 

eligible professionals who are solo practitioners in CY 2017 and subsequent CY payment 

adjustment periods. Additionally, we note that in section III.N.4.g of this proposed rule, we state 

that performance on quality and cost measures in CY 2015 will be used to calculate the VM that 

is applied to items and services for which payment is made under the PFS during CY 2017. . 

Table 55 shows the number of groups, eligible professionals, physicians, and 

nonphysician eligible professionals in groups of various sizes based on an analysis of CY 2012 

claims with a 90-day run-out period. We note that the number of eligible professionals includes 

other practitioners, such as physician assistants and nurse practitioners, in addition to physicians. 

We estimate that our proposals to apply the VM to all groups with 2 or more eligible 

professionals and to all solo practitioners in CY 2017 would affect approximately 83,500 groups 
 447 

and 210,000 solo practitioners (as identified by their TINs) that consist of approximately 815,000 

physicians and 315,000 nonphysician eligible professionals. 

TABLE 55: Eligible Professional/Physician Group Size Distribution (2012 claims) 

Group Size 

Number of 

Groups 

(TINs)* 

Eligible 

Professionals 

(EPs) 

Number of 

Physicians 

Number of 

Nonphysician 

EPs 

Percent of 

Physicians 

Percent of 

Nonphysician 

EPs 

100+ EPs 1,044 303,009 223,917 79,092 27% 25% 

50-99EPs 1,526 103,998 71,089 32,909 9% 10% 

25-49 EPs 3,675 125,314 85,127 40,187 10% 13% 

20-24 EPs 1,831 39,887 27,115 12,772 3% 4% 

10-19 EPs 8,356 112,553 76,905 35,648 9% 11% 

2-9 EPs 67,065 235,756 166807 68,949 20% 22% 

1 EP 209,950 209,950 164,334 45,616 20% 14% 

Total 293,447 1,130,467 815,294 315,173 100% 100% 

*The number of groups (TINs) does not include TINs that have one or more EPs participating in the Shared Savings 

Program, the Pioneer ACO Model, or the Comprehensive Primary Care Initiative. 

As discussed in the CY 2014 PFS proposed rule with comment period (78 FR 43500 

through 43502), we conducted statistical reliability analysis on the PQRS quality measures 

contained in the 2010 and 2011 group and individual Quality and Resource Use Reports 

(QRURs). These reports contained the PQRS quality measures used in these years, and these 

PQRS measures are similar to the PQRS measures that will be used in the VM starting in CY 

2015. The quality measures in the group reports were statistically reliable at a high level. 

Moreover, at that time, the average reliability score was high for 98 percent of the individually 

reported PQRS measures included in the individual feedback reports; therefore, with the 

exceptions discussed in section III.N.4.h of this proposed rule regarding the all cause hospital 

readmission measure, we believe that the PQRS quality measures for groups with 2 or more 
 448 

eligible professionals and solo practitioners will also be reliable since they are chosen by the 

physicians and reflect their patients’ conditions and practices’ clinical priorities. 

We believe that we can validly and reliably apply a VM to groups with 2 or more eligible 

professionals and to solo practitioners because we would be basing the quality of care composite 

on the PQRS measures selected, and reported on, by the groups (or the eligible professionals in 

the groups) and the solo practitioners. We believe that the VM should recognize the diversity of 

medical practices and the various measures used to assess quality of care furnished by these 

practices and provide flexibility on the data they report for quality measures under the PQRS. 

Therefore, beginning in the CY 2014 performance period for the groups of physicians subject to 

the CY 2016 VM, we have permitted these groups for purposes of the VM to participate in the 

PQRS as a group under the GPRO or to have at least 50% of the eligible professionals in the 

group participate in the PQRS as individuals (78 FR 74767 through74768). As a result, 

physicians and other eligible professionals in the group are able to report data on quality 

measures that reflect their own clinical practice. In the latter case, as proposed in section 

III.N.4.c of this proposed rule, a group would be included in Category 1 (as described in section 

III.N.4.c of this proposed rule) if at least 50 percent of the eligible professionals in the group 

meet the criteria to avoid the CY 2017 PQRS payment adjustment by using any of the reporting 

options available to them under the PQRS in CY 2015. 

We also conducted statistical reliability analyses on the cost measures contained in the 

2010 and 2011 group and individual QRURs. These reports contained the same 5 per capita cost 

measures that will be used for the VM. The cost measures in the group reports were statistically 

reliable at a high level, and the average reliability score was high for all of the cost measures 

included in the individual feedback reports. In addition, as discussed in the CY 2014 PFS final 

rule with comment period (78 FR 74774-74784), we are including the Medicare Spending per 
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Beneficiary (MSPB) measure in the cost composite of the VM and are adjusting the cost 

comparison approach to consider the medical specialty composition of the group of physicians. 

Based on an analysis of CY 2012 claims, we estimate that approximately 48 percent of all 

eligible professionals are in a group (as identified by a TIN) that would have the total per capita 

cost measure, as identified in §414.1235(a)(1), in its cost composite score; approximately 41 

percent of all eligible professionals are in a TIN that would have the MSPB measure in its cost 

composite score; and approximately 34 percent of all eligible professionals are in a TIN that 

would have both measures in its cost composite score. Therefore, we believe that we will be 

able to calculate a cost composite score for a significant number of groups and solo practitioners. 

In the CY 2014 PFS final rule with comment period, we finalized the proposal that if we are 

unable to attribute a sufficient number of beneficiaries to a group of physicians subject to the 

VM, and thus, are unable to calculate any of the cost measures with at least 20 cases, then the 

group’s cost composite score would be classified as “average” under the quality-tiering 

methodology (78 FR 74780 through74781). However, we note this policy was codified in 

§414.1270(b)(5) as a group of physicians subject to the value-based payment modifier will 

receive a cost composite score that is classified as “average” under §414.1275(b)(2) if such 

group does not have at least one cost measure with at least 20 cases. We believe the regulation 

text at §414.1270(b)(5) better reflects the intent of this policy, and accordingly, we propose to 

clarify that the description of this policy in the preamble of the CY 2014 PFS final rule with 

comment period (78 FR 74780 through74781) should be the same as the regulation text at 

§414.1270(b)(5). We propose to apply the same policy to groups and solo practitioners 

beginning in CY 2017. That is, a group or solo practitioner would receive a cost composite score 

that is classified as “average” under the quality-tiering methodology if the group or solo 
 450 

practitioner does not have at least one cost measure with at least 20 cases. We propose to revise 

§414.1270 accordingly. 

We believe we have provided smaller groups and solo practitioners sufficient lead time to 

understand how the VM works and how to participate in the PQRS. In the late summer of 2014, 

we plan to disseminate QRURs based on CY 2013 data to all groups of physicians and 

physicians who are solo practitioners. These QRURs will contain performance information on 

the quality and cost measures used to calculate the quality and cost composites of the VM and 

will show how all TINs would fare under the policies established for the VM. The QRURs will 

also include additional information about the TINs’ performance on the MSPB measure, 

individually-reported PQRS measures, and the specialty-adjusted cost measures. Then, during 

the summer of 2015, we intend to disseminate QRURs based on CY 2014 data to all groups of 

physicians and physicians who are solo practitioners and the reports would show how all TINs 

would fare under the policies established for the VM for the CY 2016 payment adjustment 

period. Thus, we believe all groups and solo practitioners will have adequate data to improve 

performance on the quality and cost measures that will be used to calculate the VM in CY 2017. 

Although we are sensitive to providing groups and solo practitioners with adequate lead time to 

understand the impact of the beneficiary attribution method used for the VM, we believe our 

proposal to hold harmless groups with between 2 and 9 eligible professionals and solo 

practitioners from any downward payment adjustments under quality-tiering in CY 2017 would 

likely mitigate unintended consequences that could occur (see section III.N.4.c of this proposed 

rule). 

Accordingly, we propose to revise the regulations at §414.1210 to reflect that beginning 

in the CY 2017 payment adjustment period, the VM would be applied to physician and 

nonphysician eligible professionals in groups with 2 or more eligible professionals and to solo 
 451 

practitioners based on the performance period described at §414.1215. As established in the CY 

2014 PFS final rule with comment period (78 FR 74772) and stated in section III.N.4.g of this 

proposed rule, CY 2015 is the performance period for the CY 2017 VM. Since the VM policies 

established for the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period would apply to groups and solo practitioners, we propose to amend 

the regulations under subpart N to add references to solo practitioners accordingly. We seek 

comments on all of these proposals. 

b. Application of the VM to nonphysician EPs 

Section 1848(p) of the Act requires that we establish a VM and apply it to items and 

services furnished under the PFS beginning on January 1, 2015, for specific physicians and 

groups of physicians the Secretary determines appropriate, and beginning not later than January 

1, 2017, for all physicians and groups of physicians. Section 1848(p)(7) of the Act provides the 

Secretary discretion to apply the VM on or after January 1, 2017 to eligible professionals as 

defined in section 1848(k)(3)(B) of the Act. In CY 2015 and CY 2016, we apply the VM to the 

items and services billed under the PFS by physicians in groups (as identified by their Medicareenrolled TIN) subject to the VM, but not to the other eligible professionals that also may bill 

under the TIN. We finalized in the CY 2013 PFS final rule with comment period (77 FR 69307 

through 69310) that physicians, as defined in section 1861(r) of the Act, include doctors of 

medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric 

medicine, doctors of optometry, and chiropractors. 

In section III.N.4.a. of this proposed rule, we discussed our proposal to apply the VM in 

the CY 2017 payment adjustment period and each subsequent calendar year payment adjustment 

period to physicians in groups of physicians with 2 or more eligible professionals and to 

physicians who are solo practitioners as required by section 1848(p)(4)(B)(iii)(II) of the Act. 
 452 

Under the discretion afforded the Secretary in section 1848(p)(7) of the Act, we propose 

to apply the VM beginning in the CY 2017 payment adjustment period to all of the eligible 

professionals in groups with 2 or more eligible professionals and to eligible professionals who 

are solo practitioners. That is, we propose to apply the VM beginning in CY 2017 to the items 

and services billed under the PFS by all of the physicians and nonphysician eligible professionals 

who bill under a group’s TIN. We propose to apply the VM beginning in CY 2017 to groups 

that consist only of nonphysician eligible professionals (for example, groups with only nurse 

practitioners or physician assistants). We propose to modify the definition of “group of 

physicians” under §414.1205 to also include the term “group” to reflect these proposals. We 

also propose to apply the VM beginning in CY 2017 to nonphysician eligible professionals who 

are solo practitioners. Additionally, we propose that physicians and nonphysician eligible 

professionals would be subject to the same VM policies established in earlier rulemakings and 

under 42 CFR part 414, subpart N. For example, nonphysician eligible professionals would be 

subject to the same amount of payment at risk and quality-tiering policies as physicians. We 

propose to modify the regulations under 42 CFR part 414, subpart N accordingly. 

We finalized in the CY 2013 PFS final rule with comment period (77 FR 69307 through 

69310) that, for purposes of establishing group size, we will use the definition of an eligible 

professional as specified in section 1848(k)(3)(B) of the Act. This section defines an eligible 

professional as any of the following: (1) a physician; (2) a practitioner described in section 

1842(b)(18)(C) of the Act: physician assistant, nurse practitioner, clinical nurse specialist, 

certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical 

psychologist, registered dietician, or nutrition professional; (3) a physical or occupational 

therapist or a qualified speech-language pathologist; or (4) a qualified audiologist. Beginning 

CY 2017, under our proposal, the VM would apply to all of the eligible professionals, as 
 453 

specified in section 1848(k)(3)(B) of the Act, that bill under a group’s TIN based on the TIN’s 

performance during the applicable performance period. During the payment adjustment period, 

all of the nonphysician eligible professionals who bill under a group’s TIN would be subject to 

the same VM that would apply to the physicians who bill under that TIN. 

We stated in the CY 2013 PFS final rule with comment period (77 FR 69307) that one of 

the principles that govern the implementation of the VM is our focus on shared accountability 

and that we have a role in fostering high value care for individual patients, but also focusing on 

how that patient interacts with the health care system generally. We stated our belief that the 

VM can facilitate shared accountability by assessing performance at the group practice level and 

by focusing on the total costs of care, not just the costs of care furnished by an individual 

physician. We believe that our proposal to apply the VM to the physicians and nonphysician 

eligible professionals in a group will foster shared accountability among all of the eligible 

professionals in the group and encourage them to seek innovative ways to furnish high-quality, 

patient-centered, and efficient care to the Medicare FFS patients they treat. 

Moreover, section 1848(p)(5) of the Act requires us to, as appropriate, apply the VM “in 

a manner that promotes systems-based care.” We stated in the CY 2013 PFS proposed rule that, 

in this context, systems-based care is the processes and workflows that (1) make effective use of 

information technologies, (2) develop effective teams, (3) coordinate care across patient 

conditions, services, and settings over time, and (4) incorporate performance and outcome 

measurements for improvement and accountability.10 (77 FR 44996) We believe that applying 

the VM to all of the eligible professionals in a group, rather than only the physicians in the 

 

10 Johnson JK, Miller SH, Horowitz SD. Systems-based practice: Improving the safety and quality of patient care 

by recognizing and improving the systems in which we work. In: Henriksen K, Battles JB, Keyes MA, Grady ML, 

editors. Advances in Patient Safety: New Directions and Alternative Approaches, Vol 2: Culture and Redesign. 

AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. p. 

321-330. 
 454 

group, would enhance their ability and the resources to redesign such processes and workflows 

to achieve these objectives and furnish high-quality and cost-effective clinical care with greater 

care coordination. 

As mentioned above, we are also proposing to apply the VM to groups that consist only 

of nonphysician eligible professionals, as well as solo practitioners who are nonphysician 

eligible professionals beginning in CY 2017. The quality of care composite for these groups and 

solo practitioners would be based on the quality data submitted under the PQRS at the group or 

individual level in accordance with our policy. To the extent we are able to attribute 

beneficiaries to these groups and solo practitioners under the attribution methodology proposed 

in section III.N.4.j of this proposed rule to calculate cost measures, we propose to calculate the 

cost composite using those cost measures. If a cost composite cannot be calculated for a group 

or solo practitioner, then we propose to classify the group or solo practitioner’s cost composite as 

“average” as specified in §414.1270. We seek comments on all of our proposed policies for 

applying the VM to nonphysician eligible professionals beginning in CY 2017. 

c. Approach to Setting the VM Adjustment Based on PQRS Participation 

In the CY 2014 PFS final rule with comment period (78 FR 74767-74768), we adopted a 

policy to categorize groups of physicians subject to the VM in CY 2016 based on a group’s 

participation in the PQRS. Specifically, we categorize groups of physicians eligible for the CY 

2016 VM into two categories. Category 1 includes groups of physicians that (a) meet the criteria 

for satisfactory reporting of data on PQRS quality measures through the GPRO for the CY 2016 

PQRS payment adjustment or (b) do not register to participate in the PQRS as a group practice in 

CY 2014 and that have at least 50 percent of the group’s eligible professionals meet the criteria 

for satisfactory reporting of data on PQRS quality measures as individuals for the CY 2016 

PQRS payment adjustment, or in lieu of satisfactory reporting, satisfactorily participate in a 
 455 

PQRS-qualified clinical data registry for the CY 2016 PQRS payment adjustment. For a group 

of physicians that is subject to the CY 2016 VM to be included in Category 1, the criteria for 

satisfactory reporting (or the criteria for satisfactory participation, if the PQRS-qualified clinical 

data registry reporting mechanism is selected) must be met during the CY 2014 reporting period 

for the PQRS CY 2016 payment adjustment. For the CY 2016 VM, Category 2 includes those 

groups of physicians that are subject to the CY 2016 VM and do not fall within Category 1. For 

those groups of physicians in Category 2, the VM for CY 2016 is -2.0 percent. 

We propose to use a similar two-category approach for the CY 2017 VM based on 

participation in the PQRS by groups and solo practitioners. To continue to align the VM with 

the PQRS and accommodate the various ways in which EPs can participate in the PQRS, for 

purposes of the CY 2017 VM, we propose that Category 1 would include those groups that meet 

the criteria for satisfactory reporting of data on PQRS quality measures via the GPRO (through 

use of the web-interface, EHR, or registry reporting mechanism, as proposed in section III.K of 

this proposed rule) for the CY 2017 PQRS payment adjustment. Our proposed criteria for 

satisfactory reporting of data on PQRS quality measures via the GPRO for the PQRS payment 

adjustment for CY 2017 are described in section III.K of this proposed rule. We also propose to 

include in Category 1 groups that do not register to participate in the PQRS as a group practice 

participating in the PQRS group practice reporting option (GPRO) in CY 2015 and that have at 

least 50 percent of the group’s eligible professionals meet the criteria for satisfactory reporting of 

data on PQRS quality measures as individuals (through the use of claims, EHR, or registry 

reporting mechanism,) for the CY 2017 PQRS payment adjustment, or in lieu of satisfactory 

reporting, satisfactorily participate in a PQRS-qualified clinical data registry for the CY 2017 

PQRS payment adjustment, all as proposed in section III.K of this proposed rule. We note that 

these proposals are consistent with the policies for inclusion in Category 1 as established for the 
 456 

CY 2016 VM (78 FR 74767 through 74768). We would maintain the 50 percent threshold for 

the CY 2017 VM as we expand the application of the VM to all groups and solo practitioners in 

CY 2017. Our proposed criteria for satisfactory reporting by individual eligible professionals for 

the claims, EHR, and registry reporting mechanisms and for satisfactory participation in a 

qualified clinical data registry for the CY 2017 PQRS payment adjustment are described in 

section III.K of this proposed rule. Lastly, we propose to include in Category 1 those solo 

practitioners that meet the criteria for satisfactory reporting of data on PQRS quality measures as 

individuals (through the use of claims, registry, or EHR reporting mechanism) for the CY 2017 

PQRS payment adjustment, or in lieu of satisfactory reporting, satisfactorily participate in a 

PQRS-qualified clinical data registry for the CY 2017 PQRS payment adjustment, all as 

proposed in section III.K of this proposed rule. Category 2 would include those groups and solo 

practitioners that are subject to the CY 2017 VM and do not fall within Category 1. As 

discussed in section III.N.4.f of this proposed rule, for CY 2017, we are proposing to apply a -4.0 

percent VM to groups with two or more eligible professionals and solo practitioners that fall in 

Category 2. We seek comment on these proposals. 

For a group and a solo practitioner that would be subject to the CY 2017 VM to be 

included in Category 1, the criteria for satisfactory reporting (or the criteria for satisfactory 

participation, in the case of solo practitioners and the 50 percent option described above for 

groups) would need to be met during the reporting periods occurring in CY 2015 for the CY 

2017 PQRS payment adjustment. As noted earlier, CY 2015 is the performance period for the 

CY 2017 payment adjustment period for the VM. In the event that the criteria that are finalized 

for the CY 2017 PQRS payment adjustment differ from what is proposed for the PQRS in this 

proposed rule, our intention is to align the criteria for inclusion in Category 1 to the extent 
 457 

possible with the criteria that are ultimately established for the CY 2017 PQRS payment 

adjustment. 

In the CY 2014 PFS final rule with comment period (78 FR 74768-74770), we finalized 

that the quality-tiering methodology will apply to all groups in Category 1 for the VM for CY 

2016, except that groups of physicians with between 10 and 99 eligible professionals would be 

subject only to upward or neutral adjustments derived under the quality-tiering methodology, 

while groups of physicians with 100 or more eligible professionals would be subject to upward, 

neutral, or downward adjustments derived under the quality-tiering methodology. In other 

words, we finalized that groups of physicians in Category 1 with between 10 and 99 eligible 

professionals would be held harmless from any downward adjustments derived from the qualitytiering methodology for the CY 2016 VM. 

For the CY 2017 VM, we propose to continue a similar phase-in of the quality-tiering 

based on the number of eligible professionals in the group. We propose to apply the qualitytiering methodology to all groups and solo practitioners in Category 1 for the VM for CY 2017, 

except that groups with between 2 and 9 eligible professionals and solo practitioners would be 

subject only to upward or neutral adjustments derived under the quality-tiering methodology, 

while groups with 10 or more eligible professionals would be subject to upward, neutral, or 

downward adjustments derived under the quality-tiering methodology. In other words, we 

propose that solo practitioners and groups with between 2 and 9 eligible professionals in 

Category 1 would be held harmless from any downward adjustments derived from the qualitytiering methodology for the CY 2017 VM. Accordingly, we propose to revise §414.1270 to 

reflect these proposals. We believe this proposed approach would reward groups and solo 

practitioners that provide high-quality/low-cost care, reduce program complexity, and would also 
 458 

fully engage groups and solo practitioners into the VM as we complete the phase-in of the VM in 

CY 2017. We seek comments on these proposals. 

We believe it is appropriate to hold groups with between 2 and 9 eligible professionals 

and solo practitioners in Category 1 harmless from any downward adjustments under the qualitytiering methodology, which is similar to the policy we apply to groups with between 10 and 99 

eligible professionals during the first year the VM applies to them (CY 2016). We note that we 

anticipate applying the CY 2018 VM with both upward and downward adjustments based on a 

performance period of CY 2016 to all groups and solo practitioners, and therefore, we would 

make proposals in future rulemaking accordingly. 

For groups with between 10 and 99 eligible professionals, we believe it is appropriate to 

begin both the upward and the downward payment adjustments under the quality-tiering 

methodology for the CY 2017 VM. As stated in the CY 2014 PFS final rule with comment 

period (78 FR 74769), on September 16, 2013, we made available to all groups of 25 or more 

eligible professionals an annual QRUR based on 2012 data to help groups estimate their quality 

and cost composites. As discussed in section III.N.4.a. of this proposed rule, in the late summer 

of 2014, we plan to disseminate QRURs based on CY 2013 data to all groups of physicians and 

physicians who are solo practitioners. These QRURs will contain performance information on 

the quality and cost measures used to calculate the quality and cost composites of the VM and 

will show how all TINs would fare under the policies established for the VM for the CY 2015 

payment adjustment period. Then, during the summer of 2015, we intend to disseminate QRURs 

based on CY 2014 data to all groups and solo practitioners, and the reports would show how all 

TINs would fare under the policies established for the VM for the CY 2016 payment adjustment 

period. The QRURs will also include additional information about the TINs’ performance on the 

MSPB measure, individually-reported PQRS measures, and the specialty-adjusted cost measures. 
 459 

Thus, we believe groups with between 10 and 99 eligible professionals will have adequate data 

to improve performance on the quality and cost measures that will be used to calculate the VM in 

CY 2017. As a result, we believe it is appropriate to apply both upward and downward 

adjustments under the quality-tiering methodology to groups with 10 or more eligible 

professionals in 2017. 

Based on an analysis of CY 2012 claims, we estimate that approximately 6 percent of all 

eligible professionals are in a Category 1 TIN that would be classified in tiers that would earn an 

upward adjustment, approximately 11 percent of all eligible professionals are in a Category 1 

TIN that would be classified in tiers that would receive a downward adjustment, and 

approximately 83 percent of all eligible professionals are in a Category 1 TIN that would receive 

no payment adjustment in CY 2017. These results suggest that our quality-tiering methodology 

identifies a small number of groups and solo practitioners that are outliers – both high and low 

performers – in terms of whose payments would be affected by the VM, thus limiting any 

widespread unintended consequences. 

We will continue to monitor the VM program and continue to examine the characteristics 

of those groups that could be subject to an upward or downward payment adjustment under our 

quality-tiering methodology to determine whether our policies create anomalous effects in ways 

that do not reflect consistent differences in performance among physicians and physician groups. 

d. Application of the VM to Physicians and Nonphysician Eligible Professionals that Participate 

in the Shared Savings Program, the Pioneer ACO Model, the CPC Initiative, or Other Similar 

Innovation Center Models or CMS Initiatives 

We established a policy in the CY 2013 PFS final rule with comment period 

(77 FR 69313) to not apply the VM in CY 2015 and CY 2016 to groups of physicians that 

participate in the Shared Savings Program Accountable Care Organizations (ACOs), the Pioneer 
 460 

ACO Model, the Comprehensive Primary Care (CPC) Initiative, or other similar Innovation 

Center or CMS initiatives. We stated in the CY 2014 PFS final rule with comment period (78 

FR 74766) that from an operational perspective, we will apply this policy to any group of 

physicians that otherwise would be subject to the VM, if one or more physician(s) in the group 

participate(s) in one of these programs or initiatives during the relevant performance period (CY 

2013 for the CY 2015 VM, and CY 2014 for the CY 2016 VM). 

Although section 1848(p)(4)(B)(iii)(I) of the Act gives the Secretary discretion to apply 

the VM beginning on January 1, 2015 to specific physicians and groups of physicians the 

Secretary determines appropriate, section 1848(p)(4)(B)(iii)(II) of the Act requires application of 

the VM beginning not later than January 1, 2017 to all physicians and groups of physicians. 

Therefore, as discussed in section III.N.4.a. of this proposed rule, we are proposing to apply the 

VM to all physicians in groups with 2 or more eligible professionals and to solo practitioners 

who are physicians starting in CY 2017. In section III.N.4.b of this proposed rule, we discussed 

our proposal to also apply the VM starting in CY 2017 to all nonphysician eligible professionals 

in groups with 2 or more eligible professionals and to solo practitioners who are nonphysician 

eligible professionals. We describe in this section how we propose to apply the VM beginning in 

the CY 2017 payment adjustment period to the physicians and nonphysician eligible 

professionals in groups, as well as those who are solo practitioners, participating in the Shared 

Savings Program, Pioneer ACO Model, the CPC Initiative, or other similar Innovation Center 

models or CMS initiatives. 

(1) Physicians and Nonphysician Eligible Professionals that Participate in ACOs under the 

Shared Savings Program 

Beginning with the CY 2017 payment adjustment period, we propose to apply the VM to 

physicians and nonphysician eligible professionals in groups with 2 or more eligible 
 461 

professionals and to physicians and nonphysician eligible professionals who are solo 

practitioners that participate in the Shared Savings Program. Groups and solo practitioners 

participate in the Shared Savings Program as part of an ACO as provided in section 1899 of the 

Act. Under the Shared Savings Program, an ACO may consist of multiple participating groups 

and solo practitioners (as identified by the ACO participants’ TINs). As of April 1, 2014, there 

are 338 ACOs participating in the Shared Savings Program. This number includes 31 ACOs that 

consist of only one ACO participant TIN. The ACO submits quality data on behalf of all the 

ACO participant TINs in that ACO under the Shared Savings Program. 

Beginning with the CY 2017 payment adjustment period, we propose to classify the cost 

composite for the VM as “average cost” for groups and solo practitioners (as identified by the 

ACO’s participant TINs) that participate in the Shared Savings Program during the payment 

adjustment period (for example, CY 2017). We propose to apply “average cost” to these groups 

and solo practitioners regardless of whether they participated in the Shared Savings Program 

during the performance period (for example, in CY 2015 for the CY 2017 VM). We believe that 

it would not be appropriate to apply the quality-tiering methodology to calculate the cost 

composite for these groups and solo practitioners because of the differences in the methodology 

used to calculate the cost benchmarks under the Shared Savings Program and the VM. Under the 

Shared Savings Program, cost benchmarks are based on the actual historical Medicare fee-forservice expenditures for beneficiaries that would have been assigned to the ACO during the 

historical benchmark period, and are updated to reflect changes in national FFS spending; 

however, the cost benchmarks under the VM are based on national averages. We believe that 

these are significant differences in the methodology for calculating the cost benchmarks under 

the two programs. Consequently, we believe that any attempt to calculate the cost composite for 

groups and solo practitioners participating in the Shared Savings Program using the quality-
 462 

tiering methodology would create two sets of standards for ACOs for their cost performance. 

We believe that having two sets of standards for ACOs for cost performance would be 

inappropriate and confusing. We seek comments on our proposals to classify the cost composite 

as “average cost” for groups and solo practitioners that participate in the Shared Savings 

Program during the payment adjustment period. 

For groups and solo practitioners that participate in the Shared Savings Program during 

the performance period (for example, CY 2015), but no longer participate in the Shared Savings 

Program during the payment adjustment period (for example, CY 2017), we propose to apply the 

quality-tiering methodology to calculate the cost composite for the VM for the payment 

adjustment period based on the groups’ and solo practitioners’ performance on the cost 

measures, as identified under §414.1235, during the performance period. We believe that it 

would be appropriate to apply the quality-tiering methodology to calculate the cost composite 

because these groups and solo practitioners are no longer part of the Shared Savings Program 

during the payment adjustment period and their cost benchmarks would be calculated only under 

the VM during the payment adjustment period. 

Beginning with the CY 2017 payment adjustment period, we propose to calculate the 

quality of care composite score for the VM for groups and solo practitioners that participate in an 

ACO under the Shared Savings Program in accordance with the following policies: 

(a) We propose to calculate the quality of care composite score based on the qualitytiering methodology using quality data submitted by the ACO, as discussed in section III.N.4.h 

of this proposed rule, from the performance period and apply the same score to all of the groups 

and solo practitioners under the ACO during the payment adjustment period. In other words, 

using CY 2017 as an example, we propose to calculate the quality of care composite score for the 

CY 2017 VM for all of the groups and solo practitioners participating in the ACO in CY 2017 
 463 

based on the ACO’s CY 2015 quality data. We note that in section III.N.4.h of this proposed 

rule, we are proposing to exclude the claims-based outcome measures identified under 

§414.1230 from the calculation of the quality of care composite score for groups and solo 

practitioners that participate in the Shared Savings Program during the payment adjustment 

period. 

(b) For groups and solo practitioners that participate in the ACO during the payment 

adjustment period (for example, CY 2017) and either did not participate in the Shared Savings 

Program or were part of a different ACO during the performance period (for example, CY 2015), 

we propose to calculate the quality of care composite score based on the quality-tiering 

methodology using the quality data submitted by the ACO from the performance period. For 

example, if a group or solo practitioner is in ACO 1 during CY 2017, and either was not in the 

Shared Savings Program or was part of ACO 2 during CY 2015, we would use ACO 1’s quality 

data from CY 2015 to calculate the quality of care composite. We believe this approach is 

consistent with our policy not to “track” or “carry” an individual professional’s performance 

from one TIN to another TIN (see 77 FR 69308 through 69310). In other words, if a 

professional changes groups from TIN A in the performance period to TIN B in the payment 

adjustment period, we would apply TIN B’s VM to the professional’s payments for items and 

services billed under TIN B during the payment adjustment period. 

(c) If the ACO did not exist during the performance period (for example, CY 2015), then 

we would not have the ACO’s quality data to use in the calculation of the quality of care 

composite score for the payment adjustment period (for example, CY 2017). Therefore, if the 

ACO exists during the payment adjustment period but did not exist during the performance 

period, we propose to classify the quality of care composite for all groups and solo practitioners 

that participate in the ACO during the payment adjustment period as “average quality” for the 
 464 

payment adjustment period. We propose to apply this policy to groups and solo practitioners 

regardless of their status during the performance period – in other words, regardless of whether 

they participated in the Shared Savings Program as part of a different ACO, or did not exist 

during the performance period (for example, a TIN forms or newly enrolls in Medicare after the 

end of the performance period). We believe this proposal is appropriate since we would not have 

the ACO’s quality data from the performance period to calculate a quality of care composite for 

all of the groups and solo practitioners participating in the ACO during the payment adjustment 

period. We note that some of these groups and solo practitioners may have participated in the 

PQRS during the performance period; therefore, we would have quality data for those groups 

and solo practitioners. If they were part of a different ACO during the performance period, then 

we would also have that ACO’s quality data. However, we do not believe that it would be 

appropriate to use the groups’ and solo practitioners’ PQRS or other ACO quality data from the 

performance period to calculate a quality of care composite because the groups and solo 

practitioners are part of a new ACO during the payment adjustment period. We believe this 

approach is consistent with our policy not to “track” or “carry” an individual professional’s 

performance from one TIN to another TIN (see 77 FR 69308 through 69310). In this case, if a 

TIN’s status changes from the performance period to the payment adjustment period (that is, 

participating in ACO 2 or not participating in the Shared Savings Program in the performance 

period, to participating in ACO 1 in the payment adjustment period), then we would not “track” 

or “carry” ACO 2’s quality data or the TIN’s PQRS quality data to determine the quality of care 

composite for groups and solo practitioners that participate in ACO 1. 

(d) For groups and solo practitioners that participate in the Shared Savings Program 

during the performance period (for example, CY 2015) but no longer participate in the Shared 

Savings Program during the payment adjustment period (for example, CY 2017), we propose to 
 465 

classify the quality of care composite as “average quality” for the VM for the payment 

adjustment period. Since these groups and solo practitioners were part of an ACO during the 

performance period, we would have the ACO’s quality data from that period. However, we do 

not believe that it would be appropriate to use the ACO’s quality data from the performance 

period to calculate a quality of care composite because the groups and solo practitioners are no 

longer part of the ACO during the payment adjustment period. We believe this approach is also 

consistent with our policy not to “track” or “carry” an individual professional’s performance 

from one TIN to another TIN (see 77 FR 69308 through 69310). Even though we are proposing 

to classify the quality of care composite for these groups and solo practitioners as “average 

quality,” we seek comments on whether we should use the ACO’s quality data from the 

performance period to calculate the quality composite for these groups and solo practitioners for 

the payment adjustment period. 

We seek comments on all of our proposals to calculate the quality composite for groups 

and solo practitioners participating in the Shared Savings Program as described above. A 

summary of these proposals is shown in Table 56 using TIN A and ACO 1 and ACO 2 as 

examples. 

TABLE 56: Summary of Proposed Policies for Groups and Solo Practitioners with Shared 

Savings Program Participation Changes 

Scenario 

TIN’s Status 

During the 

Performance 

Period (for 

example, CY 

2015) 

TIN’s Status 

During the 

Payment 

Adjustment 

Period 

(for example, 

CY 2017) 

TIN’s Quality 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

TIN’s Cost 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

a. Continued ACO participation - 

TIN A participates in ACO 1 

during both the performance and 

payment adjustment periods 

TIN A is part of 

ACO 1 

TIN A is part of 

ACO 1 

Based on ACO 

1’s quality data 

from the 

performance 

period (for 

example, CY 

2015 

Average cost 

b. Joining an existing ACO and 

not from another ACO - TIN A 

TIN A is not part 

of any ACO and 

TIN A is part of 

ACO 1 

Based on ACO 

1’s quality data 

Average cost 
 466 

Scenario 

TIN’s Status 

During the 

Performance 

Period (for 

example, CY 

2015) 

TIN’s Status 

During the 

Payment 

Adjustment 

Period 

(for example, 

CY 2017) 

TIN’s Quality 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

TIN’s Cost 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

was not part of any ACO during 

the performance period, but 

participates in ACO 1 during the 

payment adjustment period (ACO 

1 existed in the performance 

period) 

OR 

 Joining an existing ACO from 

another ACO - TIN A participated 

in ACO 2 during the performance 

period, but is part of ACO 1 

during the payment adjustment 

period (ACO 1 existed in the 

performance period) 

ACO 1 exists 

OR 

TIN A is not part 

of ACO 2 and 

ACO 1 exists 

from the 

performance 

period (for 

example, CY 

2015 

c. Joining a new ACO as a new 

TIN – TIN A participates in ACO 

1 during the payment adjustment 

period (ACO 1 and TIN A did not 

exist in the performance period) 

OR 

Joining a new ACO and not from 

another ACO - TIN A was not 

part of any ACO during the 

performance period, but 

participates in ACO 1 during the 

payment adjustment period (ACO 

1 did not exist in the performance 

period) 

OR 

Joining a new ACO from another 

ACO – TIN A participated in 

ACO 2 during the performance 

period, but is part of ACO 1 

during the payment adjustment 

period (ACO 1 did not exist in the 

performance period) 

TIN A and ACO 1 

did not exist 

OR 

TIN A is not part 

of any ACO and 

ACO 1 did not 

exist 

OR 

TIN A is part of 

ACO 2 and ACO 1 

did not exist 

TIN A is part of 

ACO 1 

Average quality Average cost 

d. Dropping out of an ACO - TIN 

A participated in ACO 1 during 

the performance period, but is not 

part of any ACO during the 

payment adjustment period 

TIN A is part of 

ACO 1 

TIN A is not part 

of any ACO 

Average quality Based on TIN 

A’s cost data 

for the 

performance 

period using 

the qualitytiering 

methodology 

We believe that our proposal to apply the VM to groups and solo practitioners that 

participate in ACOs under the Shared Savings Program is appropriate in light of the statutory 
 467 

requirement under section 1848(p)(4)(B)(iii)(II) of the Act to apply the VM to all physicians and 

groups of physicians beginning not later than January 1, 2017. We believe our proposals, as 

described above, would further encourage groups and solo practitioners that participate in ACOs 

under the Shared Savings Program to furnish high quality care to Medicare beneficiaries by 

providing them with an opportunity to earn upward payment adjustments. We propose to apply 

the same VM, which would be calculated based on the policies proposed above, to all groups and 

solo practitioners, as identified by their TINs, that participate in an ACO under the Shared 

Savings Program during the payment adjustment period. Consequently, the same VM would 

also apply to the physicians and nonphysician eligible professionals in those groups and to the 

physicians and nonphysician eligible professionals who are solo practitioners that participate in 

the ACO during the payment adjustment period. 

In section III.N.4.c of this proposed rule, we discussed our proposal to hold groups with 

between 2 and 9 eligible professionals and solo practitioners who are in Category 1 harmless 

from any downward adjustments under the quality-tiering methodology for the CY 2017 

payment adjustment period. We propose to also hold harmless from any downward adjustments 

groups with between 2 and 9 eligible professionals and solo practitioners that participate in 

ACOs under the Shared Savings Program during the CY 2017 payment adjustment period based 

on their size during the performance period. We would follow our established process for 

determining group size, which is described at §414.1210(c). Therefore, to the extent that a 

quality of care composite can be calculated for an ACO, and the cost composite would be 

classified as “average cost,” groups with 10 or more eligible professionals participating in the 

Shared Savings Program would be subject to an upward, downward, or no payment adjustment 

in CY 2017, and groups with between 2 and 9 eligible professionals and solo practitioners would 

be subject to an upward or no payment adjustment in CY 2017. We also propose that groups and 
 468 

solo practitioners participating in ACOs under the Shared Savings Program would be eligible for 

the additional upward payment adjustment of +1.0x for caring for high-risk beneficiaries, as 

proposed in section III.N.4.f. We propose to modify §414.1210 to reflect these proposals. 

(2) Physicians and Nonphysician Eligible Professionals that Participate in the Pioneer ACO 

Model, the Comprehensive Primary Care (CPC) Initiative, or Other Similar Innovation Center 

Models or CMS Initiatives 

Section 1115A of the Act authorizes the Innovation Center to test innovative payment 

and service delivery models to reduce Medicare, Medicaid, or Children’s Health Insurance 

Program (CHIP) expenditures, while preserving or enhancing the quality of care furnished to 

beneficiaries under those programs. Therefore, all models tested by the Innovation Center would 

be expected to assess participating entities (for example, providers, ACOs, states) based on 

quality and cost performance. As noted above, we established a policy in the CY 2013 PFS final 

rule with comment period (77 FR 69313) to not apply the VM in CY 2015 and CY 2016 to 

groups of physicians that are participating in the Pioneer ACO Model, the CPC Initiative, or in 

other Innovation Center initiatives or other CMS programs which also involve shared savings 

and where participants make substantial investments to report quality measures and to furnish 

higher quality, more efficient and effective healthcare. 

In section III.N.4.a. of this proposed rule, we discussed our proposal to apply the VM to 

all physicians in groups with 2 or more eligible professionals and to solo practitioners who are 

physicians starting in CY 2017, as required under section 1848(p)(4)(B)(iii)(II) of the Act. In 

section III.N.4.b, we discussed our proposal to also apply the VM starting in CY 2017 to all 

nonphysician eligible professionals in groups with 2 or more eligible professionals and to solo 

practitioners who are nonphysician eligible professionals. 
 469 

The Pioneer ACO Model and the CPC Initiative are scheduled to end on December 31, 

2016. Therefore, the relevant performance periods for consideration for participants in these 

initiatives are CY 2015 for the CY 2017 VM payment adjustment period and potentially CY 

2016 for the CY 2018 VM payment adjustment period. Under the Pioneer ACO Model, an ACO 

may consist of practitioners from multiple participating groups and solo practitioners (as 

identified by their individual TIN/NPI combination). Thus, a group practice may consist of one 

or more eligible professionals who participate in the Pioneer ACO Model and other eligible 

professionals who do not participate in the Pioneer ACO Model. In the case of the CPC 

Initiative, a practice site may participate in the model even if one or more other practice sites that 

use the same TIN does not participate. Beginning with the CY 2017 payment adjustment period, 

we propose to apply the VM to physicians and nonphysician eligible professionals in groups with 

2 or more eligible professionals and to physicians and nonphysician eligible professionals who 

are solo practitioners that participate in the Pioneer ACO Model or the CPC Initiative during the 

relevant performance period in accordance with the policies described below. 

(a) For groups and solo practitioners that participate in the Pioneer ACO Model or the 

CPC Initiative during the performance period (for example, CY 2015) and do not participate in 

the Shared Savings Program or other similar Innovation Center models or CMS initiatives during 

the payment adjustment period (for example, CY 2017), we propose to calculate the quality of 

care composite score for the VM for the payment adjustment period based on the following three 

scenarios: 

Scenario 1: If a group participates in the PQRS as a group practice under the PQRS 

GPRO during the performance period and meets the criteria for satisfactory reporting of data on 

PQRS quality measures via one of the GPRO reporting mechanisms, as proposed in section III.K 

of this proposed rule, for the respective PQRS payment adjustment, then we propose to use the 
 470 

PQRS GPRO data to calculate the group’s quality of care composite for the VM for the payment 

adjustment period. We propose to apply the same quality of care composite to all eligible 

professionals that bill under the group’s TIN during the payment adjustment period. We also 

propose that if the group registers for GPRO for the performance period and does not meet the 

criteria for satisfactory reporting of data on PQRS quality measures via one of the GPRO 

reporting mechanisms for the respective PQRS payment adjustment, then the group would fall in 

Category 2. As discussed in section III.N.4.f of this proposed rule, for CY 2017, we are 

proposing to apply a -4.0 percent VM to groups with two or more eligible professionals and solo 

practitioners that fall in Category 2. In this case, all eligible professionals that bill under the 

group’s TIN during the payment adjustment period would be subject to the -4.0% VM payment 

adjustment. We seek comment on this proposal. 

Scenario 2: In the case of a group that does not report under the PQRS GPRO during the 

performance period and includes one or more eligible professionals that participate in a Pioneer 

ACO under the Pioneer ACO Model or in the CPC Initiative during the performance period, as 

well as other eligible professionals that do not participate in these models, we propose that if at 

least 50 percent of all eligible professionals in the group satisfactorily report quality data to CMS 

for the performance period, then we would calculate a quality of care composite using the 

quality-tiering methodology and the satisfactorily reported data on the PQRS quality measures 

submitted by the eligible professionals in the group as individuals under PQRS. For purposes of 

this scenario, by “satisfactorily report quality data to CMS,” we mean that at least 50 percent of 

the group’s eligible professionals meet the criteria for satisfactory reporting of data on PQRS 

quality measures as individuals for the PQRS payment adjustment during the performance 

period, or in lieu of satisfactory reporting, satisfactorily participate in a PQRS-qualified clinical 

data registry for the PQRS payment adjustment during the performance period, or successfully 
 471 

report quality data to the Pioneer ACO Model or the CPC Initiative during the performance 

period. The quality of care composite would be calculated using satisfactorily reported data on 

the PQRS quality measures submitted by the eligible professionals in the group as individuals 

under PQRS regardless of whether or not the eligible professionals who report the data 

participate in the Pioneer ACO Model or the CPC Initiative. We propose to assign the group a 

quality of care composite that is the higher of “average quality” or the group’s actual 

classification as determined under the quality-tiering methodology. We propose to apply the 

same quality of care composite to all eligible professionals that bill under the group’s TIN during 

the payment adjustment period, regardless of whether they participated in the model during the 

performance period. 

We propose that if less than 50 percent of all eligible professionals in the group 

satisfactorily report quality data to CMS for the performance period, then this group would fall in 

Category 2. In other words, less than 50 percent of the group’s eligible professionals meet the 

criteria for satisfactory reporting of data on PQRS quality measures as individuals for the PQRS 

payment adjustment during the performance period, or in lieu of satisfactory reporting, 

satisfactorily participate in a PQRS-qualified clinical data registry for the PQRS payment 

adjustment during the performance period, or successfully report quality data to the Pioneer 

ACO Model or the CPC Initiative during the performance period. As discussed in section 

III.N.4.f of this proposed rule, for CY 2017, we are proposing to apply a -4.0 percent VM to 

groups with two or more eligible professionals and solo practitioners that fall in Category 2. In 

this case, all eligible professionals that bill under the group’s TIN during the payment adjustment 

period would be subject to the -4.0 percent VM payment adjustment, regardless of whether they 

participated in the model during the performance period. 
 472 

We note the eligible professionals in these groups that participate in the Pioneer ACO 

Model or the CPC Initiative submit quality data under their respective model. However, we do 

not believe that we can reasonably use the quality data submitted under these models in the 

calculation of the quality of care composite for these groups. At this time, we are unable to 

operationally integrate the data from these models with the value modifier program due to 

systems constraints and the unique nature of reporting for participants in these models. We also 

do not believe that we are able to predict how the quality data submitted under these models 

would affect the group’s quality composite. We note that because these models are at the 

forefront of innovation, we believe that the eligible professionals participating in these models 

would have higher quality performance. For example, results from the first performance year of 

the Pioneer ACO Model demonstrated that Pioneer ACOs performed better than published rates 

in fee-for-service for 15 clinical quality measures for which comparable data are available. On 

readmissions, 25 of 32 Pioneer ACOs generated lower risk-adjusted readmission rates for their 

aligned beneficiaries than the benchmark rate for all Medicare fee-for-service beneficiaries. On 

clinical quality measures that assess hypertension control for Medicare beneficiaries, the median 

rate among Pioneer ACOs with diabetes was 68 percent compared to 55 percent as measured in 

adult diabetic population in 10 managed care plans across 7 states from 2000 to 2001. Also, on 

clinical quality measures that assess low density lipoprotein (LDL) control for patients with 

diabetes, the median rate among Pioneer ACOs for low density lipoprotein control among 

beneficiaries with diabetes was 57 percent compared to 48 percent in an adult diabetic population 

in 10 managed care plans across 7 states from 2000 to 2001. For these reasons, we seek to 

ensure that these groups are at least considered to have “average” quality, as reflected in our 

proposal above. 
 473 

We also considered two alternatives to our proposal above for Scenario 2. First, we 

considered assigning these groups a quality composite of “average quality” without 

consideration of any PQRS quality data that may be available to calculate quality measure scores 

and a quality composite. We did not believe it would be appropriate to make such a proposal 

because we believe it is important to use data on quality, to the extent practicable, to determine a 

group’s quality composite. Consequently, we believe it is appropriate to use the data that is 

reported under PQRS to calculate a quality composite for these groups. We recognize that some 

eligible professionals in these groups may not submit quality data under PQRS and that these 

professionals are likely to participate in a model and submit quality data through that model. 

Since we believe that participants in these models tend to perform better than average with 

regard to quality as described above, we believe that it is possible that we would underestimate a 

group’s quality performance if we consider PQRS data only. Accordingly, to the extent that the 

data reported under PQRS by individual eligible professionals in the group results in a quality 

composite that is one standard deviation above average (that is, “high quality”), we believe it is 

likely that this composite would increase by including data (were it available) from the eligible 

professionals who report quality data through the model. Therefore, we believe that it would be 

inappropriate to reduce a quality composite from “high quality” to “average quality.” Second, 

we considered assigning a quality composite of “average quality” to groups where less than 50 

percent of all eligible professionals in the group meet the criteria for satisfactory reporting of 

data on PQRS quality measures as individuals for the PQRS payment adjustment during the 

performance period, or in lieu of satisfactory reporting, satisfactorily participate in a PQRSqualified clinical data registry for the PQRS payment adjustment during the performance period, 

because we would not have quality data for more than half of the group that we could use to 

calculate a quality composite. Similarly, if at least 50 percent of all eligible professionals in a 
 474 

group satisfactorily report or participate under PQRS as individuals, we considered using their 

PQRS quality data to calculate a quality composite for the group and applying the quality-tiering 

methodology to classify the group as high, average, or low quality. We did not believe it would 

be appropriate to make such a proposal. We do not believe that it is appropriate to classify a 

group as “low quality” when more than half of the eligible professionals in the group 

successfully report quality data (whether it be under PQRS or a model), even though we do not 

believe at this time we can reasonably use quality data reported through a model for the VM, 

because we believe that participants in these models would likely increase the group’s quality 

performance were their data included. In other words, to the extent that the data reported under 

PQRS by individual eligible professionals in the group results in a quality composite that is “low 

quality” (that is, one standard deviation below average), we believe that this could be in part 

because the quality data of higher performing eligible professionals reported through the model 

would not be included in the calculation of the quality composite. Therefore, we believe it 

would be inappropriate to classify such a group as lower than “average quality.” 

We note that it may be possible for a group to have a disproportionately large number of 

eligible professionals participating in the Pioneer ACO Model or the CPC Initiative. In this 

instance, our proposal would result in the use of the PQRS data reported by a relatively small 

number of eligible professionals who are not participating in the model to determine the quality 

of care composite that would apply to all eligible professionals in the group. We seek comment 

on the degree to which this situation occurs and the appropriateness of our proposal in this 

instance, as well as alternatives to our proposal. 

Scenario 3: If a group does not report under the PQRS GPRO during the performance 

period, consists entirely of eligible professionals that participate in the Pioneer ACO Model or 

the CPC Initiative, and successfully reports quality data to CMS under the model for the 
 475 

performance period, then we propose to classify the group’s quality of care composite as 

“average quality.” We also propose to classify as “average quality” the quality of care composite 

of solo practitioners that participate in the Pioneer ACO Model or the CPC Initiative and 

successfully report quality data to CMS under the model for the performance period. We 

propose to apply the same quality of care composite to all eligible professionals that bill under 

the group’s TIN during the payment adjustment period. These eligible professionals submit 

quality data to the Pioneer ACO Model or the CPC Initiative; however, as discussed above, we 

do not believe that we can reasonably use the model quality data in the calculation of the quality 

of care composite for these groups and solo practitioners. Additionally, we propose that if the 

group or the solo practitioner does not successfully report quality data to CMS under the model 

for the performance period, then the group or solo practitioner would fall in Category 2. As 

discussed in section III.N.4.f of this proposed rule, for CY 2017, we are proposing to apply a -4.0 

percent VM to groups with two or more eligible professionals and solo practitioners that fall in 

Category 2. In this case, all eligible professionals that bill under the group’s TIN during the 

payment adjustment period would be subject to the -4.0% VM payment adjustment. 

As an alternative to this proposal, we considered assigning “average quality” to groups 

and solo practitioners that do not successfully report quality data to CMS under the model for the 

performance period. We believe that this policy would not have been consistent with our 

proposal to consider groups and solo practitioners that do not satisfactorily report or participate 

for PQRS as Category 2 as described in section III.N.4.c of this proposed rule. We also believe 

that assigning “average quality” may inadvertently create incentives for groups and solo 

practitioners to not report quality data to CMS under these models. 

For groups and solo practitioners that participate in the Pioneer ACO Model or the CPC 

Initiative during the performance period (for example, CY 2015) and do not participate in the 
 476 

Shared Savings Program or other similar Innovation Center models or CMS initiatives during the 

payment adjustment period (for example, CY 2017) (Scenarios 1 through 3 above), we propose 

to apply the quality-tiering methodology to calculate the cost composite for the VM for the 

payment adjustment period based on a group’s and solo practitioner’s performance on the cost 

measures, as identified under §414.1235, during the performance period. We believe that it 

would be appropriate to apply the quality-tiering methodology to calculate the cost composite 

because these groups and solo practitioners are no longer part of the Pioneer ACO Model or the 

CPC during the payment adjustment period, and their cost benchmarks would be calculated only 

under the VM during the payment adjustment period. 

(b) For groups and solo practitioners that participate in the Pioneer ACO Model or the 

CPC Initiative during the performance period (for example, CY 2015) and participate in other 

similar Innovation Center models or CMS initiatives during the payment adjustment period (for 

example, CY 2017) (but not the Shared Savings Program), we propose to calculate the quality of 

care composite based on the three scenarios described above to the extent we are able. We 

recognize that these three scenarios might not be applicable to all of the various models and 

initiatives that may be developed in future years. We also propose to classify the cost composite 

for these groups and solo practitioners for the payment adjustment period as “average cost.” We 

believe that, for groups and solo practitioners participating in other similar models or initiatives 

during the payment adjustment period, calculating a cost composite based on the quality-tiering 

methodology may create two sets of standards for evaluating their cost performance; therefore, 

we believe it would be appropriate to assign “average cost” to these groups and solo 

practitioners. If we believe a different approach to applying the VM would be appropriate for a 

new model or initiative, we intend to address it in future rulemaking. 
 477 

(c) For groups and solo practitioners that participate in the Pioneer ACO Model or the 

CPC Initiative during the performance period (for example, CY 2015) and participate in an ACO 

under the Shared Savings Program during the payment adjustment period (for example, CY 

2017), we propose to calculate the quality of care composite score based on the quality-tiering 

methodology using quality data submitted by the Shared Savings Program ACO from the 

performance period. For groups and solo practitioners that participate in a Shared Savings 

Program ACO during the payment adjustment period that did not exist during the performance 

period, we propose to classify the quality of care composite as “average quality” for the payment 

adjustment period because we would not have quality data from the performance period for that 

ACO. We also propose to classify the cost composite for the VM as “average cost” for groups 

and solo practitioners that participate in a Shared Savings Program ACO during the payment 

adjustment period. As we stated in section III.N.4.d.1 of this proposed rule, we believe that there 

are significant differences in the methodology for calculating the cost benchmarks under the VM 

and the Shared Savings Program. Consequently, we believe that any attempt to calculate the cost 

composite for groups and solo practitioners participating in the Shared Savings Program using 

the quality-tiering methodology would create two sets of standards for ACOs for their cost 

performance, which would be inappropriate and confusing. These proposals are consistent with 

the proposals for participants in the Shared Savings Program described above. 

(d) In section III.N.4.c of this proposed rule, we discussed our proposal to hold groups 

with between 2 and 9 eligible professionals and solo practitioners who are in Category 1 

harmless from any downward adjustments under the quality-tiering methodology for the CY 

2017 payment adjustment period. We propose to also hold harmless from any downward 

adjustments for CY 2017 groups with between 2 and 9 eligible professionals, where one or more 

eligible professionals participate in the Pioneer ACO Model or the CPC, and solo practitioners 
 478 

that participate in the Pioneer ACO Model or the CPC during the CY 2015 performance period 

based on their size during the performance period. We would follow our established process for 

determining group size, which is described at §414.1210(c). We also propose that groups where 

one or more eligible professionals participate in the Pioneer Model or the CPC during the 

performance period, and solo practitioners participating in the Pioneer ACO Model or the CPC 

during the performance period would be eligible for the additional upward payment adjustment 

of +1.0x for caring for high-risk beneficiaries, as proposed in section III.N.4.f below. 

(e) In addition, beginning with the CY 2017 payment adjustment period, we propose to 

apply the VM to physicians and nonphysician eligible professionals in groups with 2 or more 

eligible professionals and to physicians and nonphysician eligible professionals who are solo 

practitioners that participate in other similar Innovation Center models or CMS initiatives during 

the relevant performance period for the VM in accordance with the proposed policies described 

above for the Pioneer ACO Model and the CPC Initiative. We are unable to propose an 

exhaustive list of the models and initiatives that would fall under this category because many of 

them have not yet been developed. In addition, it is possible that the timeline for implementing 

some of these new models and initiatives may not coincide with the timeline for rulemaking for 

the VM. To address these issues, we propose to rely on the following general criteria to 

determine whether a model or initiative would fall in this “other similar” category and thus 

would be subject to the policies described above for the Pioneer ACO Model and the CPC 

Initiative: (1) the model or initiative evaluates the quality of care and/or requires reporting on 

quality measures; (2) the model or initiative evaluates the cost of care and/or requires reporting 

on cost measures; (3) participants in the model or initiative receive payment based at least in part 

on their performance on quality measures and/or cost measures; (4) potential for conflict 

between the methodologies used for the VM and the methodologies used for the model or 
 479 

initiative; or (5) other relevant factors specific to a model or initiative. We note that a model or 

initiative would not have to satisfy or address all of these criteria to be included in this “other 

similar” category. Rather, the criteria are intended to serve as a general framework for 

evaluating models and initiatives with regard to the application of the VM to groups and solo 

practitioners that participate. We are seeking public comment on these or other appropriate 

criteria for determining which models or initiatives we should classify as “other similar” models, 

for the purposes of applying the policies for the Pioneer ACO Model and the CPC Initiative 

described above. 

As noted above, we recognize that the policies we finalize for the Pioneer ACO Model 

and the CPC Initiative after consideration of public comments might not be applicable to all of 

the various models and initiatives that could be developed in future years. If we believe a 

different approach to applying the VM would be appropriate for a model or initiative, we intend 

to address it in future rulemaking. In addition, if we were to determine that a model or initiative 

falls under this “other similar” category based on the general criteria that we finalize after 

consideration of public comments, we propose to provide notice to participants in the model or 

initiative through the methods of communication that are typically used for the model or 

initiative. 

We propose to modify §414.1210 to reflect all of these proposals. 

A summary of these proposals is shown in Table 57 using TIN A as an example. 

TABLE 57: Summary of Proposed Policies for Groups and Solo Practitioners with Pioneer 

ACO Model, CPC Initiative, or Other Similar Innovation Center Model or CMS Initiative 

Participation Changes 

Scenario 

TIN’s Status 

During the 

Performance 

Period (for 

example, CY 

2015) 

TIN’s Status 

During the 

Payment 

Adjustment 

Period 

(for example, 

CY 2017) 

TIN’s Quality Composite 

for the Payment 

Adjustment Period (for 

example, CY 2017) 

TIN’s Cost 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 
 480 

Scenario 

TIN’s Status 

During the 

Performance 

Period (for 

example, CY 

2015) 

TIN’s Status 

During the 

Payment 

Adjustment 

Period 

(for example, 

CY 2017) 

TIN’s Quality Composite 

for the Payment 

Adjustment Period (for 

example, CY 2017) 

TIN’s Cost 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

a. Scenario 1: TIN A 

participates in 

the Pioneer ACO Model 

or the CPC Initiative 

during the performance 

period, but does not 

participate in the Shared 

Savings Program or other 

similar Innovation Center 

models or CMS 

initiatives during the 

payment adjustment 

period (some or all of the 

eligible professionals in 

TIN A participate in the 

Pioneer ACO Model or 

CPC Initiative) 

AND 

TIN A registers for PQRS 

GPRO for the 

performance period 

TIN A is part of 

the Pioneer ACO 

Model or CPC 

Initiative 

TIN A is not 

part of the 

Shared 

Savings 

Program or 

other similar 

Innovation 

Center models 

or CMS 

initiatives 

If TIN A satisfactorily 

reports under PQRS GPRO 

for the performance period: 

Based on TIN A’s PQRS 

GPRO data 

 

If TIN A does not 

satisfactorily report under 

PQRS GPRO for the 

performance period: 

TIN A falls in Category 2 

and a -4.0 percent VM is 

applied to the TIN in the 

payment adjustment period 

If TIN A 

satisfactorily 

reports under 

PQRS GPRO for 

the performance 

period: 

Based on TIN A’s 

cost data for the 

performance 

period using the 

quality-tiering 

methodology 

 a. Scenario 2: TIN A 

participates in the Pioneer 

ACO Model or the CPC 

Initiative during the 

performance period, but 

does not participate in the 

Shared Savings Program 

or other similar 

Innovation Center models 

or CMS initiatives during 

the payment adjustment 

period (TIN A has 

one or more eligible 

professionals that 

participate in the Pioneer 

ACO Model or CPC 

Initiative and other nonparticipating eligible 

professionals) 

AND 

For the performance 

period: TIN A does not 

report under PQRS 

GPRO; some eligible 

professionals report 

quality data to the Pioneer 

ACO Model or the CPC 

Initiative and others 

report under PQRS as 

individuals 

TIN A is part of 

the Pioneer ACO 

Model or CPC 

Initiative 

TIN A is not 

part of the 

Shared 

Savings 

Program or 

other similar 

Innovation 

Center models 

or CMS 

initiatives 

If at least 50 percent of all 

eligible professionals in 

TIN A satisfactorily report 

quality data to CMS for the 

performance period: 

Higher of “average quality” 

or the actual classification 

under the quality-tiering 

methodology based on 

PQRS quality data 

submitted by the eligible 

professionals as individuals 

If less than 50 percent of all 

eligible professionals in 

TIN A satisfactorily report 

quality data to CMS for the 

performance period: 

TIN A falls in Category 2 

and a -4.0 percent VM is 

applied to the TIN in the 

payment adjustment period 

If at least 50 

percent of all 

eligible 

professionals in 

TIN A 

satisfactorily 

report quality data 

to CMS for the 

performance 

period: 

Based on TIN A’s 

cost data for the 

performance 

period using the 

quality-tiering 

methodology 
 481 

Scenario 

TIN’s Status 

During the 

Performance 

Period (for 

example, CY 

2015) 

TIN’s Status 

During the 

Payment 

Adjustment 

Period 

(for example, 

CY 2017) 

TIN’s Quality Composite 

for the Payment 

Adjustment Period (for 

example, CY 2017) 

TIN’s Cost 

Composite for 

the Payment 

Adjustment 

Period (for 

example, CY 

2017) 

a. Scenario 3: TIN A 

participates in the Pioneer 

ACO Model or the CPC 

Initiative during the 

performance period, but 

does not participate in the 

Shared Savings Program 

or other similar 

Innovation Center models 

or CMS initiatives during 

the payment adjustment 

period (all eligible 

professionals in TIN A 

participate in the Pioneer 

ACO Model or CPC 

Initiative) 

AND 

For the performance 

period: TIN A does not 

report under PQRS 

GPRO; TIN A reports 

quality data to the Pioneer 

ACO Model or the CPC 

Initiative 

TIN A is part of 

the Pioneer ACO 

Model or CPC 

Initiative 

TIN A is not 

part of the 

Shared 

Savings 

Program or 

other similar 

Innovation 

Center models 

or CMS 

initiatives 

If TIN A successfully 

reports quality data to the 

Pioneer ACO Model or 

CPC Initiative for the 

performance period: 

Average quality 

If TIN A does not 

successfully report quality 

data to the Pioneer ACO 

Model or CPC Initiative for 

the performance period: 

TIN A falls in Category 2 

and a -4.0 percent VM is 

applied to the TIN in the 

payment adjustment period 

If TIN A 

successfully 

reports quality 

data to the Pioneer 

ACO Model or 

CPC Initiative for 

the performance 

period: 

Based on TIN A’s 

cost data for the 

performance 

period using the 

quality-tiering 

methodology 

b. TIN A participates in 

the Pioneer ACO Model 

or the CPC Initiative 

during the performance 

period and participates in 

other similar Innovation 

Center models or CMS 

initiatives during the 

payment adjustment 

period (but not the Shared 

Savings Program) 

TIN A is part of 

the Pioneer ACO 

Model or CPC 

Initiative 

TIN A is part 

of other 

similar 

Innovation 

Center models 

or CMS 

initiatives (but 

not the Shared 

Savings 

Program) 

Based on Scenarios 1-3 Average cost 

c. TIN A participates in 

the Pioneer ACO Model 

or the CPC Initiative 

during the performance 

period and participates in 

an ACO under the Shared 

Savings Program during 

the payment adjustment 

period 

TIN A is part of 

the Pioneer ACO 

Model or CPC 

Initiative 

TIN A is part 

of an ACO 

under the 

Shared 

Savings 

Program 

Based on the Shared 

Savings Program ACO’s 

quality data for the 

performance period 

If the ACO did not exist in 

the performance period: 

Average quality 

Average cost 

e. Clarification Regarding Treatment of Non-assigned Claims for Non-Participating Physicians 
 482 

As indicated earlier, section 1848(p) of the Act requires the Secretary to establish a 

payment modifier that provides for differential payment to a physician or a group of physicians 

under the PFS based upon the quality of care furnished compared to cost during a performance 

period. In the CY 2013 PFS final rule with comment period in which we established a number 

of key policies for the VM, we stated that we had received few comments on our proposal to 

apply the VM to the Medicare paid amounts for the items and services billed under the PFS so 

that beneficiary cost-sharing or coinsurance would not be affected (77 FR 69309). These 

commenters generally agreed with the proposal to apply the VM to the Medicare paid amounts 

for the items and services billed under the PFS at the TIN level so that beneficiary cost-sharing 

would not be affected. Therefore, we finalized this policy and accordingly established a 

definition of the VM at §414.1205 that was consistent with the proposal and the statutory 

requirement to provide for differential payment to a physician or a group of physicians under the 

fee schedule based upon the quality of care furnished compared to cost during a performance 

period. 

We continue to believe it is important that beneficiary cost-sharing not be affected by the 

VM and that the VM should be applied to the amount that Medicare pays to physicians. 

However, in previous rulemaking, we did not directly address whether the VM would be applied 

to both assigned services for which Medicare makes payment to the physician, and to nonassigned services for which Medicare makes payment to the beneficiary. Participating 

physicians are those who have signed an agreement in accordance with section 1842(h)(1) of the 

Act to accept payment on an assignment-related basis for all items and services furnished to 

Medicare beneficiaries. In other words, participating physicians agree to accept the Medicare 

approved amount as payment in full and to charge the beneficiary only the Medicare deductible 

and coinsurance amount. In contrast, non-participating physicians have not signed an agreement 
 483 

to accept assignment for all services furnished to beneficiaries, but they can still choose to accept 

assignment for individual services. If they choose not to accept assignment for particular 

services non-participating physicians can charge the beneficiary more than the Medicareapproved amount, up to a limit called the “limiting charge.” The limiting charge is defined at 

section 1848(g)(2)(C) of the Act as 115 percent of the recognized payment amount for 

nonparticipating physicians. In contrast, if a non-participating physician chooses to accept 

assignment for a service, they receive payment from Medicare at the approved amount for nonparticipating physicians, which is 95 percent of the fee schedule amount. Over 99 percent of 

Medicare physician services are billed on an assignment related basis by both participating and 

non-participating physicians and other suppliers, with the remainder billed as non-assigned 

services by non-participating physicians and other suppliers. 

For assigned claims, Medicare makes payment directly to the physician. In accordance 

with section 1848(p)(1) of the Act and the regulations at §414.1205 and §414.1210(a), the VM 

should be applied to assigned claims. However, for non-assigned claims, the limiting charge (the 

amount that the physician can bill a beneficiary for a non-assigned service) would not be affected 

if the VM were applied to the claim. This is so, because for non-assigned claims, application of 

the VM would not affect the limiting charge. Rather, Medicare makes payment for the nonassigned services directly to the beneficiary and the physician receives all payment for a nonassigned service directly from the beneficiary. If the VM were to be applied to non-assigned 

services, then the Medicare payment to a beneficiary would be increased when the VM is 

positive and decreased when the VM is negative. The application of the VM to non-assigned 

claims would therefore directly affect beneficiaries and not physicians, contrary to our intent as 

discussed in previous rulemaking (77 FR 69309). On that basis, we are proposing to clarify that 

we would apply the VM only to assigned services and not to non-assigned services starting in 
 484 

CY 2015. We do not expect this proposed clarification, to not apply the VM to non-assigned 

claims, would be likely to affect a physician’s decision to participate in Medicare or to otherwise 

accept assignment for a particular claim. This is because the amount that a provider is entitled to 

receive from the beneficiary for non-assigned claims is not affected by whether or not the VM is 

applicable to non-assigned claims. Additionally, to the extent our proposal to expand application 

of the VM to nonphysician eligible professionals is finalized, we would likewise apply the VM 

only to services billed on an assignment-related basis and not to non-assigned services. We 

invite comments on this proposed clarification. 

f. Payment Adjustment Amount 

Section 1848(p) of the Act does not specify the amount of payment that should be subject 

to the adjustment for the VM; however, section 1848(p)(4)(C) of the Act requires the VM be 

implemented in a budget neutral manner. Budget neutrality means that payments will increase 

for some groups and solo practitioners based on high performance and decrease for others based 

on low performance, but the aggregate expected amount of Medicare spending in any given year 

for physician and nonphysician eligible professional services paid under the Medicare PFS will 

not change as a result of application of the VM. 

In the CY 2014 PFS final rule with comment period (78 FR 74770-74771), we adopted a 

policy to apply a maximum downward adjustment of 2.0 percent for the CY 2016 VM for those 

groups of physicians with 10 or more eligible professionals that are in Category 2 and for groups 

of physicians with 100 or more eligible professionals that are in Category 1 and are classified as 

low quality/high cost groups. 

Although we received comments suggesting that larger payment adjustments (both 

upward and downward) would be necessary to more strongly encourage quality improvements, 

we finalized our proposed adjustments as we believed they better aligned with our goal to 
 485 

gradually phase in the VM. However, we noted that as we gained experience with our VM 

methodologies, we would likely consider ways to increase the amount of payment at risk (77 FR 

69324). 

We received comments on the CY 2014 proposed rule suggesting that the payment 

adjustment under the VM must be of significant weight to drive physician behavior toward 

achieving high quality and low cost care and that the VM should represent a larger percentage of 

physician payments under the PFS that should be increased incrementally from 2.0 percent and 

subject to annual review. In our response to these comments, we agreed that the amount of 

payment at risk should be higher to incentivize physicians to provide high quality and low cost 

care. We also stated that our experience under PQRS has shown us that a 1.0 or 2.0 percent 

incentive payment has not produced widespread participation in the PQRS. Thus, we believed 

that we needed to increase the amount of payment at risk for the CY 2016 VM to incentivize 

physicians and groups of physicians to report PQRS data, which will be used to calculate the 

VM. We continue to believe this is the appropriate strategy. 

We believe that we can increase the amount of payment at risk because we can reliably 

apply a VM to groups with 2 or more eligible professionals and to solo practitioners in CY 2017 

as discussed in section III.N.4.a. of this proposed rule. Therefore, we propose to increase the 

downward adjustment under the VM by doubling the amount of payment at risk from 2.0 percent 

in CY 2016 to 4.0 percent in CY 2017. That is, for CY 2017, we propose to apply a -4.0 percent 

VM to groups with two or more eligible professionals and solo practitioners that fall in Category 

2. In addition, we propose to increase the maximum downward adjustment under the qualitytiering methodology in CY 2017 to -4.0 percent for groups and solo practitioners classified as 

low quality/high cost and to set the adjustment to -2.0 percent for groups and solo practitioners 

classified as either low quality/average cost or average quality/high cost. However, as discussed 
 486 

in section III.N.4.c of this proposed rule, we are proposing to hold solo practitioners and groups 

with between 2 and 9 eligible professionals that are in Category 1 harmless from any downward 

adjustments under the quality-tiering methodology in CY 2017. Consistent with our previous 

policy, we note that the estimated funds derived from the application of the downward 

adjustments to groups and solo practitioners in Category 1 and Category 2 would be available to 

all groups and solo practitioners eligible for VM upward payment adjustments. Based on an 

estimate of these funds, we also propose to increase the maximum upward adjustment under the 

quality-tiering methodology in CY 2017 to +4.0x for groups and solo practitioners classified as 

high quality/low cost and to set the adjustment to +2.0x for groups and solo practitioners 

classified as either average quality/low cost or high quality/average cost. We also propose to 

continue to provide an additional upward payment adjustment of +1.0x to groups and solo 

practitioners that care for high-risk beneficiaries (as evidenced by the average HCC risk score of 

the attributed beneficiary population). Lastly, we propose to revise §414.1270 and §414.1275(c) 

and (d) to reflect the proposed changes to the payment adjustments under the VM for the CY 

2017 payment adjustment period. Table 58 shows the proposed quality-tiering payment 

adjustment amounts for CY 2017 (based on CY 2015 performance). We believe that the 

proposed VM amount differentiates between cost and quality tiers in a more meaningful way. 

We seek comments on all of these proposals. 

TABLE 58: CY 2017 Value-Based Payment Modifier Amounts 

Cost/Quality Low Quality Average Quality High Quality 

Low Cost +0.0% +2.0x* +4.0x* 

Average Cost -2.0% +0.0% +2.0x* 

High Cost -4.0% -2.0% +0.0% 

* Groups and solo practitioners eligible for an additional +1.0x if reporting Physician Quality Reporting System 

quality measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores. 
 487 

Consistent with the policy adopted in the CY 2013 PFS final rule with comment period (77 FR 

69324 through 69325), the upward payment adjustment factor (“x” in Table 58) would be determined 

after the performance period has ended based on the aggregate amount of downward payment 

adjustments. 

In section III.N.4.d of this proposed rule, we discussed our proposal to apply the VM to 

physicians and nonphysician eligible professionals in groups with 2 or more eligible 

professionals and to physicians and nonphysician eligible professionals who are solo 

practitioners that participate in the Shared Savings Program during the payment adjustment 

period beginning with the CY 2017 payment adjustment period. We will have the final list of 

ACOs that will participate in the Shared Savings Program during the payment adjustment period 

and their participant TINs during the late fall prior to the beginning of the payment adjustment 

period (for example, the late fall of CY 2016 prior to the CY 2017 payment adjustment period). 

We note that this final list may not be available until after the beginning of the payment 

adjustment period. Therefore, we propose to calculate preliminary payment adjustment factors 

(“x” in Table 58) prior to the beginning of the payment adjustment period, and subsequently 

finalize the payment adjustment factors after the final ACO participation list is completed. We 

note that the final payment adjustment factors may be updated depending on the outcome of the 

informal inquiry process described later at section III.N.4.i of this proposed rule. 

g. Performance Period 

In the CY 2014 PFS final rule with comment period (78 FR 74771 through 74772), we 

adopted a policy that performance on quality and cost measures in CY 2015 will be used to 

calculate the VM that is applied to items and services for which payment is made under the PFS 

during CY 2017. Accordingly, we added a new paragraph (c) to §414.1215 to indicate that the 

performance period is CY 2015 for VM adjustments made in the CY 2017 payment adjustment 

period. 
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h. Quality Measures 

In the CY 2014 PFS final rule with comment period (78 FR 74773), we aligned our 

policies for the VM for CY 2016 with the PQRS group reporting mechanisms available to groups 

in CY 2014 and the PQRS reporting mechanisms available to individual eligible professionals in 

CY 2014, such that data that groups submit for quality reporting purposes through any of the 

PQRS group reporting mechanisms in CY 2014 and the data that individual eligible 

professionals submit through any of the individual PQRS reporting mechanisms in CY 2014 will 

be used for calculating the quality composite under the quality-tiering approach for the VM for 

CY 2016. Moreover, all of the quality measures for which groups and individual eligible 

professionals are eligible to report under the PQRS in CY 2014 would be used to calculate the 

VM for a group for CY 2016 to the extent the group or individual eligible professionals in the 

group submits data on such measure in accordance with our 50 percent threshold policy (78 FR 

74768). We also noted that, in accordance with 42 CFR 414.1230, three additional quality 

measures (outcome measures) for groups subject to the VM will continue to be included in the 

quality measures used for the VM in CY 2016. These measures are: (1) a composite of rates of 

potentially preventable hospital admissions for heart failure, chronic obstructive pulmonary 

disease, and diabetes; (2) a composite rate of potentially preventable hospital admissions for 

dehydration, urinary tract infections, and bacterial pneumonia; and (3) rates of an all-cause 

hospital readmissions measure (77 FR 69315). 

PQRS Reporting Mechanisms: We believe it is important to continue to align the VM for 

CY 2017 with the requirements of the PQRS, because quality reporting is a necessary component 

of quality improvement. We also seek not to place an undue burden on eligible professionals to 

report such data. Accordingly, for purposes of the VM for CY 2017, we propose to include all of 

the PQRS GPRO reporting mechanisms available to groups for the PQRS reporting periods in 
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CY 2015 and all of the PQRS reporting mechanisms available to individual eligible professionals 

for the PQRS reporting periods in CY 2015. These reporting mechanisms are described in 

Tables 21 through 49 of this proposed rule. 

PQRS Quality Measures: We propose to use all of the quality measures that are available 

to be reported under these various PQRS reporting mechanisms to calculate a group or solo 

practitioner’s VM in CY 2017 to the extent that a group (or individual eligible professionals in 

the group, in the case of the “50 percent option”) or solo practitioner submits data on these 

measures. These PQRS quality measures are described in Tables 21 through 49 of this proposed 

rule. We propose that groups with 2 or more eligible professionals would be able to elect to 

include the patient experience of care measures collected through the PQRS CAHPS survey for 

CY 2015 in their VM for CY 2017. We propose to continue to include the three outcome 

measures in §414.1230 in the quality measures used for the VM in CY 2017. For groups that are 

assessed under the “50 percent option” for the CY 2017 VM, we propose to calculate the group’s 

performance rate for each measure reported by at least one eligible professional in the group by 

combining the weighted average of the performance rates of those eligible professionals 

reporting the measure. We also propose for groups that are assessed under the “50 percent 

option” for the CY 2017 VM to classify a group’s quality composite score as ‘‘average’’ under 

the quality-tiering methodology, if all of the eligible professionals in the group satisfactorily 

participate in a PQRS qualified clinical data registry in CY 2015 and we are unable to receive 

quality performance data for those eligible professionals. If some EPs in the group report data 

using a qualified clinical data registry and we are unable to obtain the data, but other EPs in the 

group report data using the other PQRS reporting mechanisms for individuals, we would 

calculate the group’s score based on the reported performance data that we obtain through those 

other mechanisms. 
 490 

While we finalized policies in the CY 2014 final rule with comment period that would 

allow groups assessed under the “50 percent option” to have data reported through a PQRS 

qualified clinical data registry in CY 2014 used for the purposes of their CY 2016 VM to the 

extent performance data are available, we note that we did not directly address the issue of how 

we would compute the national benchmarks for these measures. Under §414.1250, benchmarks 

for the quality of care measures for the VM are the national mean of a measure’s performance 

rate during the year prior to the performance period. In the CY 2013 PFS final rule with 

comment period (77 FR 69322), we finalized a policy that if a measure is new to the PQRS, we 

will be unable to calculate a benchmark, and hence, performance on that measure will not be 

included in the quality composite. Therefore, we propose to apply that policy to measures 

reported through a PQRS qualified clinical data registry that are new to PQRS (in other words, 

measures that were not previously reported in PQRS). Performance on these measures would 

not be included in the quality composite for the VM because we would not be able to calculate 

benchmarks for them. This proposal would apply beginning with the measures reported through 

a PQRS qualified clinical data registry in the CY 2014 performance period for the CY 2016 

payment adjustment period. We welcome public comment on this proposal. 

In addition, we note that the PQRS administrative claims option, which included the 

outcome measures described in §414.1230, is no longer available through PQRS. We propose to 

clarify that we calculate benchmarks for those outcome measures described in §414.1230 using 

the national mean for a measure's performance rate during the year prior to the performance 

period in accordance with our regulation at §414.1250(b). We welcome public comment on this 

proposal. 

Quality Measures for the Shared Savings Program: Starting with the CY 2017 payment 

adjustment period, as described in section III.M. of this proposed rule, we are proposing to apply 
 491 

the value modifier to groups and solo practitioners participating in ACOs under the Shared 

Savings Program. To do -so, we are proposing quality measures and benchmarks for use with 

these groups and solo practitioners and seek public comment on these proposals. We describe 

these proposals more fully below. 

With regard to quality measures, we note that there is substantial overlap between those 

used to evaluate the ACOs under the Shared Savings Program and those used in the PQRS 

program and for the value modifier payment adjustment. For the CY 2017 payment adjustment 

period and subsequent payment adjustment periods, to determine a quality composite for the VM 

for groups and solo practitioners that participate in an ACO under the Shared Savings Program, 

we propose to use the quality measures that are identical for the two programs. Specifically, for 

the CY 2017 payment adjustment period, we propose to use the PQRS GPRO Web Interface 

measures and the outcome measure described at §414.1230(c) to determine a quality composite 

for groups and solo practitioners that participate in an ACO under the Shared Savings Program. 

Because the ACO GPRO measures and PQRS GPRO Web Interface measures will be the same 

in CY 2015, we propose to use the GPRO Web Interface measures reported by ACOs in 

determining the quality composite for groups and solo practitioners participating in ACOs under 

the Shared Savings Program in CY 2017. Utilizing these GPRO Web Interface measures in this 

regard further encourages successful quality reporting for Shared Savings Program ACOs. 

Additionally, we believe that the all-cause hospital readmissions measure as calculated for ACOs 

under the Shared Savings Program is equivalent to the all-cause hospital readmissions measure 

we have adopted for the VM at §414.1230(c) and therefore propose use of that measure as 

calculated for ACOs in the Shared Savings Program for inclusion in the VM for the CY 2017 

payment adjustment period. We note that the outcome measures described at §414.1230(a) and 

§414.1230(b) are not currently calculated for ACOs in the Shared Savings Program. These 
 492 

measures are: (1) a composite of rates of potentially preventable hospital admissions for heart 

failure, chronic obstructive pulmonary disease, and diabetes; and (2) a composite rate of 

potentially preventable hospital admissions for dehydration, urinary tract infections, and bacterial 

pneumonia. Because we have no experience with these measures in the Shared Savings 

Program, at this time, we do not propose to include these measures for groups and solo 

practitioners that participate in ACOs under that program. We propose to modify the regulations 

at §412.1230 accordingly. 

To determine the standardized scores for these quality measures proposed for use with 

those participating in ACOs under the Shared Savings Program, we propose to apply the 

benchmark policy for quality measures for the VM as described under §414.1250. Under this 

policy, the VM benchmarks are the national mean for a measure’s performance rate based on 

data from one year prior to the performance period. We believe these are the appropriate 

benchmarks to use when determining the value modifier payment adjustment because they are 

the same benchmarks used to determine the value modifier payment adjustment for other groups 

and solo practitioners. In other words, we believe that use of the VM benchmarks creates a fair 

comparison among groups and solo practitioners because we believe it is appropriate to evaluate 

those that participate in Shared Savings Program ACOs on the same basis as those that do not 

participate in the Shared Savings Program for the purpose of the value modifier. We believe the 

VM benchmarks are appropriate because they include all PQRS data available (77 FR 69322), 

including quality data used for the Shared Savings Program. On the other hand, while the Shared 

Savings Program develops benchmarks using all available Medicare fee-for-service data, we do 

not believe it is appropriate to use the benchmarks from the Shared Savings Program to 

determine standardized scores for the quality composite of the value modifier payment 

adjustment. We do not think this enables a fair comparison among groups and solo practitioners 
 493 

subject to the value modifier because the Shared Savings Program benchmarks are calculated 

using a different methodology, providing gradients by decile (including the median) of national 

performance based on data two years prior to the performance period (78 FR 74759 through 

74760). 

All-Cause Hospital Readmissions Measure: In addition, since finalizing the all-cause 

hospital readmissions measure described at §414.1230(c) in the CY 2013 PFS final rule with 

comment (77 FR 69285), we have investigated the reliability of this measure. According to 

§414.1265, to calculate a composite score for a quality or cost measure based on claims, a group 

subject to the VM must have 20 or more cases for that measure. Furthermore, according to 

§414.1265(a), if a group has fewer than 20 cases for a measure in a performance period, that 

measure is excluded from its domain and the remaining measures in the domain are given equal 

weight. 

Based on 2012 data, we found that the average reliability for the all-cause hospital 

readmissions measure was below 0.4 when we examined groups with fewer than 200 cases but 

exceeded 0.4 for groups with 200 or more cases. Although we do not believe there is a universal 

consensus concerning a minimum reliability threshold, reliability scores in the 0.4 to 0.7 range 

are often considered moderate, and scores greater than 0.7 are considered high. In general, we 

found that the groups with at least 10 eligible professionals were more likely to have 200 or more 

cases as compared to groups with fewer eligible professionals. Thirty percent of groups with 10 

or more eligible professionals had 200 or more cases, as compared to 3 percent of groups with 1-

9 eligible professionals. Nonetheless, the finding that the average reliability exceeded 0.4 for 

groups with 200 or more cases included all group sizes (1 or more eligible professionals). 

After examining the reliability of the all-cause hospital readmissions measure data for 

2012 across all group sizes and considering its impacts on the cost composite of the VM as 
 494 

discussed below, we propose to change the reliability policy (minimum number of cases) with 

respect to this measure. Specifically, beginning with the CY 2017 payment adjustment period, 

we propose to change the reliability policy (minimum number of cases) with respect to the allcause hospital readmissions measure as described in §414.1230(c) from a minimum of 20 cases 

to a minimum of 200 cases for this measure to be included in the quality composite for the VM. 

For this measure only, we propose to exclude the measure from the quality domain for a group or 

solo practitioner if the group or solo practitioner has fewer than 200 cases for the measure during 

the relevant performance period. In implementing this proposal, we note that we would only 

apply it to the all-cause hospital readmissions measure as it is calculated for groups or solo 

practitioners that are not part of a Shared Savings Program ACO. In instances where we are 

including Shared Savings Program data for groups or solo practitioners that are part of a Shared 

Savings Program ACO, we would include their all-cause hospital readmissions measure as it is 

calculated for the Shared Savings Program. We believe that this approach to implementing this 

proposal is appropriate, because the Shared Savings Program has taken into consideration the 

size of its groups in finalizing inclusion of this measure, and we value consistency with the 

Shared Savings Program’s reporting requirements for its participants, to the extent it is 

practicable. We would continue to include the measure in the VM quality domain for groups or 

solo practitioners that have 200 or more cases. We propose to modify the regulations at 

§414.1265 to reflect this proposal. We welcome comments on this proposal. 

If we were to revise the minimum case size for the all-cause hospital readmissions 

measure for the quality composite of the VM, we note that poor performance on controlling 

readmissions would continue to have an effect on the VM for groups with between 20 and 199 

cases through the cost composite of the VM. The Medicare Spending per Beneficiary (MSPB) 

measure, as finalized in the CY 2014 PFS final rule (78 FR 74775-74780), is a measure of all 
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Medicare Part A and Part B payments during an episode spanning from 3 days prior to an index 

hospital admission through 30 days post-discharge with certain exclusions. Since all Part A and 

Part B spending is included in the 30 day post-discharge window, Medicare Part A payments for 

a readmission that are included in an MSPB episode will increase the MSPB amount relative to 

an MSPB episode without a readmission in the 30-day post-discharge window. Additionally, the 

cost of readmissions is incorporated as part of the 5 total per capita cost measures that comprise 

the remainder of the cost composite of the VM. The 5 total per capita cost measures are annual 

measures that include the costs of all Part A and Part B spending during the year, including the 

costs of readmissions. Therefore, readmission costs will have the effect of increasing total per 

capita cost spending for the groups attributed these patients’ costs. As a result, poor performance 

on controlling readmissions already will have an adverse effect on an attributed group’s cost 

composite of the VM, even if poor performance on the all-cause hospital readmissions measure 

would no longer be reflected in certain groups’ or solo practitioners’ quality composite of the 

VM due to having fewer than 200 all-cause hospital readmission cases. Even for those groups 

for which the all-cause hospital readmissions measure would be excluded from the quality 

composite calculations, groups would continue to have incentive to control readmissions, since 

doing so would reduce readmission costs, thereby improving performance on the paymentstandardized, risk-adjusted cost measures used for the cost composite of the VM. 

i. Proposed Expansion of the Informal Inquiry Process to Allow Corrections for the 

Value-Based Payment Modifier 

Section 1848(p)(10) of the Act provides that there shall be no administrative or judicial 

review under section 1869 of the Act, section 1878 of the Act, or otherwise of the following: 

● The establishment of the VM; 
 496 

● The evaluation of the quality of care composite, including the establishment of 

appropriate measures of the quality of care; 

● The evaluation of the cost composite, including the establishment of appropriate 

measures of costs; 

● The dates of implementation of the VM; 

● The specification of the initial performance period and any other performance period; 

● The application of the VM; and 

● The determination of costs. 

 These statutory requirements regarding limitations of review are reflected in 

§414.1280. Despite the preclusion of administrative and judicial review, we previously indicated 

in the CY 2013 PFS final rule with comment period (77 FR 69326) that we believed an informal 

review mechanism is appropriate for groups of physicians to review and to identify any possible 

errors prior to application of the VM, and we established an informal inquiry process at 

§414.1285. We stated that we intend to disseminate reports containing CY 2013 data in the fall 

of 2014 to groups of physicians subject to the VM in 2015 and that we will make a help desk 

available to address questions related to the reports. 

We believe it would be appropriate to align with PQRS to consider requests for informal 

review of whether a group or solo practitioner successfully reported under the PQRS program 

and requests for reconsideration of PQRS data as described in section III.K, as well as to expand 

our current informal inquiry process to accept requests from groups and solo practitioners to 

review and correct certain other errors related to the VM, such as errors made by CMS in 

assessing the eligibility of a group or solo practitioner for the value modifier based on 

participation in a Shared Savings Program ACO, the Pioneer ACO Model, the CPC Initiative, or 

other similar Innovation Center models or CMS initiatives; computing standardized scores; 
 497 

computing domain scores; computing composite scores; or computing outcome or cost measures. 

We are working to develop and operationalize the necessary infrastructure to support such a 

corrections process, but at this time, we do not believe we would be able to implement the 

process until 2016 at the earliest. 

Therefore, for the CY 2015 payment adjustment period, to align with PQRS, we are 

proposing to expand the informal inquiry process at §414.1285 to establish an initial corrections 

process that would allow for some limited corrections to be made. Specifically, under this initial 

corrections process, for the CY 2015 payment adjustment period, we are proposing to establish a 

deadline of January 31, 2015 for a group to request correction of a perceived error made by CMS 

in the determination of its CY 2015 VM payment adjustment. Alternatively, we seek comment 

on a deadline of no later than the end of February 2015 to align with the PQRS informal review 

process. We would then make a determination regarding the request. At this time, we do not 

anticipate it would be operationally feasible for us to fully evaluate errors with regard to quality 

measure data and accept data as described above under section III.K. for the CY 2015 payment 

adjustment period, and thus we propose to classify a TIN as “average quality” in the event we 

determine that we have made an error in the calculation of quality composite. We propose to 

recompute a TIN’s cost composite in the event we determine that we have made an error in its 

calculation. We propose to adjust a TIN’s quality tier if we make corrections to a TIN’s quality 

and/or cost composites as a result of this initial corrections process. We note that there would be 

no administrative or judicial review of the determinations resulting from this expanded informal 

inquiry process under section 1848(p)(10) of the Act. 

Starting with the CY 2016 payment adjustment period (which has a performance period 

of CY 2014), we are proposing to continue the expanded informal inquiry process at §414.1285 

as described above. However, in anticipation of having the necessary operational infrastructure 
 498 

to support the reconsideration of quality measure data, we are proposing to establish a 30-day 

period that would start after the release of the QRURs for the applicable performance period for 

a group or solo practitioner to request correction of a perceived error made by CMS in the 

determination of the group or solo practitioner’s VM for that payment adjustment period. These 

QRURs will contain performance information on the quality and cost measures used to calculate 

the quality and cost composites of the VM and will show how all TINs would fare under the 

policies established for the VM for the CY 2015 payment adjustment period. Similar to our 

proposal for the initial corrections process in CY 2015, we would then make a determination 

regarding the requests received. Since we anticipate it would be operationally feasible for us to 

fully evaluate errors with regard to quality measure data at that point, and accept data as 

described above under section III.K. for the CY 2016 payment adjustment period, we propose to 

recompute a TIN’s quality composite and/or cost composite in the event we determine that we 

have made an error in the calculation. We note that if the operational infrastructure is not 

available to allow this recomputation, we propose to continue the approach of the initial 

corrections process to classify a TIN as “average quality” in the event we determine that we have 

made an error in the calculation of the quality composite. We propose to adjust a TIN’s quality 

tier if we make a correction to a TIN’s quality and/or cost composites as a result of this 

corrections process. We note that there would be no administrative or judicial review of the 

determinations resulting from this expanded informal inquiry process under section 1848(p)(10) 

of the Act. 

In future rulemaking and guidance, we plan to address how we would propose to refine 

and further develop this expanded informal inquiry process to allow for corrections for the value 

modifier. We believe it is important that the corrections process not undermine incentives for 

appropriate timely reporting. We welcome comment on these proposals, especially regarding the 
 499 

types of errors, timeline and other considerations that should be given to both the initial 

corrections process in the CY 2015 payment adjustment period and the corrections process we 

propose beginning with the CY 2016 payment adjustment period. 

j. Potential Methods to Address NQF Concerns Regarding the Total Per Capita Cost Measures 

In the CY 2013 PFS final rule with comment period (77 FR 69322), we established a 

policy to create a cost composite for each group subject to the VM that includes five paymentstandardized and risk-adjusted annual per capita cost measures. To calculate each group’s per 

capita cost measures, we first attribute beneficiaries to the group. We attribute beneficiaries 

using a two-step attribution methodology that is based on the assignment methodology used for 

the Shared Savings Program and the PQRS GPRO and that focuses on the delivery of primary 

care services (77 FR 69320). 

In the CY 2014 PFS final rule with comment period (78 FR 74780), we finalized 

inclusion of the MSPB measure as proposed in the cost composite beginning with the CY 2016 

VM, with a CY 2014 performance period. As we proposed, we are using the MSPB amount as 

the measure’s performance rate rather than converting it to a ratio as is done under the Hospital 

Inpatient Quality Reporting (IQR) and VBP Programs. We finalized that the MSPB measure is 

added to the total per capita costs for all attributed beneficiaries domain and equally weighted 

with the total per capita cost measure in that domain. Additionally, we finalized that an MSPB 

episode is attributed to a single group of physicians that provides the plurality of Part B services 

(as measured by standardized allowed charges) during the index admission, for the purpose of 

calculating that group’s MSPB measure rate. Finally, we finalized a minimum of 20 MSPB 

episodes for inclusion of the MSPB measure in a physician group’s cost composite. 

Additionally, in the CY 2014 PFS final rule with comment period (78 FR 74780), we 

finalized our proposal to use the specialty adjustment method to create the standardized score for 
 500 

each group’s cost measures beginning with the CY 2016 VM. That is, we refined our current 

peer group methodology to account for specialty mix using the specialty adjustment method. We 

also finalized our proposal to include this policy in our cost composite methodology. 

Additionally, we finalized our proposal to identify the specialty for each EP based on the 

specialty that is listed on the largest share of the EP’s Part B claims. 

As discussed in the CY 2014 PFS final rule with comment period (78 FR 74781), we 

submitted the total per capita cost measure for National Quality Forum (NQF) endorsement in 

January 2013. In the final voting in September 2013, the NQF Cost and Resource Use 

Committee narrowly voted against the measure by a count of 12 in support and 13 in opposition. 

We are proposing to address two of the major concerns that Committee raised in its review of the 

measure. First, we propose modifications to our two-step attribution methodology. Second, we 

propose to reverse the current exclusion of certain Medicare beneficiaries during the 

performance period. We discuss these proposals further below, and they would apply beginning 

with the CY 2017 payment adjustment period for the VM. The proposals would apply to all five 

of the total per capita cost measures under §414.1235(a)(1) through (5). The modifications to the 

two-step attribution methodology also would apply to the methodology used for attributing 

beneficiaries for the computation of claims based quality measures under §414.1230, except for 

participants in the Shared Savings Program as described later. 

The attribution methodology for the 5 total per capita cost measures and claims based 

quality measures in the VM, as finalized in the CY 2013 PFS final rule with comment period (77 

FR 66318 through 66320), includes two steps. Before applying the two steps, however, we first 

identify all beneficiaries who have had at least one primary care service rendered by a physician 

in the group. Primary care services include evaluation and management visits in office, other 

outpatient, skilled nursing facility, and home settings. After this “pre-step”, we assign, under 
 501 

Step 1, beneficiaries to the group practice who had a plurality of primary care services (as 

measured by allowed charges) rendered by primary care physicians in the group, which include 

Family Practice, Internal Medicine, General Practice, and Geriatric Medicine. If a beneficiary is 

non-assigned under Step 1, we proceed to Step 2, which is to assign beneficiaries to the group 

practice whose affiliated non-primary care physicians, nurse practitioners (NPs), physician 

assistants (PAs), and clinical nurse specialists (CNSs) together provided the plurality of primary 

care services (as measured by allowed charges), as long as at least one primary care service was 

provided by a non-primary care physician in the group. 

To address NQF concerns regarding the attribution methodology of the total per capita 

cost measure, we propose two modifications to the two-step attribution methodology as applied 

to the five total per capita cost measures, as well as the claims based quality measures in the VM. 

NQF Committee members discussed how primary care services often are provided by NPs, PAs, 

or CNSs, but Step 1 of the attribution methodology assigns beneficiaries to the group who had a 

plurality of primary care services rendered by primary care physicians in the group. After further 

consideration, we agree that it is appropriate to include NPs, PAs, and CNSs in Step 1 of the 

attribution method insofar as they provide primary care services. Consequently, we propose to 

move these NPs, PAs, and CNSs from Step 2 of the attribution method to Step 1. This proposed 

change would affect all five of the total per capita cost measures under §414.1235(a)(1) through 

(5) and the claims-based quality measures under §414.1230. 

Additionally, we propose to remove the “pre-step” described above for the purposes of 

the value modifier. The “pre-step” was included in the Shared Savings Program assignment 

methodology to comply with the statutory requirement (77 FR 67851) that beneficiary 

assignment be based upon the utilization of primary care services furnished by a physician. 

However, no such limitation exists for the VM. Consequently, we propose to remove the “pre-
 502 

step” that identifies a pool of assignable beneficiaries that have had at least one primary care 

service furnished by a physician in the group. Removing the “pre-step” would result in 

streamlining the attribution process and attributing beneficiaries based on a plurality of primary 

care services according to Step 1 and Step 2. In addition, we believe that this proposal would 

ensure that beneficiaries can be assigned to group practices made up of nonphysician eligible 

professionals because it would eliminate the criterion that a beneficiary have at least one primary 

care service furnished by a physician in the group practice. This proposed change (removing the 

“pre-step”) would affect all five of the total per capita cost measures under §414.1235(a)(1) 

through (5) and the claims-based quality measures under §414.1230. 

The two step attribution rule would remain intact after these two proposed modifications, 

and the method would continue to be generally consistent with the method of assignment of 

beneficiaries under the Shared Savings Program, as specified under §414.1240. As discussed 

previously, the “pre-step” would be removed. We would assign, under Step 1, beneficiaries to 

the group who had a plurality of primary care services (as measured by allowed charges) 

rendered by primary care physicians, NPs, PAs, or CNSs in the group. If a beneficiary is nonassigned under Step 1, we still would proceed to Step 2, which would assign beneficiaries to the 

group practice whose affiliated non-primary care physicians provided the plurality of primary 

care services (as measured by allowed charges). We propose these modifications only for groups 

and solo practitioners who are not participating in the Shared Savings Program. We note that for 

groups and solo practitioners who participate in the Shared Savings Program, we would not 

remove the pre-step or change the attribution methodology for quality measures and cost 

measures, but would continue to rely on the methodology used by the Shared Savings Program to 

attribute beneficiaries to ACOs in the Shared Savings Program. 
 503 

One of the reasons we originally proposed this two-step attribution process for the total 

per capita cost measures and claims based quality measures was that it was aligned with the 

attribution methodologies used by the Shared Savings Program and also the PQRS GPRO web 

interface (77 FR 69318 through 69320). We recognize that these programs may seek to establish 

changes to their methodologies, and note that for the purposes of the VM, we intend to retain the 

two-step beneficiary attribution methodology that was described in the CY 2013 PFS final rule 

with comment period (77 FR 69318 through 69320), subject to the changes proposed above. 

However, to address the concerns raised by NQF, we believe the proposed modification to the 

two-step beneficiary attribution method would more appropriately reflect the multiple ways in 

which primary care services are provided, which are not limited to physician groups. We 

welcome comments on our proposed modification to the two-step attribution methodology as 

applied to the five total per capita cost measures under §414.1235(a)(1) through (5) and to the 

claims-based quality measures under §414.1230 of the VM. 

Second, NQF committee members raised concerns about the exclusion of certain 

beneficiaries in the methodology used for the total per capita cost measure. Committee members 

expressed concern that end-of-life costs were not being captured by the measure. We considered 

this argument and agree that it is important to include certain beneficiaries with these costs 

during the performance period. As a result, we propose to include certain part-year Medicare 

FFS beneficiaries. This proposed change would affect all five of the total per capita cost 

measures under §414.1235(a)(1) through (5). We believe the proposed change would provide a 

more complete assessment of end of life costs associated with the patients a physician group sees 

during the year. We seek comment on this proposal. 

We propose to continue excluding other part-year beneficiaries (those who spend part of 

the performance period in a Medicare Advantage (Part C) plan and those enrolled in Part A only 
 504 

or Part B only for part of the performance period and both Part A and Part B for the remainder of 

the performance period). Excluding part-year Medicare Advantage enrollees would remain 

consistent with the Shared Savings Program and PQRS GPRO web interface reporting policy. If 

we were to include these part-year Medicare Advantage enrollees, we would need to determine a 

method to impute their costs for the portion of the performance period in which they were 

enrolled in FFS Medicare Parts A and B so that we could compare beneficiaries’ annual per 

capita costs appropriately. Similarly, Medicare Part A only or Medicare Part B only enrollees 

who were enrolled in both Part A and Part B for only part of the performance period would also 

require a method to impute their costs if they were no longer excluded. Furthermore, these Part 

A only or Part B only beneficiaries are excluded from the Shared Savings Program and PQRS 

GPRO methodology. 

We propose including Medicare FFS beneficiaries who are newly enrolled to Medicare 

during the performance period and enrolled in both Part A and Part B while in Medicare FFS. 

Additionally, while we believe inclusion of new enrollees is inconsistent with GPRO’s 

methodology, it would be consistent with the Shared Savings Program’s methodology. We 

welcome comments on the inclusion of these part-year beneficiaries. We also welcome 

comments on whether other part-year Medicare FFS beneficiaries (that is, those who are partyear Medicare Advantage enrollees or part-year Medicare Part A only or Part B only enrollees) 

should be included in the five total per capita cost measures under §414.1235(a)(1) through (5) in 

the VM. 

In this proposed rule, we are choosing not to address the other concerns about the total 

per capita cost measures that were raised by NQF. First, we are deferring addressing the issue of 

whether to incorporate socioeconomic status in our measures until after the NQF has finalized its 

guidance regarding risk adjustment for resource use measures. Second, we are not proposing to 
 505 

include Part D data in the total per capita cost measures at this time due to the complexity of the 

issue. Based on data compiled by the Medicare Payment Advisory Commission (MedPAC), we 

estimate that approximately 60 percent of Medicare FFS beneficiaries were enrolled in standalone Part D in 2013.11 Including Part D data would incorrectly indicate higher costs for these 

beneficiaries compared to others without Part D coverage. Before we are able to propose 

inclusion of Part D data, we would need to determine an approach to address this issue. We 

welcome comments on suggested methods for including Part D data in the total per capita cost 

measures. 

k. Discussion Regarding Treatment of Hospital-Based Physicians 

We are considering including or allowing groups that include hospital-based physicians 

or solo practitioners who are hospital-based to elect the inclusion of Hospital Value-Based 

Purchasing (VBP) Program performance in their VM calculation in future years of the program. 

We would include hospital performance for the hospital or hospitals in which they practice. We 

would propose such a change through future notice and comment rulemaking, taking into 

consideration public comment and any relevant empirical evidence available at that time. We 

are considering this potential policy to expand the performance data included for hospital-based 

physicians and to better align incentives for quality improvement and cost control across CMS 

programs. Such a policy would also address public comments we received on the CY 2014 PFS 

proposed rule (78 FR 74775), suggesting that the Hospital VBP Program total performance score 

for the hospital in which a specialist practices should be used in the VM. Commenters made this 

suggestion, noting that there were limited measures that apply to certain specialties and that 

 

11 Please see http://www.medpac.gov/documents/Mar14_EntireReport.pdf for underlying data. We estimated that 

there were 37.3 million Medicare FFS beneficiaries by subtracting the number of beneficiaries enrolled in Medicare 

Advantage (14.5 million) from the estimated total number of Medicare beneficiaries using data in table 13-1 (P. 

328). We estimated that there were 22.4 million beneficiaries with a stand-alone prescription drug plan, which 

represented 64 percent of the 35 million beneficiaries with Medicare Part D coverage (p. 355). 
 506 

those specialties may exercise wide influence over the quality of care provided in a hospital. We 

note that a hospital’s final Hospital VBP Program performance for a given performance period 

would not be available to a group at the time that they register for PQRS reporting. In other 

words, if we were to establish a voluntary policy where groups could elect to include hospital 

performance, they would make the election to have that performance included in their VM for a 

payment adjustment period based on the hospital’s historic VBP Program performance which 

would be known to the TIN at the time of election. 

To identify groups or solo practitioners that would have Hospital VBP Program 

performance data in their VM or allow such groups to elect its inclusion, we first have to identify 

who would have this option. Because the VM is applied at the TIN level, we believe that the 

election to include Hospital VBP Program data must also be made at the TIN level. We 

considered two general methods for identifying which TINs represent hospital-based physicians 

and should therefore have Hospital VBP Program data included or have the option to elect its 

inclusion. The first approach would be self-nomination, by which a group would attest that it is 

comprised primarily of hospital-based physicians. This approach would be consistent with 

public comment we received on the CY 2013 PFS proposed rule (77 FR 69312), in which 

commenters suggested that we should include hospital performance information on a voluntary 

basis and that it should be based on self-nomination. The second approach would be for CMS to 

specify criteria that a TIN would have to satisfy, to have Hospital VBP Program data included or 

have the option to elect its inclusion. The latter approach might provide a more objective 

method for determining whether a TIN would be eligible to elect inclusion of hospital 

performance information or would have it automatically included in its VM. These criteria could 

include specialty types or percentage of Medicare payments for services provided in the hospital 

setting. For example, the EHR Incentive Program has defined in 42 CFR 495.4 a hospital-based 
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EP generally as an EP who furnishes 90 percent or more of his or her covered professional 

services in sites of service identified by the codes used in the HIPAA standard transaction as an 

inpatient hospital or emergency room setting. We could adopt a similar criterion for identifying 

hospital-based physicians for the purpose of electing or receiving mandatory inclusion of 

Hospital VBP Program data in the VM. If we were to take the approach of identifying 

appropriate criteria for eligibility for inclusion of hospital performance data, we would need to 

then determine whether the criteria would have to apply to the majority of physicians within a 

given TIN, or whether the TIN as a whole would have to meet the criteria in the aggregate. That 

is, using the example criterion above, we could either require that 90 percent of the total 

Medicare covered professional services provided by all physicians within a given TIN are 

furnished in a hospital setting or require that some proportion of the individual physicians within 

a TIN provide 90 percent of their individual Medicare covered services in the hospital setting. 

Additionally, since we are proposing to expand application of the VM to nonphysician eligible 

professionals, we seek comment on whether these methods should apply in identifying hospitalbased nonphysician eligible professionals in addition to hospital based physicians. We welcome 

public comment on the appropriate methodology to identify hospital-based groups and solo 

practitioners for the purpose of having Hospital VBP Program data included or allowing them to 

elect inclusion of Hospital VBP Program performance data in the VM at the TIN level. 

After determining which groups or solo practitioners would be eligible to have hospital 

VBP Program performance data included or to elect inclusion of hospital VBP Program 

performance data in the VM, we would require a methodology to determine which hospital or 

hospitals’ performance would apply to a given TIN. We could base this determination on the 

plurality of services provided by a TIN. That is, the TIN would be attributed the Hospital VBP 

Program performance of the hospital at which its physicians (or physicians and nonphysician 
 508 

eligible professionals) billed the most professional services during a given performance period. 

Alternatively, we could attribute hospital performance to a TIN that provided some threshold of 

its hospital-based services at that hospital. For example, we could require that a TIN have 

performed at least 30 percent of its hospital-based services at a given hospital to have that 

hospital’s performance included in the TIN’s VM. In that example, a TIN could have up to three 

hospitals’ performance included in its VM. We could weight the performance of the hospitals 

included, based on Medicare dollars paid to the TIN for services their physicians (or physicians 

and nonphysician eligible professionals) provided to beneficiaries hospitalized at a given 

hospital, or based on number of cases treated by physicians (or physicians and nonphysician 

eligible professionals) from the TIN that are discharged from a given hospital. We welcome 

public comment on these or other alternatives for determining which hospital or hospitals’ 

Hospital VBP Program performance data should be included in a physician TIN’s VM and how 

to weight the hospitals, if more than one is included. 

After we have determined which hospital or hospitals’ Hospital VBP Program 

performance data would be included in a TIN’s VM, we would have to incorporate that 

hospital’s or hospitals’ Total Performance Score(s) (TPS(s)) or some subset of it into the VM. 

Under the Hospital VBP Program, a hospital receives a TPS, which is a weighted total of 

underlying quality performance scores the hospital receives on quality and efficiency measures 

included in the program. Further details about the Hospital VBP Program may be found on 

CMS’ website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-basedpurchasing/. We generally finalize the measures, domains into which the measures are grouped 

for scoring purposes, and scoring methodology (which includes the measure and domain weights 

that apply to a particular program year) for each Hospital VBP Program year in the IPPS/LTCH 
 509 

final rule that we issue each summer. For the FY 2017 Hospital VBP Program, the finalized 

domains are: Safety; Clinical Care (subdivided into Clinical Care – Outcomes and Clinical Care 

– Process); Efficiency and Cost Reduction; and Patient and Caregiver Centered Experience of 

Care/Care Coordination (78 FR 50703 through 50704). Other proposals for the FY 2017 

Hospital VBP Program can generally be found in the FY 2015 IPPS/LTCH Proposed Rule (79 

FR 28117 through 28134). 

When determining what part of the TPS to include in the VM, we have to consider the 

varied performance periods of measures included in the Hospital VBP Program. The majority of 

measures used in the Hospital VBP Program are scored based on calendar year performance 

periods, and performance on measures under the program is used to adjust the base-operating 

DRG payment made to hospitals under the IPPS on a fiscal year basis. For these measures in 

which calendar year performance periods are used, hospitals generally report data two calendar 

years prior to the fiscal year in which their performance on those measures will affect their 

payment. For example, hospitals’ CY 2016 performance on these measures under the program 

would affect their FY 2018 payments. If we were to incorporate Hospital VBP Program 

performance into the VM as in the example, we could incorporate the CY 2016 performance into 

VMs for CY 2018 physician payments. 

In determining which portion of the TPS to include in the VM, we also have to consider 

the incentives generated by different approaches. Inclusion of the entire TPS score encourages 

shared accountability for and shared incentive to improve on all aspects of the quality of care 

provided during a hospitalization, while selecting some subset might better target factors over 

which physicians exert more influence. The latter approach might, for example, exclude 

measures such as HCAHPS survey dimensions focused on nursing interventions. 
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We considered three options for including Hospital VBP Program performance in the 

VM: (1) Include the entire TPS in the cost composite; (2) Include the Efficiency and Cost 

Reduction domain score in the cost composite, and include all or some subset of the other 

domain scores in the quality composite; and (3) Include some subset of the measures in the cost 

and quality composites. The first approach, inclusion of the TPS in the cost composite, was 

suggested during public comment on the CY 2014 PFS rule (78 FR 74775). This approach is a 

straightforward one and it encourages joint accountability and coordination between hospitals 

and physicians on all aspects of hospital quality. However, it could be construed as counting 

quality measures within the cost composite because, as noted above, the TPS is computed based 

on hospital performance on measures in a number of quality domains in addition to hospital 

performance on the Medicare Spending Per Beneficiary measure in the Efficiency and Cost 

Reduction domain. Additionally, we note that the VM is structured in such a manner that a score 

would need to be included as part of either the quality composite or the cost composite. Under 

this approach and the second one, measures with performance periods exceeding one calendar 

year would be captured in the VM for a given payment year. The second approach, inclusion of 

the Efficiency and Cost Reduction domain score in the cost composite and all or some subset the 

other domain scores in the quality composite remains relatively straightforward, encourages 

shared accountability and coordination between hospitals and physicians on all aspects of 

hospital quality, and enables us to avoid counting quality measures within the VM cost 

composite, but it could still capture measures with performance periods exceeding a calendar 

year in the VM for a given year. We note that for the Hospital VBP Program, the Efficiency and 

Cost Reduction domain includes Medicare Spending per Beneficiary measure attributed to 

hospitals and that, starting with the CY 2016 payment adjustment period, the VM includes as 

part of its total cost domain the Medicare Spending per Beneficiary measure attributed to groups. 
 511 

While the third approach would be the most complex one, inclusion of some subset of the 

domain measures in the cost and quality composites would enable us to use only measures with 

performance periods aligning with the remainder of the VM measures to be included in the 

quality and cost composites, if we wished to do so. It would also enable us to identify measures 

over which we believe hospital-based physicians exert sufficient influence to be held accountable 

through payment adjustments. The third approach places less emphasis on hospital and 

physician coordination to improve all aspects of the quality of care provided during a 

hospitalization and it requires a judgment call regarding which measures to include. We believe 

that the second approach, inclusion of all TPS domains or some subset of the TPS domains in the 

VM, with the Efficiency and Cost Reduction domain included in the cost composite and the 

other domains (based on whether all of the measures in the domain have the same performance 

periods as the performance period being considered in the VM) included in the quality composite 

would strike the best balance between a straightforward approach, appropriate capture of 

different aspects of the TPS as they relate to the VM composites, and encouraging physician and 

hospital coordination to improve all aspects of care provided to Medicare beneficiaries who are 

hospitalized. We welcome public comment on the approaches we considered, as well as 

alternative approaches for inclusion of all or part of the Hospital VBP Program TPS into the VM. 

We also welcome public comment on what criteria we should consider in selecting a subset of 

Hospital VBP Program measures or domains in the VM, if we were to adopt such a policy. 

Once we have determined which portion of the TPS to include in the VM, if we were to 

move forward with including Hospital VBP performance data into the VM, we would need to 

determine how we would incorporate it into the quality and cost composite scores. If more than 

one hospital’s Hospital VBP Program performance data were to be included in a given TIN’s 

VM because a multiple hospital attribution approach were selected, as discussed above, we 
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would first weight the hospitals’ performance. That performance could be measured at the TPS 

level, the domain level, or the individual measure level, depending which we decide to use, also 

discussed above. We could treat the TPS itself, the individual domain, or the individual measure 

as an additional measure in the composite or composites into which we incorporate it. Under 

this approach, the TPS, domain, or measure score could be given a standardized score, similar to 

other measures within the VM. For example, a given hospital’s Efficiency and Cost Reduction 

Domain score would be arrayed along with that of all other TINs electing inclusion and the 

standardized score would be calculated, according to the methodology we finalized in the CY 

2013 PFS final rule with comment period (77 FR 69321). That standardized score would then be 

weighted into the cost composite for the value modifier. The weight could depend on the 

number of measures underlying the domain score or TPS, it could be weighted evenly with other 

composite measures if calculated at the individual measure level, or it could be assigned a weight 

based on relative importance of the measure, to be determined through rulemaking. We 

welcome public comment on this potential methodology or other approaches for including 

Hospital VBP Program performance into a TIN’s VM. 

5. Physician Feedback Program 

Section 1848(n) of the Act requires us to provide confidential reports to physicians (and, 

as determined appropriate by the Secretary, to groups of physicians) that measure the resources 

involved in furnishing care to Medicare FFS beneficiaries. Section 1848(n)(1)(A)(iii) of the Act 

also authorizes us to include information on the quality of care furnished to Medicare FFS 

beneficiaries. In the fall of 2013, we provided QRURs to certain physicians and groups as 

discussed below, which were based on CY 2012 data. We intend to make reports based on CY 

2013 data available in the fall of 2014. These reports provide physicians and groups of 

physicians with comparative performance data (both quality and resource use) that can be used to 
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improve quality and coordinate care furnished to Medicare FFS beneficiaries. Additionally, in 

June 2013 and June 2014, we provided Supplemental QRURs to group report recipients that 

featured episode-based costs of care. We derived these episode-based costs using an episode 

grouper as required by section 1848(n)(9)(A) of the Act, as well as using methodologies 

proposed in the FY 2015 IPPS rule to measure episode costs under the Hospital Value Based 

Purchasing program (79 FR 28122 through 28124). 

a. CY 2013 Quality and Resource Use Reports Based on CY 2013 Data and Disseminated in CY 

2014. 

On September 16, 2013, we made available CY 2012 QRURs to 6,779 groups nationwide 

with 25 or more EPs. These reports covered approximately 400,000 physicians practicing in 

large medical groups. The QRURs provided groups of 100 or more EPs with quality-tiering 

information on 2012 data that they could use to decide whether to elect to be assessed under the 

quality-tiering approach that we adopted for the VM that will be applied in 2015, based on 2013 

performance. Additionally, and in response to feedback we received from prior year recipients 

of the QRURs, the CY 2012 QRURs contained detailed beneficiary-specific data on each 

group’s attributed beneficiaries and their hospitalizations, and the group’s associated eligible 

professionals. Complementing the CY 2012 QRURs were three downloadable drill down tables 

that provide information on each beneficiary attributed to the group and each eligible 

professional billing under the group’s TIN. We have received very positive feedback from 

report recipients and expect to enhance the information we provide in future years. 

In the late summer of 2014, we plan to disseminate the QRURs based on CY 2013 data to 

all physicians (that is, TINs of any size) even though groups with fewer than 100 eligible 

professionals will not be subject to the VM in CY 2015. Additionally, in CY 2015, the VM will 

not apply to any group that participated in the Shared Saving Program, the Pioneer ACO model, 
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or the Comprehensive Primary Care Initiative during the performance period (CY 2013). These 

reports will contain performance on the quality and cost measures used to score the composites 

and additional information to help physicians coordinate care and improve the quality of care 

furnished. 

b. Episode Costs and the Supplemental QRURs 

Section 1848(n)(9)(A) of the Act requires CMS to develop an episode grouper and 

include episode-based costs in the QRURs. An episode of care consists of medical and/or 

procedural services that address a specific medical condition or procedure that are delivered to a 

patient within a defined time period and are captured by claims data. An episode grouper 

organizes administrative claims data into episodes. 

We have developed a prototype set of episodes that expands upon the set of episodes that 

were described in the CY 2014 PFS final rule with comment period (78 FR 74785). In June 

2013, we made available to 54 large group practices Supplemental QRURs based on 2011 data 

that illustrated the general approach to classifying episodes of care. The 2011 Supplemental 

QRURs included episode-based costs for five clinical conditions (pneumonia, acute myocardial 

infarction (AMI), coronary artery disease, percutaneous coronary intervention (PCI), and 

coronary artery bypass graft (CABG)), which also were broken into 12 episode subtypes to 

account for various underlying clinical factors. We chose these episode types to gain experience 

with the prototype methodology of the episode grouper in acute, chronic, and procedural 

conditions. In summer 2014, we distributed Supplemental QRURs based on 2012 data to a 

greater number of groups (groups with at least 100 EPs12EPs) that included a broader set of 

 

12For Supplemental QRUR purposes, groups were also included if they did not to participate in multiple 

accountable care organizations (ACOs) and did not to participate in more than one of the following initiatives in 

program year 2012: the Shared Savings Program, the Pioneer Accountable Care Organization (ACO) Model, or the 

Comprehensive Primary Care Initiative (CPCI). 
 515 

episodes than the 2011 Supplemental QRURs. In addition to the five clinical conditions in the 

2011 Supplemental QRURs, the 2012 Supplemental QRURs included: chronic congestive heart 

failure (CHF); chronic obstructive pulmonary disease (COPD)/asthma; acute COPD/asthma; 

permanent pacemaker system replacement/insertion; and bilateral cataract removal with lens 

implant. For the 2012 Supplemental QRURs, we broke down these episode types into 20 

subtypes altogether. In addition to these 20 episode subtypes, we included in the 2012 

Supplemental QRURs 6 clinical episode-based measures that we are adapting from those 

considered for inclusion in the Hospital VBP program (79 FR 28122 through 28124). These 6 

additional episode-based measures will be described following discussion of the 20 episode 

subtypes. 

For the 20 episode subtypes discussed above, we applied different attribution rules, 

depending on episode type (for example, chronic, acute, or procedural) and whether the episode 

included a hospitalization. Following feedback we received from physician groups on the 2011 

Supplemental QRURs, we have simplified our attribution rules to a single plurality attribution 

rule with a 20 percent minimum threshold. We believe that it is critical to attribute an episode to 

the group of physicians that is in the best position to oversee the quality of care furnished and the 

resources used to furnish that care. For chronic episodes, attribution was based on the plurality 

of outpatient E&M visits during the episode, because these conditions seem best managed in an 

outpatient setting. For acute inpatient-based episodes, attribution was based the plurality of 

inpatient E&M visits during the trigger event; for outpatient-based acute episodes, attribution 

was based on the plurality of E&M visits during the entire episode. For procedural episodes, 

attribution is made to the group that includes the performing surgeon. For chronic and acute 

episodes, attribution required at least 20 percent of the relevant type of E&M visits, as applicable 

to the episode type. Additional tie-breaking rules were applied when necessary, and further 
 516 

details on attribution rules can be found in “Detailed Methods of the 2012 Medical Group 

Practice Supplemental Quality and Resource Use Reports (QRURs)” at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. 

To control for patient case-mix, we applied a risk-adjustment methodology. We also 

used a slightly different risk adjustment methodology to adjust the costs for the underlying risk 

factors for the beneficiaries with these episodes as compared to the total per capita cost measures 

that we have used in the CY 2013 QRURs. The episode grouper used to generate the 2012 

episode data for the 20 episode subtypes, as discussed above, adjusted costs for health and 

treatment history in the 6 months prior to the beginning of the episode. The risk-adjustment 

methodology calculated each episode’s expected cost based on health (for example, severity), 

and non-health (for example, age) explanatory variables. Using these variables, the riskadjustment model calculated the predicted cost of an episode using information available at the 

start of the episode. The use of such a prospective risk model avoids allowing providers to 

influence their risk-adjusted costs by changing their treatment patterns during the episode. We 

are continuing to examine ways to refine this approach as we develop further episode costs for 

additional clinical conditions. All cost figures used in the risk-adjustment model are paymentstandardized. 

We have worked with stakeholders and specialty societies to gain input for the next 

iteration of the Supplemental QRURs. Based on input received, we have modified episode 

attribution rules, and increased drill down capability. The Supplemental QRURs contained 

summary information about each episode type, comparisons to national benchmarks, as well as 

specific information describing each episode attributed to the group of physicians. We view 

these 2012 Supplemental QRURs as part of an extended process of incorporating episode costs 
 517 

into the QRURs. We intend to further develop the episode grouper and to broaden the range of 

conditions that are addressed by episode grouping, such as the additional clinical episode based 

measures we adapted from the Hospital Value-Based Purchasing Program. The feedback that 

CMS expects from the medical practice groups on the 2012 Supplemental QRURs will inform 

next steps. 

In the future, we plan to further develop these episode reports and to include not only 

additional episodes, and to make this information available to an even greater number of medical 

group practices. In addition, we have begun preliminary investigation of how to marry these 

measures of resource use with clinical quality measures included in the PQRS, because resource 

use is to be considered in context of the quality of care furnished for the value modifier. We 

have also begun investigation of how to align episode measures across provider settings and 

describe this effort more below. 

We note that for the 2012 Supplemental QRURs released in summer of 2014, we 

included six additional clinical episode-based measures that were adapted from measures 

proposed for future inclusion in the Hospital VBP Program. In the FY 2015 IPPS proposed rule 

(79 FR 28122 through 28124), we discussed six clinical episode-based condition-specific 

measures for hospitals that we also adapted for use in the 2012 Supplemental QRURs. In that 

proposed rule, we stated that these measures that we are considering for potential future 

inclusion in the Hospital VBP Program would create additional incentives for coordination 

between hospitals and physicians to optimize the care they provide to Medicare beneficiaries and 

would facilitate alignment between the Hospital VBP Program and the VM. Initially, these 

measures have been included only in the Physician Feedback Program, through the 2012 

Supplemental QRURs, and we would consider whether to propose their inclusion in the VM 

through future rulemaking. 
 518 

The episode-based measures we included in the 2012 Supplemental QRURs and are 

considering for future inclusion in the Hospital VBP Program are similar in many ways to the 

MSPB measures already included in the Efficiency domain of the Hospital VBP Program and 

finalized in the CY 2014 PFS final rule (78 FR 74780) for the VM. As discussed in the FY 2015 

IPPS proposed rule (79 FR 28123), like the MSPB measure, these episode-based standardized 

payment measures would include services initiated during an episode that spans from 3 days 

prior to a hospital admission through 30 days post-discharge from the hospital. While the MSPB 

measure includes all Medicare Part A and Part B payments during this time window, the six 

hospital-based episodes only include Medicare payments for services that are clinically related to 

the health conditions treated during the hospital stay that triggered the episode. We sum the 

standardized Medicare payment amounts for Part A and Part B services provided during this 

timeframe. Medicare payments included in these episode-based measures are standardized 

according to the CMS standardization methodology finalized for the MSPB in the FY 2012 

IPPS/LTCH PPS final rule (76 FR 51626). Episodes in the six new measures are risk-adjusted in 

a manner similar to the MSPB measure risk adjustment methodology finalized in the FY 2013 

IPPS final rule (76 FR 51625 through 51626).13 The payment standardization methodology is 

available in the document entitled “CMS Price Standardization” available at 

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQne

tTier4&cid=1228772057350. The risk adjustment methodology specific to these six episodebased standardized payment measures can be found on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

 

13 There are a few difference between the risk adjustment approaches for the six clinical episode-based measures 

and the MSPB. MSPB episodes are risk-adjusted at the Major Diagnostic Category (MDC) level, whereas two of the 

new episode-based measures, the hip episode measure and the knee episode measure, represent conditions that are in 

the same MDC. Accordingly, the six clinical episode-based measures are individually risk-adjusted at the specific 

episode type level, to recognize the distinctions. 
 519 

Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html.. 

Risk adjustment and payment standardization allow us to compare performance on these 

measures in the QRURs, attributed to a physician group, across physician groups. 

We included three medical and three surgical episodes in the 2012 Supplemental QRURs. 

The medical episode measures are for the following conditions: (1) kidney/urinary tract 

infection; (2) cellulitis; and (3) gastrointestinal hemorrhage. A medical episode is ‘triggered’ by 

an inpatient claim with a specified MS-DRG. The surgical episode measures are: (1) hip 

replacement; (2) knee replacement/revision; and (3) lumbar spine fusion/refusion. A surgical 

episode is triggered when an inpatient claim has one of the specified MS-DRGs and at least one 

of the procedure codes specified for that episode. We welcome public comment on the three 

medical and three surgical episode measures that we included in the 2012 Supplemental QRURs. 

Attribution for the six clinical episode-based measures at the group level are the same as 

the rules used for comparable types of the 20 episode subtypes in the 2012 Supplemental QRURs 

as discussed above. Attribution rules varied depending on whether a the clinical episode-based 

measure was one of the three surgical (or procedural) episodes or one of the three medical (or 

acute condition) episodes. Further details on attribution rules can be found in “Detailed Methods 

of the 2012 Medical Group Practice Supplemental Quality and Resource Use Reports (QRURs)” 

at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html 

Specifications for these six clinical episode-based measures, including the MS-DRG and 

procedure codes used to identify each of the episodes, and details of episode construction 

methodology, are available in “Detailed Methods of the 2012 Medical Group Practice 

Supplemental Quality and Resource Use Reports (QRURs)” at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
 520 

Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. We 

welcome public comments on these specifications and the construction of the six clinical 

episode-based measures that we included in the 2012 Supplemental QRURs. 

CMS’ episodes will continue to evolve over the coming years as more experience is 

gained. More information about the Supplemental QRURs can be found at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. 

We will continue to seek stakeholder input as we develop the episode framework. We 

are considering proposing to add episode-based payment measures to the VM through future 

rulemaking for all 12 episode subtypes, or some subset of these episode subtypes, of the selected 

respiratory and selected heart conditions that have appeared in both the 2011 Supplemental 

QRURs and 2012 Supplemental QRURs. These 12 episode subtypes include: pneumonia (all), 

pneumonia without an inpatient hospitalization, pneumonia with an inpatient hospitalization, 

acute myocardial infarction (now called acute coronary syndrome or ACS), ACS without 

percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG), ACS with 

PCI, ACS with CABG, coronary artery disease (now called ischemic heart disease or IHD), IHD 

without ACS, IHD with ACS, CABG without preceding ACS, and PCI without preceding ACS. 

Additionally, we are considering proposing to add hospital episode-based payment measures to 

the VM at a later time, such as the six hospital episodes described above. We welcome public 

comments on the specifications included on the Website and the construction of the episodebased payment measures that we are considering. 

c. Future Plans for the Physician Feedback Reports 

We will continue to develop and refine the annual QRURs in an iterative manner. As we 

have done in previous years, we will seek to further improve the reports by welcoming 
 521 

suggestions from recipients, specialty societies, professional associations, and others. We have 

worked with several specialty societies to develop episode costs or other cost or utilization 

metrics to include in the annual QRURs. We believe these efforts could be productive as we use 

the QRURs to not only describe how the VM would apply, but in addition to provide groups with 

utilization and other statistics that can be used for quality improvement and care coordination. 

In the late summer of 2014, we plan to disseminate the QRURs based on CY 2013 data to 

all physicians (that is, TINs of any size) even though groups with fewer than 100 eligible 

professionals will not be subject to the VM in CY 2015. Additionally, the VM will not apply to 

any group that participated in the Shared Saving Program, the Pioneer ACO model, or the 

Comprehensive Primary Care Initiative during the performance period (CY 2013). These reports 

will contain performance on the quality and cost measures used to score the composites and 

additional information to help physicians coordinate care and improve the quality of care 

furnished. Improvements to this year’s reports include: additional supplementary information 

on the specialty adjusted benchmarks; inclusion of the individual PQRS measures for 

informational purposes for individual EPs reporting PQRS measures on their own; enhanced drill 

down tables; and a dashboard with key performance measures. The reports will be based on the 

VM policies that were finalized in the CY 2013 PFS final rule with comment period (77 FR 

69310), and that will affect physician payment starting January 1, 2015. Groups will, therefore, 

have an opportunity to see how the policies adopted will apply to them. After the reports are 

released we will again solicit feedback from physicians and continue to work with our partners to 

improve them. We note that physicians will have some time to determine the impact of our 

revised policies and revise their practices accordingly before the new policies impact them. We 

look forward to continue working with the physician community to improve the QRURs. 
 522 

IV. Collection of Information Requirements 

 Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in 

the Federal Register and solicit public comment before a collection of information requirement 

is submitted to the Office of Management and Budget (OMB) for review and approval. To fairly 

evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) 

of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following 

issues: 

● The need for the information collection and its usefulness in carrying out the proper 

functions of our agency. 

● The accuracy of our estimate of the information collection burden. 

● The quality, utility, and clarity of the information to be collected. 

● Recommendations to minimize the information collection burden on the affected 

public, including automated collection techniques. 

To derive average costs, we used data from the U.S. Bureau of Labor Statistics for all 

salary estimates. The salary estimates include the cost of fringe benefits, calculated at 35 percent 

of salary, which is based on the June 2012 Employer Costs for Employee Compensation report 

by the Bureau. 

 We are soliciting public comment on each of the section 3506(c)(2)(A)-required issues 

for the following information collection requirements (ICRs). For cohesion, the ICRs are set out 

below under the same headings found in sections II (Provisions of the Proposed Rule for PFS) 

and III (Other Provisions of the Proposed Regulations) of this preamble. 

A. Information Collection Requirements (ICRs) 

1. ICRs Regarding the Removal of Employment Requirements for Services Furnished Incident 

to Rural Health Clinics and Federally Qualified Health Center Visits 
 523 

This provision would remove the requirement that nonphysician RHC or FQHC 

practitioners be W-2 employees. This action would not require the modification of existing 

contracts or the creation of new contracts, nor does CMS collect any information on contracting. 

Consequently, the provision is not subject to the requirements under the Paperwork Reduction 

Act of 1995 (44 U.S.C. 3501 et seq.). 

2. ICRs Regarding Access to Identifiable Data for the Center for Medicare and Medicaid 

Models 

While this provision concerns the evaluation of 3021-funded models, section 3021(a) of 

the Affordable Care Act exempts any collection of information associated with the testing and 

evaluation or expansion of 3021-funded models from the requirements of the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

3. ICRs Regarding Molecular Diagnostic Testing Local Coverage Determination Process 

The information collection requirements and burden associated with the proposed LCD 

process for clinical diagnostic laboratory testing would not impose any new or revised reporting, 

recordkeeping, or third-party disclosure requirements and, therefore, does not require additional 

OMB review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et 

seq.). 

4. ICRs Regarding the Solicitation of Comments on the Payment Policy for Substitute Physician 

Billing Arrangements 

In this section of this preamble, we are soliciting public comments regarding substitute 

physician billing arrangements. Since we are not proposing any new or revised collection of 

information requirements, this section is not subject to the requirements under the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

5. Reports of Payments or Other Transfers of Value to Covered Recipients 
 524 

ICRs Regarding Reports of Payments or Other Transfers of Value and Physician Ownership and 

Investment Interests (§403.904(c)(8) (d)(3), and (g)) 

The proposed amendment of §403.904(c)(8) would require applicable manufacturers and 

applicable group purchasing organizations (GPOs) to report the marketed name of covered and 

non-covered drugs, devices, biologicals and medical supplies. This amendment would have nonmeasurable effect on current burden estimates since the manufacturers and GPOs are already 

required to report the marketed name for drugs and biologicals and report either the marketed 

name, therapeutic area, or product category for devices and medical supplies. This requirement 

has been approved by OMB under control number 0938-1173 

Section 403.904(d)(3) would require that applicable manufacturers and applicable GPOs 

report the form of payment or other transfers of value as: cash or cash equivalent, in-kind items 

or services, stock, stock option, or any other ownership investment. The burden associated with 

this provision is the time and effort it would take each applicable manufacturer and applicable 

GPO to revise their reporting system to report the form of payment. 

The proposed removal of § 403.904(g) would require applicable manufacturers and 

applicable GPOs of covered drugs, devices, biologicals, and medical supplies to report annually 

to CMS all payments or other transfers of value provided as compensation for speaking at a 

continuing education program. The ongoing burden associated with this provision is the time 

and effort it would take each applicable manufacturer and applicable GPO to report payments or 

other transfers of value to CMS which were provided to physicians at a continuing education 

program. We estimate that it will take 1.0 hour to report payments or other transfers of value to 

CMS which were provided to physician at a continuing education program. 

We estimate that it would take 1.0 hour to report payments or other transfers of value to 

CMS which were provided to physician covered recipients as compensation for speaking at a 
 525 

continuing education program and 0.5 hours to revise an applicable manufacturer or applicable 

GPO’s reporting system to report the form of payment. 

In deriving these figures, we used the following hourly labor rates and estimated the time 

to complete each task: $26.39/hr and 1.0 hours for support staff to report payments or other 

transfers of value to CMS which were provided to physician covered recipients as compensation 

for speaking at a continuing education program and $47.55/hr and 0.5 hours for support to revise 

their reporting system to report the form of payment. 

The preceding requirements and burden estimates will be added to the existing PRArelated requirements and burden estimates that have been approved by OMB under OCN 0938-

1173. 

6. ICRs Regarding Physician Payment, Efficiency, and Quality Improvements – Physician 

Quality Reporting System 

The annual burden estimate is calculated separately for the 2015 PQRS for: (1) 

individual eligible professionals and group practices using the claims (for eligible professionals 

only), (2) qualified registry and QCDR, (3) EHR-based reporting mechanisms, and (4) group 

practices using the group practice reporting option (GPRO). There is also a separate annual 

burden estimate for qualified registry and QCDR vendors who wish to be qualified to submit 

quality measures data. Please note that we are grouping group practices using the qualified 

registry and EHR-based reporting mechanisms with the burden estimate for individual eligible 

professionals using the qualified registry and EHR-based reporting mechanisms because we 

believe the criteria for satisfactory reporting for group practices using these 2 reporting 

mechanisms under the GPRO are similar to the satisfactory reporting criteria for eligible 

professionals using these reporting mechanisms. 
 526 

a. Burden Estimate for PQRS Reporting by Individual Eligible Professionals: Reporting in 

General 

According to the 2012 Reporting Experience, “more than 1.2 million eligible 

professionals were eligible to participate in the 2012 PQRS, Medicare Shared Savings Program, 

and Pioneer ACO Model.”14 In this burden estimate, we assume that 1.2 million eligible 

professionals, the same number of eligible professionals eligible to participate in the PQRS in 

2012, will be eligible to participate in the PQRS. Historically, the PQRS has never experienced 

100 percent participation in reporting for the PQRS. Therefore, we believe that although 1.2 

million eligible professionals will be subject to the 2017 PQRS payment adjustment, not all 

eligible participants will report quality measures data for purposes of the 2017 PQRS payment 

adjustment. In this burden estimate, we will only provide burden estimates for the eligible 

professionals and group practices who attempt to submit quality measures data for purposes of 

the 2017 PQRS payment adjustment. 

In 2012, 435,871 eligible professionals (36 percent of eligible professionals, including 

those who belonged to group practices that reported under the GPRO and eligible professionals 

within an ACO that participated in the PQRS via the Shared Savings Program or Pioneer ACO 

model) participated in the PQRS, Medicare Shared Savings Program, or Pioneer ACO Model.15 

We expect to see a significant increase in participation in reporting for the PQRS in 2015 than 

2012 as eligible professionals were not subject to a PQRS payment adjustment in 2012. Last 

year, we estimated that we would see a 50 percent participation rate in 2015. We still believe 

that a 14 percent increase in participation from 2012 is reasonable in 2015. Therefore, we 

estimate that 50 percent of eligible professionals (or approximately 600,000 eligible 

 

14 Centers for Medicare and Medicaid Services, 2012 Reporting Experience Including Trends (2007—2013): 

Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program, March 14, 2014, at xiii. 15 Id. at XV. 
 527 

professionals) will report quality measures data for purposes of the 2017 PQRS payment 

adjustment. 

With respect to the PQRS, the burden associated with the requirements of this voluntary 

reporting initiative is the time and effort associated with individual eligible professionals 

identifying applicable quality measures for which they can report the necessary information, 

selecting a reporting option, and reporting the information on their selected measures or 

measures group to CMS using their selected reporting option. 

We believe the labor associated with eligible professionals and group practices reporting 

quality measures data in the PQRS is primarily handled by an eligible professional’s or group 

practice’s billing clerk or computer analyst trained to report quality measures data. Therefore, 

we will consider the hourly wage of a billing clerk and computer analyst in our estimates. For 

purposes of this burden estimate, we assume that a billing clerk will handle the administrative 

duties associated with participating in the PQRS. According to information published by the 

Bureau of Labor Statistics, available at http://www.bls.gov/oes/current/oes433021.htm, the mean 

hourly wage for a billing clerk is approximately $16.00/hour. Therefore, for purposes of 

handling administrative duties, we estimate an average labor cost of $16.00/hour. In addition, 

for purposes of this burden estimate, we assume that a computer analyst will engage in the duties 

associated with the reporting of quality measures. According to information published by the 

Bureau of Labor Statistics, available at http://www.bls.gov/oes/current/oes151121.htm, the mean 

hourly wage for a computer analyst is approximately $41.00/hour. Therefore, for purposes of 

reporting on quality measures, we estimate an average labor cost of $41.00/hour. 

For individual eligible professionals, the burden associated with the requirements of this 

reporting initiative is the time and effort associated with eligible professionals identifying 

applicable quality measures for which they can report the necessary information, collecting the 
 528 

necessary information, and reporting the information needed to report the eligible professional’s 

measures. We believe it is difficult to accurately quantify the burden because eligible 

professionals may have different processes for integrating the PQRS into their practice’s work 

flows. Moreover, the time needed for an eligible professional to review the quality measures and 

other information, select measures applicable to his or her patients and the services he or she 

furnishes to them, and incorporate the use of quality data codes into the office work flows is 

expected to vary along with the number of measures that are potentially applicable to a given 

professional’s practice. Since eligible professionals are generally required to report on at least 9 

measures covering at least 3 National Quality Strategy domains criteria for satisfactory reporting 

(or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) for the 2017 PQRS 

payment adjustment, we assume that each eligible professional reports on an average of 9 

measures for this burden analysis. 

For eligible professionals who are participating in PQRS for the first time, we will assign 

5 total hours as the amount of time needed for an eligible professional’s billing clerk to review 

the PQRS measures list, review the various reporting options, select the most appropriate 

reporting option, identify the applicable measures or measures groups for which they can report 

the necessary information, review the measure specifications for the selected measures or 

measures groups, and incorporate reporting of the selected measures or measures groups into the 

office work flows. The measures list contains the measure title and brief summary information 

for the eligible professional to review. Assuming the eligible professional has received no 

training from his/her specialty society, we estimate it will take an eligible professional’s billing 

clerk up to 2 hours to review this list, review the reporting options, and select a reporting option 

and measures on which to report. If an eligible professional has received training, then we 

believe this would take less time. CMS believes 3 hours is plenty of time for an eligible 
 529 

professional to review the measure specifications of 9 measures or 1 measures group they select 

to report for purposes of participating in PQRS and to develop a mechanism for incorporating 

reporting of the selected measures or measures group into the office work flows. Therefore, we 

believe that the start-up cost for an eligible professional to report PQRS quality measures data is 

5 hours x $16/hour = $80. 

We continue to expect the ongoing costs associated with PQRS participation to decline 

based on an eligible professional’s familiarity with and understanding of the PQRS, experience 

with participating in the PQRS, and increased efforts by CMS and stakeholders to disseminate 

useful educational resources and best practices. 

We believe the burden associated with reporting the quality measures will vary 

depending on the reporting mechanism selected by the eligible professional. As such, we break 

down the burden estimates by eligible professionals and group practices participating in the 

GPRO according to the reporting mechanism used. 

b. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Claims-Based Reporting Mechanism 

According to the 2011 PQRS and eRx Experience Report, in 2011, 229,282 of the 

320,422 eligible professionals (or 72 percent) of eligible professionals used the claims-based 

reporting mechanism. According to the 2012 Reporting Experience, 248,206 eligible 

professionals participated in the PQRS using the claims-based reporting mechanism in 2012.16

 

Preliminary estimates show that 252,567 eligible professionals participated in the PQRS using 

the claims-based reporting mechanism in 2013.17

 

16 Id. at xvi. See Figure 4. 17 Id. 
 530 

According to the historical data cited above, while the claims-based reporting mechanism 

is still the most widely-used reporting mechanism, we are seeing a decline in the use of the 

claims-based reporting mechanism in the PQRS. While these eligible professionals continue to 

participate in the PQRS, these eligible professionals have started to shift towards the use of other 

reporting mechanisms – mainly the GPRO web interface (whether used by a PQRS GPRO or an 

ACO participating in the PQRS via the Medicare Shared Savings Program or the Pioneer ACO 

Model), registry, or the EHR-based reporting mechanisms. For purposes of this burden estimate, 

based on PQRS participation using the claims-based reporting mechanism in 2012 and 2013, we 

assume that approximately 250,000 eligible professionals will participate in the PQRS using the 

claims-based reporting mechanism. 

For the claims based reporting option, eligible professionals must gather the required 

information, select the appropriate quality data codes (QDCs), and include the appropriate QDCs 

on the claims they submit for payment. The PQRS will collect QDCs as additional (optional) 

line items on the existing HIPAA transaction 837 P and/or CMS form CMS-1500 ( OMB control 

number 0938-0999). We do not anticipate any new forms and or any modifications to the 

existing transaction or form. We also do not anticipate changes to the 837 P or CMS-1500 for 

CY 2015. 

We estimate the cost for an eligible professional to review the list of quality measures or 

measures groups, identify the applicable measures or measures group for which they can report 

the necessary information, incorporate reporting of the selected measures into the office work 

flows, and select a PQRS reporting option to be approximately $205 per eligible professional 

($41 per hour x 5 hours). 

Based on our experience with the Physician Voluntary Reporting Program (PVRP), we 

continue to estimate that the time needed to perform all the steps necessary to report each 
 531 

measure (that is, reporting the relevant quality data code(s) for 9 measures measure) would range 

from 15 seconds (0.25 minutes) to over 12 minutes for complicated cases and/or measures, with 

the median time being 1.75 minutes. To report 9 measures, we estimate that it would take 

approximately 2.25 minutes to 108 minutes to perform all of the necessary reporting steps. 

Per measure, at an average labor cost of $41/hour per practice, the cost associated with 

this burden will range from $0.17 to about $8.20 for more complicated cases and/or measures, 

with the cost for the median practice being $1.20. To report 9 measures, using an average labor 

cost of $41/hour, we estimated that the cost of reporting for an eligible professional via claims 

would range from $1.53 (2.25 minutes or 0.0375 hours x $41/hour) to $73.80 (108 minutes or 

1.8 hours x $41/hour) per reported case. 

The total estimated annual burden for this requirement will also vary along with the 

volume of claims on which quality data is reported. In previous years, when we required 

reporting on 80 percent of eligible cases for claims based reporting, we found that on average, 

the median number of reporting instances for each of the PQRS measures was 9. Since we 

reduced the required reporting rate by over one third to 50 percent, then for purposes of this 

burden analysis we assume that an eligible professional or eligible professional in a group 

practice will need to report each selected measure for 6 reporting instances. The actual number 

of cases on which an eligible professional or group practice is required to report quality measures 

data will vary, however, with the eligible professional's or group practice’s patient population 

and the types of measures on which the eligible professional or group practice chooses to report 

(each measure's specifications includes a required reporting frequency). 

Based on these assumptions, we estimate that the total annual reporting burden per 

individual eligible professional associated with claims based reporting will range from 13.5 

minutes (0.25 minutes per measure x 9 measures x 6 cases per measure) to 648 minutes (12 
 532 

minutes per measure x 9 measures x 6 cases per measure), with the burden to the median practice 

being 94.5 minutes (1.75 minutes per measure x 9 measures x 6 cases). We estimate the total 

annual reporting cost per eligible professional or eligible professional in a group practice 

associated with claims based reporting will range from $9.18 ($0.17 per measure x 9 measures x 

6 cases per measure) to $442.80 ($8.20 per measure x 9 measures x 6 cases per measure), with 

the cost to the median practice being $64.58 per eligible professional ($1.20 per measure x 9 

measures x 6 cases per measure). 

c. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Qualified Registry-based and QCDR-based Reporting Mechanisms 

In 2011, approximately 50,215 (or 16 percent) of the 320,422 eligible professionals 

participating in PQRS used the qualified registry-based reporting mechanism. According to the 

2012 Reporting Experience, 36,473 eligible professionals reported individual measures via the 

registry-based reporting mechanism, and 10,478 eligible professionals reporting measures groups 

via the registry-based reporting mechanism in 2012.18 Therefore, approximately 47,000 eligible 

professionals participated in the PQRS using the registry-based reporting mechanism in 2012. 

Please note that we currently have no data on participation in the PQRS via a QCDR as 2014 is 

the first year in which an eligible professional may participate in the PQRS via a QCDR. 

We believe that the rest of the eligible professionals not participating in other PQRS 

reporting mechanisms will use either the registry or QCDR reporting mechanisms for the 

following reasons: 

● The PQRS measures set is moving away from use of claims-based measures and 

moving towards the use of registry-based measures. 

 

18 Id. at xvi. See Figure 4. 
 533 

● We believe the number of QCDR vendors will increase as the QCDR reporting 

mechanism evolves. 

Therefore, based on these assumptions, we expect to see a significant jump from 47,000 

eligible professionals to approximately 165,000 eligible professionals using either the registrybased reporting mechanism or QCDR in 2015. We believe the majority of these eligible 

professionals will participate in the PQRS using a QCDR, as we presume QCDRs will be larger 

entities with more members. 

For qualified registry based and QCDR-based reporting, there will be no additional time 

burden for eligible professionals or group practices to report data to a qualified registry as 

eligible professionals and group practices opting for qualified registry based reporting or use of a 

QCDR will more than likely already be reporting data to the qualified registry for other purposes 

and the qualified registry will merely be repackaging the data for use in the PQRS. Little, if any, 

additional data will need to be reported to the qualified registry or QCDR solely for purposes of 

participation in the PQRS. However, eligible professionals and group practices will need to 

authorize or instruct the qualified registry or QCDR to submit quality measures results and 

numerator and denominator data on quality measures to CMS on their behalf. We estimate that 

the time and effort associated with this will be approximately 5 minutes per eligible professional 

or eligible professional within a group practice. 

Please note that, unlike the claims-based reporting mechanism that would require an 

eligible professional to report data to CMS on quality measures on multiple occasions, an 

eligible professional would not be required to submit this data to CMS, as the qualified registry 

or QCDR would perform this function on the eligible professional’s behalf. 

d. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: EHR-Based Reporting Mechanism 
 534 

According to the 2011 PQRS and eRx Experience Report, in 2011, 560 (or less than 1 

percent) of the 320,422 eligible professionals participating in PQRS used the EHR-based 

reporting mechanism. In 2012 there was a sharp increase in reporting via the EHR-based 

reporting mechanism. Specifically, according to the 2012 Reporting Experience, in 2012, 19,817 

eligible professionals submitted quality data for the PQRS through a qualified EHR.19

 

We believe the number of eligible professionals and group practices using the EHR-based 

reporting mechanism will steadily increase as eligible professionals become more familiar with 

EHR products and more eligible professionals participate in programs encouraging the use of an 

EHR, such as the EHR Incentive Program. In particular, we believe eligible professionals will 

transition from using the claims-based to the EHR-based reporting mechanism. To account for 

this anticipated increase, we continue to estimate that approximately 50,000 eligible 

professionals, whether participating as an individual or part of a group practice under the GPRO, 

would use the EHR-based reporting mechanism in CY 2015. 

For EHR-based reporting, which includes EHR reporting via a direct EHR product and an 

EHR data submission vendor’s product, the eligible professional or group practice must review 

the quality measures on which we will be accepting PQRS data extracted from EHRs, select the 

appropriate quality measures, extract the necessary clinical data from his or her EHR, and submit 

the necessary data to the CMS-designated clinical data warehouse. 

For EHR based reporting for the PQRS, the individual eligible professional or group 

practice may either submit the quality measures data directly to CMS from their EHR or utilize 

an EHR data submission vendor to submit the data to CMS on the eligible professional’s or 

group practice’s behalf. To submit data to CMS directly from their EHR, the eligible 

 

19 Id. at xv. 
 535 

professional or eligible professional in a group practice must have access to a CMS specified 

identity management system, such as IACS, which we believe takes less than 1 hour to obtain. 

Once an eligible professional or eligible professional in a group practice has an account for this 

CMS specified identity management system, he or she will need to extract the necessary clinical 

data from his or her EHR, and submit the necessary data to the CMS designated clinical data 

warehouse. With respect to submitting the actual data file for the respective reporting period, we 

believe that this will take an eligible professional or group practice no more than 2 hours, 

depending on the number of patients on which the eligible professional or group practice is 

submitting. We believe that once the EHR is programmed by the vendor to allow data 

submission to CMS, the burden to the eligible professional or group practice associated with 

submission of data on quality measures should be minimal as all of the information required to 

report the measure should already reside in the eligible professional's or group practice’s EHR. 

e. Burden Estimate for PQRS Reporting by Group Practices Using the GPRO Web Interface 

As we noted in last year’s estimate, according to the 2011 Experience Report, 

approximately 200 group practices participated in the GPRO in 2011. According to the 2012 

Reporting Experience, 66 practices participated in the PQRS GPRO.20 In addition, 144 ACOs 

participated in the PQRS GPRO through either the Medicare Shared Savings Program (112 

ACOs) or Pioneer ACO Model (32 practices).21 These group practices encompass 134,510 

eligible professionals (or approximately 140,000 eligible professionals).22 Since it seems that 

roughly 200 group practices participated in the GPRO in 2011 and 2012, based on these 

numbers, we assume that 200 group practices (accounting for approximately 135,000 eligible 

professionals) will participate in the PQRS using the GPRO web interface in 2015. 

 

20 Id. at xv. 21 Id. at xvi. 22 Id. at 18. 
 536 

With respect to the process for group practices to be treated as satisfactorily submitting 

quality measures data under the PQRS, group practices interested in participating in the PQRS 

through the GPRO must complete a self-nomination process similar to the self-nomination 

process required of qualified registries. However, since a group practice using the GPRO web 

interface would not need to determine which measures to report under PQRS, we believe that the 

self-nomination process is handled by a group practice’s administrative staff. Therefore, we 

estimate that the self-nomination process for the group practices for the PQRS involves 

approximately 2 hours per group practice to review the PQRS GPRO and make the decision to 

participate as a group rather than individually and an additional 2 hours per group practice to 

draft the letter of intent for self-nomination, gather the requested TIN and NPI information, and 

provide this requested information. It is estimated that each self-nominated entity will also 

spend 2 hours undergoing the vetting process with CMS officials. We assume that the group 

practice staff involved in the group practice self-nomination process has an average practice 

labor cost of $16 per hour. Therefore, assuming the total burden hours per group practice 

associated with the group practice self-nomination process is 6 hours, we estimate the total cost 

to a group practice associated with the group practice self-nomination process to be 

approximately $96 ($16 per hour x 6 hours per group practice). 

The burden associated with the group practice reporting requirements under the GPRO is 

the time and effort associated with the group practice submitting the quality measures data. For 

physician group practices, this would be the time associated with the physician group completing 

the web interface. We estimate that the time and effort associated with using the GPRO web 

interface will be comparable to the time and effort associated to using the PAT. As stated above, 

the information collection components of the PAT have been reviewed by OMB and are 

approved under OCN 0938-0941(form CMS-10136) with an expiration date of July 31, 2015, for 
 537 

use in the PGP, MCMP, and EHR demonstrations. As the GPRO was only recently implemented 

in 2010, it is difficult to determine the time and effort associated with the group practice 

submitting the quality measures data. As such, we will use the same burden estimate for group 

practices participating in the GPRO as we use for group practices participating in the PGP, 

MCMP, and EHR demonstrations. Since these changes will not have any impact on the 

information collection requirements associated with the PAT and we will be using the same data 

submission process used in the PGP demonstration, we estimate that the burden associated with a 

group practice completing data for PQRS under the web interface will be the same as for the 

group practice to complete the PAT for the PGP demonstration. In other words, we estimate 

that, on average, it will take each group practice 79 hours to submit quality measures data via the 

GPRO web interface at a cost of $40 per hour. Therefore, the total estimated annual cost per 

group practice is estimated to be approximately $3,160. 

7. ICRs Regarding the Medicare Shared Savings Program 

Section 3022 of the Affordable Care Act exempts any collection of information 

associated with the Medicare Shared Savings Program from the requirements of the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

B. Summary of Proposed Burden Estimates 

 Table 59 summarizes this rule’s proposed requirements and burden estimates. 

TABLE 59: Proposed Annual Recordkeeping and Reporting Requirements and Burden 

Regulation 

Section(s) 

OMB 

& 

CMS 

ID #s Respondents 

Responses 

(total) 

Burden 

(time) per 

Response 

Total 

Annual 

Burden 

(hours) 

Labor 

Cost of 

Reporting

($/hr) 

Total Cost 

($) 

403.904(d)(3) 0938-

1173 

(CMS10419 

1,150 

(manufacturers) 

1,150 1.0 hr 

(reporting) 

1,150 26.39 30,349 

0.5 hr 

(system 

upgrades) 

575 47.55 27,341 

420 (GPOs) 420 1.0 hr 

(reporting) 

420 26.39 11,084 
 538 

Regulation 

Section(s) 

OMB 

& 

CMS 

ID #s Respondents 

Responses 

(total) 

Burden 

(time) per 

Response 

Total 

Annual 

Burden 

(hours) 

Labor 

Cost of 

Reporting

($/hr) 

Total Cost 

($) 

0.5 hr 

(system 

upgrades) 

210 47.55 9,986 

CY 2015 

PQRS (start up 

for first time 

participants) 

0938-

1059 

(CMS10276) 

164,000 164,000 5 hr 820,000 16.00 13,120,000 

CY 2015 

PQRS 

(Claims-Based 

Reporting 

Mechanism) 

0938-

1059 

(CMS10276) 

250,000 250,000 

(preparation) 

5 hr 1,250,000 41.00 51,250,000 

13,500,000 

(reporting)* 

1.75 min 393,750 41.00 16,143,750 

CY 2015 

PQRS 

(Qualified 

Registry-based 

and QCDRbased 

Reporting 

Mechanisms) 

0938-

1059 

(CMS10276) 

165,000 165,000 5 min 13,750 N/A** N/A 

CY 2015 

PQRS (EHRBased 

Reporting 

Mechanism) 

0938-

1059 

(CMS10276) 

50,000 50,000 N/A*** N/A N/A N/A 

CY 2015 

PQRS (Group 

Practices 

Using the 

GPRO Web 

Interface) 

0938-

1059 

(CMS10276) 

200 200 (selfnomination 

process) 

6 hr 1,200 16.00 19,200 

200 

(reporting) 

79 hr 15,800 41.00 647,800 

TOTAL 630,770 14,130,970 -- 2,496,855 -- 81,259,510 

*13,500,000 = 250,000 x number of measures (9) x number of cases (6). 

**There is no set cost. As explained above, the cost would vary depending on the registry used. Additionally, many 

EPs and group practices using a registry or QCDR will most likely use a registry or QCDR for other purposes. 

***As explained above, the burden associated with the submission of data is minimal. 

C. Submission of PRA-Related Comments 

 We have submitted a copy of this proposed rule to OMB for its review of the rule’s 

information collection and recordkeeping requirements. These requirements are not effective 

until they have been approved by OMB. 
 539 

 To obtain copies of the supporting statement and any related forms for the proposed 

paperwork collections referenced above, access CMS’ website at 

http://www.cms.hhs.gov/PaperworkReductionActof1995; email your request, including your 

address, phone number, OMB number, and CMS document identifier, to 

Paperwork@cms.hhs.gov; or call the Reports Clearance Office at 410–786–1326. 

 We invite public comments on these potential information collection requirements. If 

you comment on these information collection and recordkeeping requirements, please submit 

your comments electronically as specified in the ADDRESSES section of this proposed rule. 

 PRA-specific comments must be received by September 2, 2014. 

V. Response to Comments 

Because of the large number of public comments we normally receive on Federal 

Register documents, we are not able to acknowledge or respond to them individually. We will 

consider all comments we receive by the date and time specified in the "DATES" section of this 

preamble, and, when we proceed with a subsequent document, we will respond to the comments 

in the preamble to that document. 
 540 

VI. Regulatory Impact Analysis 

A. Statement of Need 

 This proposed rule is necessary to make payment and policy changes under the Medicare 

PFS and to make required statutory changes under the Pathway for SGR Reform Act of 2013 and 

the PAMA. This proposed rule also is necessary to make changes to Part B payment policy for 

clinical diagnostic lab tests and other Part B related policies. 

B. Overall Impact 

We have examined the impact of this rule as required by Executive Order 12866 on 

Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving 

Regulation and Regulatory Review (February 2, 2013), the Regulatory Flexibility Act (RFA) 

(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, section 202 of 

the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 

13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of 

available regulatory alternatives and, if regulation is necessary, to select regulatory approaches 

that maximize net benefits (including potential economic, environmental, public health and 

safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be 

prepared for major rules with economically significant effects ($100 million or more in any 

1 year). We estimate, as discussed below in this section, that the PFS provisions included in this 

proposed rule will redistribute more than $100 million in 1 year. Therefore, we estimate that this 

rulemaking is "economically significant" as measured by the $100 million threshold, and hence 

also a major rule under the Congressional Review Act. Accordingly, we have prepared a RIA 

that, to the best of our ability, presents the costs and benefits of the rulemaking. The RFA 
 541 

requires agencies to analyze options for regulatory relief of small entities. For purposes of the 

RFA, small entities include small businesses, nonprofit organizations, and small governmental 

jurisdictions. Most hospitals, practitioners and most other providers and suppliers are small 

entities, either by nonprofit status or by having annual revenues that qualify for small business 

status under the Small Business Administration standards. (For details see the SBA's website at 

http://www.sba.gov/content/table-small-business-size-standards (refer to the 620000 series)). 

Individuals and States are not included in the definition of a small entity. 

The RFA requires that we analyze regulatory options for small businesses and other 

entities. We prepare a regulatory flexibility analysis unless we certify that a rule would not have 

a significant economic impact on a substantial number of small entities. The analysis must 

include a justification concerning the reason action is being taken, the kinds and number of small 

entities the rule affects, and an explanation of any meaningful options that achieve the objectives 

with less significant adverse economic impact on the small entities. 

Approximately 95 percent of practitioners, other providers and suppliers are considered 

to be small entities, based upon the SBA standards. There are over 1 million physicians, other 

practitioners, and medical suppliers that receive Medicare payment under the PFS. Because 

many of the affected entities are small entities, the analysis and discussion provided in this 

section as well as elsewhere in this proposed rule is intended to comply with the RFA 

requirements. 

In addition, section 1102(b) of the Act requires us to prepare an RIA if a rule may have a 

significant impact on the operations of a substantial number of small rural hospitals. This 

analysis must conform to the provisions of section 603 of the RFA. For purposes of section 

1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a 
 542 

Metropolitan Statistical Area for Medicare payment regulations and has fewer than 100 beds. 

We are not preparing an analysis for section 1102(b) of the Act because we have determined, and 

the Secretary certifies, that this proposed rule would not have a significant impact on the 

operations of a substantial number of small rural hospitals. 

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies 

assess anticipated costs and benefits on State, local, or tribal governments or on the private sector 

before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 

dollars, updated annually for inflation. In 2014, that threshold is approximately $141 million. 

This proposed rule would impose no mandates on state, local, or tribal governments or on the 

private sector. 

Executive Order 13132 establishes certain requirements that an agency must meet when it 

promulgates a proposed rule (and subsequent final rule) that imposes substantial direct 

requirement costs on State and local governments, preempts State law, or otherwise has 

Federalism implications. Since this regulation does not impose any costs on State or local 

governments, the requirements of Executive Order 13132 are not applicable. 

We have prepared the following analysis, which together with the information provided 

in the rest of this preamble, meets all assessment requirements. The analysis explains the 

rationale for and purposes of this proposed rule; details the costs and benefits of the rule; 

analyzes alternatives; and presents the measures we would use to minimize the burden on small 

entities. As indicated elsewhere in this proposed rule, we are proposing to implement a variety 

of changes to our regulations, payments, or payment policies to ensure that our payment systems 

reflect changes in medical practice and the relative value of services, and to implement statutory 

provisions. We provide information for each of the policy changes in the relevant sections of 
 543 

this proposed rule. We are unaware of any relevant Federal rules that duplicate, overlap, or 

conflict with this proposed rule. The relevant sections of this proposed rule contain a description 

of significant alternatives if applicable. 

C. Changes in Relative Value Unit (RVU) Impacts 

1. Resource-Based Work, PE, and MP RVUs 

Section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or decreases in RVUs may 

not cause the amount of expenditures for the year to differ by more than $20 million from what 

expenditures would have been in the absence of these changes. If this threshold is exceeded, we 

make adjustments to preserve budget neutrality. 

Our estimates of changes in Medicare revenues for PFS services compare payment rates 

for CY 2014 with proposed payment rates for CY 2015 using CY 2013 Medicare utilization. 

The payment impacts in this proposed rule reflect averages by specialty based on Medicare 

utilization. The payment impact for an individual physician could vary from the average and 

would depend on the mix of services the practitioner furnishes. The average percentage change 

in total revenues would be less than the impact displayed here because practitioners and other 

entities generally furnish services to both Medicare and non-Medicare patients. In addition, 

practitioners and other entities may receive substantial Medicare revenues for services under 

other Medicare payment systems. For instance, independent laboratories receive approximately 

83 percent of their Medicare revenues from clinical laboratory services that are paid under the 

Clinical Lab Fee Schedule. 

The annual update to the PFS conversion factor (CF) is calculated based on a statutory 

formula that measures actual versus allowed or “target” expenditures, and applies a sustainable 

growth rate (SGR) calculation intended to control growth in aggregate Medicare expenditures for 
 544 

physicians’ services. This update methodology is typically referred to as the “SGR” 

methodology, although the SGR is only one component of the formula. Medicare PFS payments 

for services are not withheld if the percentage increase in actual expenditures exceeds the SGR. 

Rather, the PFS update, as specified in section 1848(d)(4) of the Act, is adjusted to eventually 

bring actual expenditures back in line with targets. If actual expenditures exceed allowed 

expenditures, the update is reduced. If actual expenditures are less than allowed expenditures, 

the update is increased. We provide our most recent estimate of the SGR and physician update 

for CY 2015 on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/. 

The PAMA has replaced the reduction in the PFS update that would otherwise occur on 

January 1, 2015 with a zero percent update from January 1, 2015 to March 31, 2015. We 

estimate that, based upon the zero percent update and the adjustments necessary to maintain 

budget neutrality for the policies in this proposed rule the CF for this period will be $35.7977. 

Although the PAMA provides for a zero percent update for only the first 3 months of the year, 

the impacts in this proposed rule are based upon this CF being applicable throughout the year. 

However, in the absence of further Congressional action, the applicable update for the remainder 

of the year will be based on the statutory SGR formula and the CF will be adjusted accordingly. 

By law, we are required to apply these updates in accordance with sections 1848(d) and 

(f) of the Act, and any negative updates can only be averted by an Act of the Congress. While 

the Congress has provided temporary relief from negative updates for every year since 2003, a 

long-term solution is critical. We are committed to working with the Congress to permanently 

reform the SGR methodology for Medicare PFS updates. 
 545 

Table 60 shows the payment impact on PFS services of the proposals contained in this 

proposed rule. To the extent that there are year-to-year changes in the volume and mix of 

services provided by practitioners, the actual impact on total Medicare revenues will be different 

from those shown in Table 60 (CY 2015 PFS Proposed Rule Estimated Impact on Total Allowed 

Charges by Specialty). The following is an explanation of the information represented in 

Table 60: 

● Column A (Specialty): Identifies the specialty for which data is shown. 

● Column B (Allowed Charges): The aggregate estimated PFS allowed charges for the 

specialty based on CY 2013 utilization and CY 2014 rates. That is, allowed charges are the PFS 

amounts for covered services and include coinsurance and deductibles (which are the financial 

responsibility of the beneficiary). These amounts have been summed across all services 

furnished by physicians, practitioners, and suppliers within a specialty to arrive at the total 

allowed charges for the specialty. 

● Column C (Impact of Work RVU Changes): This column shows the estimated CY 

2015 impact on total allowed charges of the proposed changes in the work RVUs, including the 

impact of changes due to potentially misvalued codes. 

● Column D (Impact of PE RVU Changes): This column shows the estimated CY 2014 

impact on total allowed charges of the proposed changes in the PE RVUs. 

● Column E (Impact of RVU Changes): This column shows the estimated CY 2015 

impact on total allowed charges of the proposed changes in the MP RVUs, which are primarily 

driven by the required five-year review and update of MP RVUs. 
 546 

● Column F (Combined Impact): This column shows the estimated CY 2015 combined 

impact on total allowed charges of all the proposed changes in the previous columns. Column F 

may not equal the sum of columns C, D, and E due to rounding. 

TABLE 60: CY 2015 PFS Proposed Rule Estimated Impact on Total Allowed Charges by 

Specialty* 

(A) 

Specialty

(B) 

Allowed 

Charges 

(mil)

(C) 

Impact 

of Work 

RVU 

Changes

(D) 

Impact 

of PE 

RVU 

Changes

(E) 

Impact 

of MP 

RVU 

Changes

(F) 

Combined 

Impact**

TOTAL $87,374 0% 0% 0% 0%

ALLERGY/IMMUNOLOGY $215 0% 0% 0% 0%

ANESTHESIOLOGY $1,979 0% 0% 0% 0%

AUDIOLOGIST $60 0% 0% -1% -1%

CARDIAC SURGERY $351 0% 0% -1% -1%

CARDIOLOGY $6,420 0% 0% 0% 1%

CHIROPRACTOR $803 0% 0% -1% -1%

CLINICAL PSYCHOLOGIST $695 0% -1% 0% -1%

CLINICAL SOCIAL WORKER $514 0% -1% 0% -1%

COLON AND RECTAL SURGERY $158 0% 0% 0% 0%

CRITICAL CARE $285 0% 0% 0% 1%

DERMATOLOGY $3,162 0% 0% 0% 0%

DIAGNOSTIC TESTING FACILITY $705 0% -2% 0% -2%

EMERGENCY MEDICINE $3,024 0% 0% 1% 1%

ENDOCRINOLOGY $455 0% 0% 0% 0%

FAMILY PRACTICE $6,061 1% 1% 0% 2%

GASTROENTEROLOGY $1,875 0% 0% 0% 0%

GENERAL PRACTICE $498 0% 0% 0% 0%

GENERAL SURGERY $2,222 0% 0% 0% 0%

GERIATRICS $224 1% 1% 0% 1%

HAND SURGERY $159 0% 0% 0% 0%

HEMATOLOGY/ONCOLOGY $1,803 0% 1% 0% 1%

INDEPENDENT LABORATORY $703 0% 3% 0% 3%

INFECTIOUS DISEASE $647 0% 0% 0% 1%

INTERNAL MEDICINE $11,026 1% 1% 0% 2%

INTERVENTIONAL PAIN MGMT $672 0% 1% 0% 1%

INTERVENTIONAL RADIOLOGY $270 0% -1% 0% -1%

MULTISPECIALTY CLINIC/OTHER $83 0% 0% 0% 1%
 547 

(A) 

Specialty

(B) 

Allowed 

Charges 

(mil)

(C) 

Impact 

of Work 

RVU 

Changes

(D) 

Impact 

of PE 

RVU 

Changes

(E) 

Impact 

of MP 

RVU 

Changes

(F) 

Combined 

Impact**

PHY 

NEPHROLOGY $2,167 0% 0% 0% 0%

NEUROLOGY $1,502 0% 0% 0% 0%

NEUROSURGERY $733 0% 0% 1% 1%

NUCLEAR MEDICINE $48 0% 0% 0% 1%

NURSE ANES / ANES ASST $1,177 0% 0% 0% 0%

NURSE PRACTITIONER $2,201 0% 0% 0% 1%

OBSTETRICS/GYNECOLOGY $690 0% 0% 0% 0%

OPHTHALMOLOGY $5,663 0% 0% -2% -2%

OPTOMETRY $1,152 0% 1% -1% 0%

ORAL/MAXILLOFACIAL SURGERY $44 0% 0% 0% 0%

ORTHOPEDIC SURGERY $3,649 0% 0% 0% 0%

OTHER $27 0% 0% -1% -1%

OTOLARNGOLOGY $1,167 0% 0% 0% 0%

PATHOLOGY $1,067 0% 1% 0% 1%

PEDIATRICS $58 0% 0% 0% 0%

PHYSICAL MEDICINE $998 0% 0% 0% 0%

PHYSICAL/OCCUPATIONAL 

THERAPY $2,806 0% 0% 1% 1%

PHYSICIAN ASSISTANT $1,553 0% 0% 0% 1%

PLASTIC SURGERY $368 0% 0% -1% 0%

PODIATRY $1,979 0% 0% 0% 0%

PORTABLE X-RAY SUPPLIER $109 0% -3% 0% -3%

PSYCHIATRY $1,330 0% 0% 0% 0%

PULMONARY DISEASE $1,784 0% 0% 0% 0%

RADIATION ONCOLOGY $1,796 0% -4% 0% -4%

RADIATION THERAPY CENTERS $60 0% -8% 0% -8%

RADIOLOGY $4,497 0% -1% 0% -2%

RHEUMATOLOGY $538 0% 0% 0% 0%

THORACIC SURGERY $340 0% 0% 0% 0%

UROLOGY $1,829 0% 0% 0% 0%

VASCULAR SURGERY $970 0% 0% 0% 1%

*Table 60 shows only the payment impact on PFS services and does not include the effects of the change 

in the CF scheduled to occur on April 1, 2015 under current law. 

** Column F may not equal the sum of columns C, D, and E due to rounding. 
 548 

2. CY 2015 PFS Impact Discussion 

a. Work RVU Impacts 

 The changes in work RVU impacts are almost entirely attributable to the payment for 

CCM services beginning in CY 2015. We finalized this separately billable CCM service in the 

CY 2014 final rule with comment period, effective beginning in CY 2015 (78 FR 74414 through 

74427). We propose a payment rate for CCM services for CY 2015 in this proposed rule. 

Payment for this service at the proposed rate is expected to result in modest payment increases 

for family practice, internal medicine, and geriatrics. 

b. PE RVU Impacts 

Payment for CCM services also has a positive impact on the PE RVUs attributable to 

family practice, internal medicine, and geriatrics. The most widespread specialty impacts in PE 

RVUs are generally related to our proposal to implement the RUC recommendation regarding 

the film-to-digital migration of imaging inputs, which primarily affects portable x-ray suppliers, 

diagnostic testing facilities, and interventional radiology. Radiation oncology and radiation 

treatment centers are negatively impacted by our proposal to treat radiation treatment vaults as 

indirect PE rather than direct PEs. Other impacts result from adjustments of PE RVUs for 

services as discussed in section II.B. 

c. MP RVU Impacts 

The changes in MP RVUs are primarily attributable to proposed changes as part of the 

statutorily required review of MP RVUs every five years as described in section II.C of this 

proposed rule. Of particular note are the impacts on the specialties of ophthalmology (-2 

percent) and optometry (-1 percent). In the course of preparation of the proposed MP RVUs, we 

discovered that we had made an error in calculating the MP RVUs for ophthalmology codes in 
 549 

the last five-year review CY that resulted in higher MP RVUs for ophthalmology and 

optometry for CY 2010 than would have resulted had the MP RVUs been calculated correctly. 

d. Combined Impact 

 Column F of Table 60 displays the estimated CY 2015 combined impact on total allowed 

charges by specialty of all the proposed RVU changes. These impacts are estimated prior to the 

application of the negative CF update effective April 1, 2015, applicable under the current 

statute. 

Table 61 (Impact of Proposed Rule on CY 2015 Payment for Selected Procedures) shows the 

estimated impact on total payments for selected high volume procedures of all of the proposed 

changes. We have included proposed payment rates for the period of January 1, 2015 through 

March 31, 2015, as well as those for April 1, 2015 through December 31, 2015. We selected 

these procedures for sake of illustration from among the most commonly furnished by a broad 

spectrum of specialties. The change in both facility rates and the nonfacility rates are shown. 

For an explanation of facility and nonfacility PE, we refer readers to Addendum A of this 

proposed rule. 
 550 

TABLE 61: Impact of Proposed Rule on CY 2015 Payment for Selected Procedures 

(Based on the March 2014 Preliminary Physician Update) 

 Facility Non-Facility

CPT1/ 

HCPCS MOD Short Descriptor CY 20142

CY 2015 

 Jan 1- 

March 313

% 

Change CY 20142

CY 2015 

Jan 1- 

March 

313

% 

Change 

11721 Debride nail 6 or more $25.43 $25.42 0% $45.14 $45.46 1%

17000 Destruct premalg lesion $53.38 $52.98 -1% $75.23 $74.82 -1%

27130 Total hip arthroplasty $1,394.94 $1397.90 0% NA NA NA

27244 Treat thigh fracture $1,261.68 $1,269.03 1% NA NA NA

27447 Total knee arthroplasty $1,394.22 $1,397.54 0% NA NA NA

33533 Cabg arterial single $1,955.92 $1,930.93 -1% NA NA NA

35301 Rechanneling of artery $1,200.42 $1,189.92 -1% NA NA NA

43239 Egd biopsy single/multiple $152.25 $151.78 0% $405.51 $408.81 1%

66821 After cataract laser surgery $324.55 $314.66 -3% $342.47 $333.28 -3%

66984 Cataract surg w/iol 1 stage $673.11 $647.22 -4% NA NA NA

67210 Treatment of retinal lesion $523.37 $506.18 -3% $540.92 $523.36 -3%

71010 Chest x-ray 1 view frontal NA NA NA $24.00 $22.55 -6%

71010 26 Chest x-ray 1 view frontal $9.31 $9.31 0% $9.31 $9.31 0%

77056 Mammogram both breasts NA NA NA $116.07 $164.31 42%

77056 26 Mammogram both breasts $44.42 $43.67 -2% $44.42 $43.67 -2%

77057 Mammogram screening NA NA NA $82.75 $134.96 63%

77057 26 Mammogram screening $35.82 $35.08 -2% $35.82 $35.08 -2%

77427 Radiation tx management x5 $186.28 $189.01 1% $186.28 $189.01 1%

88305 26 Tissue exam by pathologist $38.33 $38.30 0% $38.33 $38.30 0%

90935 Hemodialysis one evaluation $73.44 $73.39 0% NA NA NA

92012 Eye exam establish patient $54.81 $52.98 -3% $87.05 $85.56 -2%

92014 Eye exam&tx estab pt 1/>vst $82.75 $80.54 -3% $126.10 $124.22 -1%

93000 Electrocardiogram complete NA NA NA $16.84 $17.18 2%

93010 Electrocardiogram report $8.60 $8.59 0% $8.60 $8.59 0%

93015 Cardiovascular stress test NA NA NA $75.94 $76.61 1%
 551 

 Facility Non-Facility

CPT1/ 

HCPCS MOD Short Descriptor CY 20142

CY 2015 

 Jan 1- 

March 313

% 

Change CY 20142

CY 2015 

Jan 1- 

March 

313

% 

Change 

93307 26 Tte w/o doppler complete $45.85 $46.18 1% $45.85 $46.18 1%

93458 26 L hrt artery/ventricle angio $325.63 $320.03 -2% $325.63 $320.03 -2%

98941 Chiropract manj 3-4 regions $35.46 $35.08 -1% $41.55 $41.17 -1%

99203 Office/outpatient visit new $77.02 $77.32 0% $108.18 $108.47 0%

99213 Ofice/outpatient visit est $51.58 $51.55 0% $73.08 $73.39 0%

99214 Office/outpatient visit est $79.17 $79.11 0% $107.83 $108.11 0%

99222 Initial hospital care $138.63 $138.18 0% NA NA NA

99223 Initial hospital care $204.19 $204.40 0% NA NA NA

99231 Subsequent hospital care $39.41 $39.38 0% NA NA NA

99232 Subsequent hospital care $72.36 $73.03 1% NA NA NA

99233 Subsequent hospital care $104.24 $104.89 1% NA NA NA

99236 Observ/hosp same date $219.24 $219.80 0% NA NA NA

99239 Hospital discharge day $107.47 $108.47 1% NA NA NA

99283 Emergency dept visit $61.97 $62.29 1% NA NA NA

99284 Emergency dept visit $118.22 $119.21 1% NA NA NA

99291 Critical care first hour $224.61 $225.53 0% $274.76 $276.72 1%

99292 Critical care addl 30 min $112.48 $112.76 0% $123.23 $123.86 1%

99348 Home visit est patient NA NA NA $84.54 $84.48 0%

99350 Home visit est patient NA NA NA $178.40 $177.91 0%

G0008 Immunization admin NA NA NA $25.08 $25.42 1%

1

CPT codes and descriptions are copyright 2013 American Medical Association. All Rights Reserved. Applicable 

FARS/DFARS apply. 

2

The CY 2014 CF is $35.8228. 

3 Payments based on the CY 2014 CF of $35.8228, adjusted to $35.7977 to include the budget neutrality adjustment 

and the zero percent update in the CF required by PAMA.

 
 552 

D. Effect of Proposed Changes in Telehealth List 

 As discussed in section II.E. of this proposed rule, we are proposing to add several new 

codes to the list of Medicare telehealth services. Although we expect these changes to increase 

access to care in rural areas, based on recent utilization of similar services already on the 

telehealth list, we estimate no significant impact on PFS expenditures from the proposed 

additions. 

E. Effect of Proposed Changes in Geographic Practice Cost Indices (GPCIs) 

As discussed in section II.D of this proposed rule, we are required to review and revise 

the GPCIs at least every 3 years and phase in the adjustment over 2 years (if there has not been 

an adjustment in the past year). For CY 2015, we are not proposing any revisions related to the 

data or the methodologies used to calculate the GPCIs except in regard to the Virgin Islands 

locality discussed in section II.E. However, since the 1.0 work GPCI floor provided in section 

1848(e)(1)(E) of the Act is set to expire on March 31, 2015, we have included two set of GPCIs 

and GAFs for CY 2015 – one set for January 1, 2015 through March 31, 2015 and another set for 

April 1, 2015 through December 31, 2015. The April 1, 2015 through December 31, 2015 

GPCIs and GAFs reflect the statutory expiration of the 1.0 work GPCI floor. 

F. Other Provisions of the Proposed Regulation 

1. Ambulance Fee Schedule 

The statutory ambulance extender provisions are self-implementing. As a result, there 

are no policy proposals associated with these provisions or associated impact in this rule. We are 

proposing only to correct the dates in the Code of Federal Regulations (CFR) at 42 CFR 

414.610(c)(1)(ii) and 42 CFR 414.610(c)(5)(ii) to conform the regulations to these selfimplementing statutory provisions. 

The geographic designations for approximately 99.48 percent of ZIP codes would be 
 553 

unchanged if we adopt OMB’s revised statistical area delineations and the updated RUCA codes. 

There are a similar number of ZIP codes that would change from rural to urban (122, or 0.28 

percent) and from urban to rural (100, or 0.23 percent). In general, if we adopt OMB’s revised 

delineations and the updated RUCA codes, it is expected that ambulance providers and suppliers 

in 100 ZIP codes within 11 states may experience payment increases while ambulance providers 

and suppliers in 122 ZIP codes within 22 states may experience payment decreases. None of the 

current “Super Rural Bonus” areas would lose their status if we adopt the revised OMB 

delineations and the updated RUCA codes. We estimate that the adoption of the revised OMB 

delineations and the updated RUCA codes would have minimal fiscal impact on the Medicare 

program because payments would, in effect, be redistributed. 

2. Clinical Laboratory Fee Schedule 

 There is no impact because we are merely deleting language from the Code of Federal 

Regulations. 

3. Removal of Employment Requirements for Services Furnished “Incident to” RHC and 

FQHC Visits 

 The removal of employment requirements for services furnished “incident to” RHC and 

FQHC visits will provide RHCs and FQHCs with greater flexibility in meeting their staffing 

needs, which may result in increasing access to care in underserved areas. There is no cost to the 

federal government, and we cannot estimate a cost savings for RHCs or FQHCs. 

4. Access to Identifiable Data for the Center for Medicare and Medicaid Models 

 Given that, in general, participants in Innovation Center models receive funding support 

to participate in model tests, we do not anticipate an impact. 

5. Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests 

 The Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests in 
 554 

section III.F of this proposed rule would not impact CY 2015 physician payments under the PFS. 

6. Private Contracting/Opt Out 

 We are correcting cross-references and outdated terminology in the regulations that we 

inadvertently neglected to revise, and proposing a change in the appeals process to be used for 

certain appeals relating to opt-out private contracting. We anticipate no or minimal impact as a 

result of these corrections. 

7. Payment Policy for Locum Tenens Physicians 

 We are soliciting public comments regarding substitute physician billing arrangements. 

Since we are not proposing any new or revised requirements, there is no impact. 

8. Reports of Payments or Other Transfers of Value to Covered Recipients 

The changes to the Transparency Reports and Reporting of Physician Ownership or 

Investment Interests in section III.I of this proposed rule would not impact CY 2015 physician 

payments under the PFS. 

9. Physician Compare 

There will be no impact for the Physician Compare website because we are not collecting 

any information for the Physician Compare website. 

10. Physician Quality Reporting System 

According to the 2012 Reporting Experience, “more than 1.2 million eligible 

professionals were eligible to participate in the 2012 PQRS, Medicare Shared Savings Program, 

and Pioneer ACO Model.”23 In this burden estimate, we assume that 1.2 million eligible 

professionals, the same number of eligible professionals eligible to participate in the PQRS in 

2012, will be eligible to participate in the PQRS. Since all eligible professionals are subject to 

 

23 Centers for Medicare and Medicaid Services, 2012 Reporting Experience Including Trends (2007—2013): 

Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program, March 14, 2014, at xiii. 
 555 

the 2017 PQRS payment adjustment, we estimate that all 1.2 million eligible professionals will 

participate, participate (which includes, for the purposes of this discussion, being eligible for the 

2017 PQRS payment adjustment) in the PQRS in 2015 for purposes of meeting the criteria for 

satisfactory reporting (or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) 

for the 2017 PQRS payment adjustment. 

Historically, the PQRS has never experienced 100 percent participation in reporting for 

the PQRS. Therefore, we believe that although 1.2 million eligible professionals will be subject 

to the 2017 PQRS payment adjustment, not all eligible participants will actually report quality 

measures data for purposes of the 2017 PQRS payment adjustment. In this burden estimate, we 

will only provide burden estimates for the eligible professionals and group practices who attempt 

to submit quality measures data for purposes of the 2017 PQRS payment adjustment. In 2012, 

435,871 eligible professionals (36 percent) eligible professionals (including those who belonged 

to group practices that reported under the GPRO and eligible professionals within an ACO that 

participated in the PQRS via the Shared Savings Program or Pioneer ACO Model) participated in 

the PQRS, Medicare Shared Savings Program, or Pioneer ACO Model.24 We expect to see a 

significant increase in participation in reporting for the PQRS in 2015 than 2012 as eligible 

professionals were not subject to a PQRS payment adjustment in 2012. Last year, we estimated 

that we would see a 50 percent participation rate in 2015. We still believe that a 14 percent 

increase in participation from 2012 is reasonable in 2015. Therefore, we estimate that 50 percent 

of eligible professionals (or approximately 600,000 eligible professionals) will report quality 

measures data for purposes of the 2017 PQRS payment adjustment. 

For participation in the PQRS using the claims-based reporting mechanism, according to 

the 2011 PQRS and eRx Experience Report, in 2011, 229,282 of the 320,422 eligible 

 

24 Id. at XV. 
 556 

professionals (or 72 percent) of eligible professionals used the claims-based reporting 

mechanism. According to the 2012 Reporting Experience, 248,206 eligible professionals 

participated in the PQRS using the claims-based reporting mechanism in 2012.25 Preliminary 

estimates show that 252,567 eligible professionals participated in the PQRS using the claimsbased reporting mechanism in 2013.26 According to the historical data cited above, although the 

claims-based reporting mechanism is still the most widely-used reporting mechanism, we are 

seeing a decline in the use of the claims-based reporting mechanism in the PQRS. Although 

these eligible professionals continue to participate in the PQRS, these eligible professionals have 

started to shift towards the use of other reporting mechanisms – mainly the GPRO web interface 

(whether used by a PQRS GPRO or an ACO participating in the PQRS via the Medicare Shared 

Savings Program or Pioneer ACO model), registry, or the EHR-based reporting mechanisms. 

For purposes of this burden estimate, based on PQRS participation using the claims-based 

reporting mechanism in 2012 and 2013, we will assume that approximately 250,000 eligible 

professionals will participate in the PQRS using the claims-based reporting mechanism. 

For participation in the PQRS using a qualified registry or QCDR, in 2011, 

approximately 50,215 (or 16 percent) of the 320,422 eligible professionals participating in PQRS 

used the qualified registry-based reporting mechanism. According to the 2012 Reporting 

Experience, 36,473 eligible professionals reported individual measures via the registry-based 

reporting mechanism, and 10,478 eligible professionals reporting measures groups via the 

registry-based reporting mechanism in 2012.27 Therefore, approximately 47,000 eligible 

professionals participated in the PQRS using the registry-based reporting mechanism in 2012. 

Please note that we currently have no data on participation in the PQRS via a QCDR as 2014 is 

 

25 Id. at xvi. See Figure 4. 26 Id. 27 Id. at xvi. See Figure 4. 
 557 

the first year in which an eligible professional may participate in the PQRS via a QCDR. We 

believe that the rest of the eligible professionals not participating in other PQRS reporting 

mechanisms will use either the registry or QCDR reporting mechanisms for the following 

reasons: (1) the PQRS measures set is moving away from use of claims-based measures and 

moving towards the use of registry-based measures; or (2) we believe the number of QCDR 

vendors will increase as the QCDR reporting mechanism evolves. Therefore, based on these 

assumptions, we expect to see a significant jump from 47,000 eligible professionals to 

approximately 165,000 eligible professionals using either the registry-based reporting 

mechanism or QCDR in 2015. We believe the majority of these eligible professionals will 

participate in the PQRS using a QCDR, as we presume QCDRs will be larger entities with more 

members. 

For participation in the PQRS using the EHR-based reporting mechanism, according to 

the 2011 PQRS and eRx Experience Report, in 2011, 560 (or less than 1 percent) of the 320,422 

eligible professionals participating in PQRS used the EHR-based reporting mechanism. 2012 

saw a sharp increase in reporting via the EHR-based reporting mechanism. Specifically, 

according to the 2012 Reporting Experience, in 2012, 19,817 eligible professionals submitted 

quality data for the PQRS through a qualified EHR.28 We believe the number of eligible 

professionals and group practices using the EHR-based reporting mechanism will steadily 

increase as eligible professionals become more familiar with EHR products and more eligible 

professionals participate in programs encouraging use of an EHR, such as the EHR Incentive 

Program. In particular, we believe eligible professionals will transition from using the claimsbased to the EHR-based reporting mechanisms. To account for this anticipated increase, we 

 

28 Id. at xv. 
 558 

continue to estimate that approximately 50,000 eligible professionals, whether participating as an 

individual or part of a group practice under the GPRO, would use the EHR-based reporting 

mechanism in CY 2015. 

For participation in the PQRS using the GPRO web interface, as we noted in last year’s 

estimate, according to the 2011 Experience Report, approximately 200 group practices 

participated in the GPRO in 2011. According to the 2012 Reporting Experience, 66 practices 

participated in the PQRS GPRO.29 In addition, 144 ACOs participated in the PQRS GPRO 

through either the Medicare Shared Savings Program (112 ACOs) or Pioneer ACO Model (32 

practices).30 These group practices encompass 134,510 eligible professionals (or approximately 

140,000 eligible professionals).31 Since it seems that roughly 200 group practices participated in 

the GPRO in 2011 and 2012, based on these numbers, we will assume that 200 group practices 

(accounting for approximately 135,000 eligible professionals) will participate in the PQRS using 

the GPRO web interface in 2015. 

Please note that, while we are proposing the reporting of CAHPS survey measures using 

a CMS-certified survey vendor, we are not including this reporting mechanism in this impact 

statement as we believe that eligible professionals wishing to report CAHPS survey measures 

will do so for purposes other than the PQRS. 

(a) Assumptions for Burden Estimates 

For the PQRS, the burden associated with the requirements of this voluntary reporting 

initiative is the time and effort associated with individual eligible professionals identifying 

applicable quality measures for which they can report the necessary information, selecting a 

 

29 Id. at xv. 30 Id. at xvi. 31 Id. at 18. 
 559 

reporting option, and reporting the information on their selected measures or measures group to 

CMS using their selected reporting option. 

We believe the labor associated with eligible professionals and group practices reporting 

quality measures data in the PQRS is primarily handled by an eligible professional’s or group 

practice’s billing clerk or computer analyst trained to report quality measures data. Therefore, 

we will consider the hourly wage of a billing clerk and computer analyst in our estimates. For 

purposes of this burden estimate, we will assume that a billing clerk will handle the 

administrative duties associated with participating in the PQRS. According to information 

published by the Bureau of Labor Statistics, available at 

http://www.bls.gov/oes/2013/may/oes433021.htm, the mean hourly wage for a billing clerk is 

approximately $16.80/hour. Therefore, for purposes of handling administrative duties, we 

estimate an average labor cost of $16.00/hour. In addition, for purposes of this burden estimate, 

we will assume that a computer analyst will engage in the duties associated with the reporting of 

quality measures. According to information published by the Bureau of Labor Statistics, 

available at http://www.bls.gov/oes/2013/may/oes151121.htm, the mean hourly wage for a 

computer analyst is approximately $41.00/hour. Therefore, for purposes of reporting on quality 

measures, we estimate an average labor cost of $41.00/hour. 

For individual eligible professionals, the burden associated with the requirements of this 

reporting initiative is the time and effort associated with eligible professionals identifying 

applicable quality measures for which they can report the necessary information, collecting the 

necessary information, and reporting the information needed to report the eligible professional’s 

measures. We believe it is difficult to accurately quantify the burden because eligible 

professionals may have different processes for integrating the PQRS into their practice’s work 

flows. Moreover, the time needed for an eligible professional to review the quality measures and 
 560 

other information, select measures applicable to his or her patients and the services he or she 

furnishes to them, and incorporate the use of quality data codes into the office work flows is 

expected to vary along with the number of measures that are potentially applicable to a given 

professional’s practice. Since eligible professionals are generally required to report on at least 9 

measures covering at least 3 National Quality Strategy domains criteria for satisfactory reporting 

(or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) for the 2017 PQRS 

payment adjustment, we will assume that each eligible professional reports on an average of 9 

measures for this burden analysis. 

For eligible professionals who are participating in PQRS for the first time, we will assign 

5 total hours as the amount of time needed for an eligible professional’s billing clerk to review 

the PQRS Measures List, review the various reporting options, select the most appropriate 

reporting option, identify the applicable measures or measures groups for which they can report 

the necessary information, review the measure specifications for the selected measures or 

measures groups, and incorporate reporting of the selected measures or measures groups into the 

office work flows. The measures list contains the measure title and brief summary information 

for the eligible professional to review. Assuming the eligible professional has received no 

training from his/her specialty society, we estimate it will take an eligible professional’s billing 

clerk up to 2 hours to review this list, review the reporting options, and select a reporting option 

and measures on which to report. If an eligible professional has received training, then we 

believe this would take less time. We believe 3 hours is plenty of time for an eligible 

professional to review the measure specifications of 9 measures or 1 measures group they select 

to report for purposes of participating in PQRS and to develop a mechanism for incorporating 

reporting of the selected measures or measures group into the office work flows. Therefore, we 
 561 

believe that the start-up cost for an eligible professional to report PQRS quality measures data is 

5 hours x $16/hour = $80. 

We believe the burden associated with actually reporting the quality measures will vary 

depending on the reporting mechanism selected by the eligible professional. As such, we break 

down the burden estimates by eligible professionals and group practices participating in the 

GPRO according to the reporting mechanism used. 

(b) Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Claims-Based Reporting Mechanism 

For the claims-based reporting option, eligible professionals must gather the required 

information, select the appropriate quality data codes (QDCs), and include the appropriate QDCs 

on the claims they submit for payment. The PQRS will collects QDCs as additional (optional) 

line items on the existing HIPAA transaction 837-P and/or CMS Form 1500 (OCN: 0938-0999). 

We do not anticipate any new forms and or any modifications to the existing transaction or form. 

We also do not anticipate changes to the 837-P or CMS Form 1500 for CY 2015. 

We estimate the cost for an eligible professional to review the list of quality measures or 

measures groups, identify the applicable measures or measures group for which they can report 

the necessary information, incorporate reporting of the selected measures into the office work 

flows, and select a PQRS reporting option to be approximately $205 per eligible professional 

($41 per hour x 5 hours). 

Based on our experience with the Physician Voluntary Reporting Program (PVRP), we 

continue to estimate that the time needed to perform all the steps necessary to report each 

measure (that is, reporting the relevant quality data code(s) for 9 measures measure) would range 

from 15 seconds (0.25 minutes) to over 12 minutes for complicated cases and/or measures, with 

the median time being 1.75 minutes. To report 9 measures, we estimate that it would take 
 562 

approximately 2.25 minutes to 108 minutes to perform all the steps necessary to report 9 

measures. 

Per measure, at an average labor cost of $41/hour per practice, the cost associated with 

this burden will range from $0.17 in labor to about $8.20 in labor time for more complicated 

cases and/or measures, with the cost for the median practice being $1.20. To report 9 measures, 

using an average labor cost of $41/hour, we estimated that the time cost of reporting for an 

eligible professional via claims would range from $1.53 (2.25 minutes or 0.0375 hours x 

$41/hour) to $73.80 (108 minutes or 1.8 hours x $41/hour) per reported case. 

The total estimated annual burden for this requirement will also vary along with the 

volume of claims on which quality data is reported. In previous years, when we required 

reporting on 80 percent of eligible cases for claims-based reporting, we found that on average, 

the median number of reporting instances for each of the PQRS measures was 9. Since we 

reduced the required reporting rate by over one-third to 50 percent, then for purposes of this 

burden analysis we will assume that an eligible professional or eligible professional in a group 

practice will need to report each selected measure for 6 reporting instances. The actual number 

of cases on which an eligible professional or group practice is required to report quality measures 

data will vary, however, with the eligible professional's or group practice’s patient population 

and the types of measures on which the eligible professional or group practice chooses to report 

(each measure's specifications includes a required reporting frequency). 

Based on the assumptions discussed previously, we estimate the total annual reporting 

burden per individual eligible professional associated with claims-based reporting will range 

from 13.5 minutes (0.25 minutes per measure x 9 measures x 6 cases per measure) to 648 

minutes (12 minutes per measure x 9 measures x 6 cases per measure), with the burden to the 

median practice being 94.5 minutes (1.75 minutes per measure x 9 measures x 6 cases). We 
 563 

estimate the total annual reporting cost per eligible professional or eligible professional in a 

group practice associated with claims-based reporting will range from $9.18 ($0.17 per measure 

x 9 measures x 6 cases per measure) to $442.80 ($8.20 per measure x 9 measures x 6 cases per 

measure), with the cost to the median practice being $64.58 per eligible professional ($1.20 per 

measure x 9 measures x 6 cases per measure). 

(c) Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Qualified Registry-based and QCDR-based Reporting Mechanisms 

For qualified registry-based and QCDR-based reporting, there will be no additional time 

burden for eligible professionals or group practices to report data to a qualified registry as 

eligible professionals and group practices opting for qualified registry-based reporting or use of a 

QCDR will more than likely already be reporting data to the qualified registry for other purposes 

and the qualified registry will merely be re-packaging the data for use in the PQRS. Little, if 

any, additional data will need to be reported to the qualified registry or QCDR solely for 

purposes of participation in the PQRS. However, eligible professionals and group practices will 

need to authorize or instruct the qualified registry or QCDR to submit quality measures results 

and numerator and denominator data on quality measures to CMS on their behalf. We estimate 

that the time and effort associated with this will be approximately 5 minutes per eligible 

professional or eligible professional within a group practice. 

Based on the assumptions discussed above and in Part B of this supporting statement, 

Table 62 provides an estimate of the total annual burden hours and total annual cost burden 

associated with eligible professionals using the qualified registry-based or QCDR-based 

reporting mechanism. Please note that, unlike the claims-based reporting mechanism that would 

require an eligible professional to report data to us on quality measures on multiple occasions, an 
 564 

eligible professional would not be required to submit this data to us, as the qualified registry or 

QCDR would perform this function on the eligible professional’s behalf. 

(d) Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: EHR-Based Reporting Mechanism 

For EHR-based reporting, which includes EHR reporting via a direct EHR product and an 

EHR data submission vendor’s product, the eligible professional or group practice must review 

the quality measures on which we will be accepting PQRS data extracted from EHRs, select the 

appropriate quality measures, extract the necessary clinical data from his or her EHR, and submit 

the necessary data to the our designated clinical data warehouse. 

For EHR-based reporting for the PQRS, the individual eligible professional or group 

practice may either submit the quality measures data directly to us from their EHR or utilize an 

EHR data submission vendor to submit the data to us on the eligible professional’s or group 

practice’s behalf. To submit data to us directly from their EHR, the eligible professional or 

eligible professional in a group practice must have access to our specified identity management 

system, such as IACS, which we believe takes less than 1 hour to obtain. Once an eligible 

professional or eligible professional in a group practice has an account for our specified identity 

management system, he or she will need to extract the necessary clinical data from his or her 

EHR, and submit the necessary data to the our designated clinical data warehouse. With respect 

to submitting the actual data file for the respective reporting period, we believe that this will take 

an eligible professional or group practice no more than 2 hours, depending on the number of 

patients on which the eligible professional or group practice is submitting. We believe that once 

the EHR is programmed by the vendor to allow data submission to us, the burden to the eligible 

professional or group practice associated with submission of data on quality measures should be 
 565 

minimal as all of the information required to report the measure should already reside in the 

eligible professional's or group practice’s EHR. 

(e) Burden Estimate for PQRS Reporting by Group Practices Using the GPRO Web Interface 

 With respect to the process for group practices to be treated as satisfactorily submitting 

quality measures data under the PQRS, group practices interested in participating in the PQRS 

through the group practice reporting option (GPRO) must complete a self-nomination process 

similar to the self-nomination process required of qualified registries. However, since a group 

practice using the GPRO web interface would not need to determine which measures to report 

under PQRS, we believe that the self-nomination process is handled by a group practice’s 

administrative staff. Therefore, we estimate that the self-nomination process for the group 

practices for the PQRS involves approximately 2 hours per group practice to review the PQRS 

GPRO and make the decision to participate as a group rather than individually and an additional 

2 hours per group practice to draft the letter of intent for self-nomination, gather the requested 

TIN and NPI information, and provide this requested information. It is estimated that each selfnominated entity will also spend 2 hours undergoing the vetting process with CMS officials. We 

assume that the group practice staff involved in the group practice self-nomination process has 

an average practice labor cost of $16 per hour. Therefore, assuming the total burden hours per 

group practice associated with the group practice self-nomination process is 6 hours, we estimate 

the total cost to a group practice associated with the group practice self-nomination process to be 

approximately $96 ($16 per hour x 6 hours per group practice). 

The burden associated with the group practice reporting requirements under the GPRO is 

the time and effort associated with the group practice submitting the quality measures data. For 

physician group practices, this would be the time associated with the physician group completing 

the web interface. We estimate that the time and effort associated with using the GPRO web 
 566 

interface will be comparable to the time and effort associated to using the PAT. As stated above, 

the information collection components of the PAT have been reviewed by OMB and was 

approved under OMB control number 0938-0941- Form 10136, with an expiration date of 

December 31, 2011 for use in the PGP, MCMP, and EHR demonstrations. As the GPRO was 

only recently implemented in 2010, it is difficult to determine the time and effort associated with 

the group practice submitting the quality measures data. As such, we will use the same burden 

estimate for group practices participating in the GPRO as we use for group practices 

participating in the PGP, MCMP, and EHR demonstrations. Since these changes will not have 

any impact on the information collection requirements associated with the PAT and we will be 

using the same data submission process used in the PGP demonstration, we estimate that the 

burden associated with a group practice completing data for PQRS under the web interface will 

be the same as for the group practice to complete the PAT for the PGP demonstration. In other 

words, we estimate that, on average, it will take each group practice 79 hours to submit quality 

measures data via the GPRO web interface at a cost of $40 per hour. Therefore, the total 

estimated annual cost per group practice is estimated to be approximately $3,160. 

Tables 62 and 63 provide our total estimated costs for reporting in the PQRS for the 2017 

PQRS payment adjustment, the reporting periods of which occur in CY 2015. 

Table 62: Summary of Burden Estimates for Eligible Professionals and/or Group Practices 

using the Claims, Qualified registry, and EHR-based Reporting Mechanisms 

 Minimum 

Burden 

Estimate 

Maximum 

Burden 

Estimate 

Estimated Annual Burden Hours for Claims-based Reporting (for 

individual eligible professionals only) 1,201,543 3,633,006.40

Estimated Annual Burden for Qualified registry-based or QCDR-based 

Reporting 1,333,695 1,333,695

Estimated Annual Burden Hours for EHR-based Reporting 

450,000 450,000

Estimated Total Annual Burden Hours for Eligible Professionals or 

Eligible Professionals in a Group Practice 2,985,238 5,416,701.40 

Estimated Cost for Claims-based Reporting (for individual eligible 

professionals only) $53,545,000 $161,875,000
 567 

 Minimum 

Burden 

Estimate 

Maximum 

Burden 

Estimate 

Estimated Cost for Qualified registry-based Reporting 

$54,681,495 $54,681,495

Estimated Cost for EHR-based Reporting 

$16,400,000 $16,400,000

Estimated Total Annual Cost for Eligible Professionals or Eligible 

Professionals in a Group Practice $124,626,495 $232,956,495

Table 63: Estimated Costs per Vendor to Participate in the PQRS 

Maximum 

Burden 

Estimate 

Estimated # of Participating Group Practices 200 

Estimated # of Burden Hours Per Group Practice to Self-Nominate to Participate in 

PQRS and the Electronic Prescribing Incentive Program Under the Group Practice 

Reporting Option 

6 

Estimated # of Burden Hours Per Group Practice to Report Quality Measures 79 

Estimated Total Annual Burden Hours Per Group Practice 85 

Estimated Total Annual Burden Hours for Group Practices 17,000 

Estimated Cost Per Group Practice to Self-Nominate to Participate in PQRS for the 

Group Practice Reporting Option 

$96 

Estimated Cost Per Group Practice to Report Quality Measures $3,160 

Estimated Total Annual Cost Per Group Practice $3,256 

Annual Burden Cost for Group Practices $651,200 

11. EHR Incentive Program 

 The changes to the EHR Incentive Program in section III.L of this proposed rule would 

not impact CY 2015 physician payments under the PFS. 

12. Medicare Shared Saving Program 

 The requirements for participating in the Medicare Shared Saving Program and the 

impacts of these requirements were established in the final rule implementing the Medicare 

Shared Savings Program that appeared in the Federal Register on November 2, 2011 

(76 FR 67802). The proposals for the Medicare Shared Savings Program set forth in the 

CY 2015 MPFS proposed rule revisit the current quality performance standard, propose changes 

to the quality measures, propose modifications to the timeframe between updates to the quality 
 568 

performance benchmarks, and propose to establish an additional incentive to reward ACO 

quality improvement. Since the proposed policies are not expected to increase the quality 

reporting burden for ACOs participating in the Shared Savings Program and their ACO 

participants, there is no impact for these proposals. 

13. Value-Based Payment Modifier and the Physician Feedback Program 

 Section 1848(p) of the Act requires that we establish a VM and apply it to specific 

physicians and groups of physicians the Secretary determines appropriate starting January 1, 

2015 and to all physicians and groups of physicians by January 1, 2017. Section 1848(p)(4)(C) 

of the Act requires the VM to be budget neutral. Budget-neutrality means that, in aggregate, the 

increased payments to high performing physicians and groups of physicians equal the reduced 

payments to low performing physicians and groups of physicians. 

The proposed changes to the VM in section III.N of this proposed rule would not impact 

CY 2015 physician payments under the PFS. We finalized the VM policies that would impact 

the CY 2015 physician payments under the PFS in the CY 2013 PFS final rule with comment 

period (77 FR 69306-69326). 

In the CY 2013 PFS final rule with comment period, we finalized policies to phase-in 

the VM by applying it starting January 1, 2015 to payments under the Medicare PFS for 

physicians in groups of 100 or more eligible professionals. We identify a group of physicians 

as a single taxpayer identification number (TIN). We apply the VM to the items and services 

billed by physicians under the TIN, not to other eligible professionals that also may bill under 

the TIN. We established CY 2013 as the performance period for the VM that will be applied to 

payments during CY 2015 (77 FR 69314). We also finalized that we will not apply the VM in 

CYs 2015 and 2016 to any group of physicians that is participating in the Medicare Shared 
 569 

Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care Initiative, or 

other similar Innovation Center or CMS initiatives (77 FR 69313). 

We finalized policies to determine the amount of the VM for CY 2015 by categorizing 

groups of physicians with 100 or more eligible professionals into two categories. Category 1 

includes groups of physicians that either (a) self-nominate for the PQRS as a group and report at 

least one measure or (b) elect the PQRS Administrative Claims option as a group. Category 2 

includes groups that do not fall within either of the two subcategories (a) or (b) of Category 1. 

Groups within Category 1 may elect to have their VM for CY 2015 calculated using the qualitytiering methodology, which could result in an upward, neutral, or downward adjustment 

amount. The VM for groups of physicians in Category 1 that do not elect-quality tiering is 0.0 

percent, meaning that these groups will not receive a payment adjustment under the VM for CY 

2015. Category 2 includes groups that do not fall within either of the two subcategories (a) or 

(b) of Category 1. For the groups that are in Category 2, the VM for the CY 2015 payment 

adjustment period is -1.0 percent. 

 Under the quality-tiering approach, each group’s quality and cost composites are 

classified into high, average, and low categories depending upon whether the composites are at 

least one standard deviation above or below the mean. We compare the group’s quality of care 

composite classification with the cost composite classification to determine the VM adjustment 

for the CY 2015 payment adjustment period according to the amounts in Table 64. 

TABLE 64: 2015 Value-Based Payment Modifier Amounts under Quality-Tiering 

Cost/Quality Low Quality Average Quality High Quality 

Low Cost +0.0% +1.0x* +2.0x* 

Average Cost -0.5% +0.0% +1.0x* 

High Cost -1.0% -0.5% +0.0% 

* Groups of physicians eligible for an additional +1.0x if (1) reporting Physician Quality Reporting System quality 

measures through the GPRO web-interface or CMS-qualified registry, and (2) average beneficiary risk score is in 

the top 25 percent of all beneficiary risk scores. 
 570 

To ensure budget neutrality, we first aggregate the downward payment adjustments in 

Table 64 for those groups in Category 1 that have elected quality tiering with the -1.0 percent 

downward payment adjustments for groups of physicians subject to the VM that fall within 

Category 2. Using the aggregate downward payment adjustment amount, we then calculate the 

upward payment adjustment factor (x). These calculations will be done after the performance 

period has ended. 

 At the time of this proposed rule, we have not completed the analysis of the impact of the 

VM in CY 2015 on physicians in groups with 100 or more eligible professionals based on their 

performance in CY 2013. Therefore, in this proposed rule, we present estimates based on CY 

2012 claims data that were used to produce the 2012 QRURs, which were available to groups of 

25 or more eligible professionals on September 16, 2013. The findings from the CY 2012 

QRURs will be available on the CMS website at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeedbackProgram/2012-QRUR.html in a document titled 

“Experience Report for the Performance Year 2012 Quality and Resource Use Reports”. We 

will update this section in the CY 2015 final rule with comment period based on CY 2013 data 

that will be used to calculate the value-based payment modifier in CY 2015. The impact of the 

policies for the CY 2017 VM proposed in this rule, if finalized, would be discussed in the PFS 

rule for CY 2017. 

 Please note that we are not able to determine which groups would fall in Category 1 and 

Category 2, as described above, using CY 2012 claims data. Therefore, the 2012 estimates that 

we present in this section are based on groups for which we produced a 2012 QRUR and for 

whom the quality or cost composite could be calculated. Based on our simulation of the 1,032 

groups with 100 or more eligible professionals for which we produced a 2012 QRUR and for 

whom the quality or cost composite could be calculated, the vast majority of groups (81.0 
 571 

percent) are in the average quality and average cost tiers (this includes groups missing either the 

quality or cost composite score, who are assigned to average quality or average cost). The 

simulation also found that approximately 8 percent of groups are in tiers that would receive an 

upward adjustment, resulting in a payment incentive of between +1.0x and +2.0x percent; and 

approximately 10.4 percent of groups are in tiers that would receive a downward adjustment of 

between -0.5 and -1.0 percent to payments under Medicare PFS (Table 65). 

TABLE 65: Simulated Distribution Using 2012 Data of Quality and Cost Tiers for Groups 

with 100 or More Eligible Professionals for Which a Quality or Cost Composite Score 

Could Be Calculated (1,032 Groups) 

Cost/Quality Low 

Quality 

Average 

Quality 

High 

Quality 

Low Cost 0.5% 3.3% 0.7% 

Average Cost 4.4% 81.0% 4.0% 

High Cost 3.6% 2.4% 0.2% 

In 2013, 136 groups with 100 or more eligible professionals elected to have their CY 

2015 VM calculated using the quality-tiering methodology; therefore, these groups will receive 

an upward, neutral, or downward adjustment based on the calculation of their quality and cost 

composites. The VM for groups with 100 or more eligible professionals that did not elect quality 

tiering and self-nominated for the PQRS as a group and reported at least one measure or elected 

the PQRS administrative claims option will be 0.0 percent, meaning that these groups will not 

receive a payment adjustment under the VM in CY 2015. 

 Please note that in CY 2015, only the physicians in groups with 100 or more eligible 

professionals that are in Category 1 and elect quality-tiering will be subject to upward, 

downward, or no payment adjustment under the VM according to Table 64. Additionally, 

physicians in groups with 100 or more eligible professionals that fall in Category 2 will be 

subject to the -1.0 percent value-modifier payment adjustment in CY 2015. In the CY 2015 final 
 572 

rule with comment period, we will present the actual number of groups and physicians that will 

be subject to the VM in CY 2015. 

G. Alternatives Considered

 This proposed rule contains a range of policies, including some provisions related to 

specific statutory provisions. The preceding preamble provides descriptions of the statutory 

provisions that are addressed, identifies those policies when discretion has been exercised, 

presents rationale for our final policies and, where relevant, alternatives that were considered. 

H. Impact on Beneficiaries 

There are a number of changes in this proposed rule that would have an effect on 

beneficiaries. In general, we believe that many of the proposed changes, including the 

refinements of the PQRS with its focus on measuring, submitting, and analyzing quality data; 

establishing the basis for the VM to adjust physician payment beginning in CY 2015; improved 

accuracy in payment through revisions to the inputs used to calculate payments under the PFS 

and the five year review of MPRVUs; and revisions to payment for Part B drugs will have a 

positive impact and improve the quality and value of care provided to Medicare beneficiaries. 

 Most of the aforementioned proposed policy changes could result in a change in 

beneficiary liability as relates to coinsurance (which is 20 percent of the fee schedule amount if 

applicable for the particular provision after the beneficiary has met the deductible). To illustrate 

this point, as shown in Table 61, the CY 2014 national payment amount in the nonfacility setting 

for CPT code 99203 (Office/outpatient visit, new) is $77.02, which means that in CY 2014 a 

beneficiary would be responsible for 20 percent of this amount, or $15.40. Based on this 

proposed rule, using the current (CY 2014) CF of $35.8228, adjusted to $35.7997 to include 

budget neutrality, the CY 2015 national payment amount in the nonfacility setting for CPT code 
 573 

99203, as shown in Table 61, is $77.32, which means that, in CY 2015, the proposed beneficiary 

coinsurance for this service would be $15.46. 

 In section II.H, we propose to define colorectal cancer screening to include the anesthesia 

associated with the procedure. If this proposal is adopted, there would be no beneficiary 

coinsurance or deductible applied to anesthesia associated with screening colonoscopy even 

when the anesthesia is furnished by a different practitioner than the one who furnishes the 

procedure. 

I. Accounting Statement 

As required by OMB Circular A-4 (available at 

http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 66 (Accounting Statement), 

we have prepared an accounting statement. This estimate includes growth in incurred benefits 

from CY 2014 to CY 2015 based on the FY 2015 President's Budget baseline. Note that 

subsequent legislation changed the updates for 2015 from those shown in the 2015 President’s 

Budget baseline. 

TABLE 66: Accounting Statement: 

Classification of Estimated Expenditures 

CATEGORY TRANSFERS 

CY 2015 Annualized Monetized Transfers Estimated decrease in expenditures of $1.1 billion for 

PFS CF update. 

From Whom To Whom? Federal Government to physicians, other 

practitioners and providers and suppliers who receive 

payment under Medicare. 

CY 2015 Annualized Monetized Transfers Estimated increase in payment of $234 million. 

From Whom To Whom? Federal Government to eligible professionals who 

satisfactorily participate in the Physician Quality 

Reporting System (PQRS). 

TABLE 67: Accounting Statement: 

Classification of Estimated Costs, Transfer, and Savings 
 574 

CATEGORY TRANSFER 

CY 2015 Annualized Monetized Transfers 

of beneficiary cost coinsurance.

$9 million

From Whom to Whom? Federal Government to Beneficiaries. 

J. Conclusion 

The analysis in the previous sections, together with the remainder of this preamble, 

provides an initial "Regulatory Flexibility Analysis." The previous analysis, together with the 

preceding portion of this preamble, provides a Regulatory Impact Analysis. 

 In accordance with the provisions of Executive Order 12866, this regulation was 

reviewed by the Office of Management and Budget. 
 575 

List of Subjects 

42 CFR Part 403 

Grant programs-health, Health insurance, Hospitals, Intergovernmental relations, 

Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 405 

Administrative practice and procedure, Health facilities, Health professions, Kidney 

diseases, Medical devices, Medicare, Reporting and recordkeeping requirements, Rural areas, 

X-rays. 

42 CFR Part 410 

Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting 

and recordkeeping requirements, Rural areas, X-rays. 

42 CFR Part 414 

Administrative practice and procedure, Health facilities, Health professions, Kidney 

diseases, Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 425 

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

42 CFR Part 498 

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

 
 576 

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services 

proposes to amend 42 CFR chapter IV as set forth below: 

PART 403—SPECIAL PROGRAMS AND PROJECTS 

1. The authority citation for part 403 continues to read as follows: 

Authority: 42 U.S.C. 1395b-3 and Secs. 1102 and 1871 of the Social Security Act (42 

U.S.C. 1302 and 1395hh). 

§403.902 [Amended] 

2. Section 403.902 is amended by removing the definition of “Covered device”. 

3. Section 403.904 is amended by-- 

a. Revising paragraphs (c)(8) and (d)(3) and (4). 

b. Adding paragraphs (d)(5) and (6). 

c. Removing paragraph (g). 

d. Redesignating paragraphs (h) and (i) as paragraphs (g) and (h), respectively. 

The revisions and additions read as follows: 

§403.904 Reports of payments or other transfers of value to covered recipients. 

* * * * * 

(c) * * * 

(8) Related covered and non-covered drug, device, biological or medical supply. Report 

the marketed name of the related covered and non-covered drugs, devices, biologicals, or 

medical supplies, unless the payment or other transfer of value is not related to a particular 

covered or non-covered drug, device, biological or medical supply. 

(i) For drugs and biologicals, if the marketed name has not yet been selected, applicable 

manufacturers must indicate the name registered on clinicaltrials.gov. 
 577 

(ii) For devices and medical supplies, applicable manufacturers may also report the 

therapeutic area or product category for the device or medical supply. 

(iii) Applicable manufacturers must indicate if the related drug, device, biological, or 

medical supply is covered or non-covered. 

(iv) Applicable manufacturers must indicate if the payment or other transfer of value is 

not related to any covered or non-covered drug, device, biological or medical supply. 

* * * * * 

(d) * * * 

(3) Stock. 

(4) Stock option. 

(5) Any other ownership interest. 

(6) Dividend, profit or other return on investment. 

* * * * * 

 4. New subparts J and K are added to part 403 to read as follows: 

Subpart J—[Reserved] 

Subpart K--Access to Identifiable Data for the Center for Medicare and Medicaid Models 

Sec. 

403.1100 Purpose and scope. 

403.1105 Definitions. 

403.1110 Evaluation of models. 

Subpart J—[Reserved] 

Subpart K--Access to Identifiable Data for the Center for Medicare and Medicaid Models 

§403.1100 Purpose and scope. 
 578 

 The regulations in this subpart implement section 1115A of the Act. The intent of that 

section is to enable CMS to test innovative payment and service delivery models to reduce 

program expenditures while preserving and/or enhancing the quality of care furnished to 

individuals under titles XVIII, XIX, and XXI of the Act. The Secretary is also required to 

conduct an evaluation of each model tested. 

§403.1105 Definitions. 

For purposes of this subpart-- 

Applicable title means titles XVIII, XIX, or XXI of the Act. 

§403.1110 Evaluation of models. 

(a) Evaluation. The Secretary conducts an evaluation of each model tested under section 

1115A of the Act. Such evaluation must include an analysis of the following: 

(1) The quality of care furnished under the model, including the measurement of patientlevel outcomes and patient-centeredness criteria determined appropriate by the Secretary. 

(2) The changes in spending under the applicable titles by reason of the model. 

(b) Information. Any State or other entity participating in the testing of a model under 

section 1115A of the Act must collect and report such information, including “protected health 

information” as that term is defined at 45 CFR 160.103, as the Secretary determines is necessary 

to monitor and evaluate such model. Such data must be produced to the Secretary at the time 

and in the form and manner specified by the Secretary. 

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED 

5. The authority citation for part 405 continues to read as follows: 

Authority: Secs. 205(a), 1102, 1861, 1862(a), 1869, 1871, 1874, 1881, and 1886(k) of 

the Social Security Act (42 U.S.C. 405(a), 1302, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 

1395rr and 1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C. 263a). 
 579 

6. Section 405.400 is amended by revising the definition of “Emergency care services” to 

read as follows: 

§405.400 Definitions. 

 * * * * * 

Emergency care services means “emergency services” as that term is defined in §424.101 

of this chapter.

 * * * * * 

§405.420 [Amended] 

7. Section 405.420 is amended in paragraph (e) by removing the phrase 

“Medicare+Choice” and adding in its place the phrase “Medicare Advantage”.

§405.425 [Amended] 

8. Section 405.425 is amended in paragraph (a) by removing the phrase 

“Medicare+Choice” and adding in its place the phrase “Medicare Advantage”.

§405.450 [Amended] 

9. Section 405.450 is amended by— 

a. In paragraph (a) removing the reference “405.803” and adding in its place the reference 

“498.3(b)”. 

b. In paragraph (b) removing the reference “405.803” and adding in its place “405.924”. 

§405.455 [Amended] 

10. Section 405.455 is amended by— 

a. In the section heading removing the phrase “Medicare+Choice” and adding in its place 

the phrase “Medicare Advantage”.

b. In the introductory text removing the phrase “Medicare+Choice (M+C)” and adding in 

its place the phrase “Medicare Advantage”. 
 580 

11. Section 405.924 is amended by adding paragraph (b)(15) to read as follows: 

§405.924 Actions that are initial determinations. 

 * * * * * 

(b) * * * 

(15) A claim not payable to a beneficiary for the services of a physician who has optedout. 

 * * * * * 

12. Section 405.2413 is amended by— 

a. In paragraph (a)(4) removing “;” and adding in its place “; and”. 

b. Revising paragraph (a)(5). 

c. Removing paragraph (a)(6). 

The revision reads as follow: 

§405.2413 Services and supplies incident to a physician's services. 

 (a) * * * 

(5) Furnished under the direct supervision of a physician. 

 * * * * * 

 13. Section 405.2415 is amended by— 

a. Revising the section heading and paragraph (a)(5). 

b. In paragraph (a)(4) removing “;” and adding in its place “; and”. 

c. Removing paragraph (a)(6). 

The revision reads as follows: 

§405.2415 Services and supplies incident to nurse practitioner, physician assistant, or 

certified nurse-midwife services. 

(a) * * * 
 581 

(5) Furnished under the direct supervision of a nurse practitioner, physician assistant, or 

certified nurse-midwife. 

 * * * * * 

 14. Section 405.2452 is amended by— 

a. In paragraph (a)(4) removing “;” and adding in its place “; and”. 

b. Revising paragraph (a)(5). 

c. Removing paragraph (a)(6). 

The revision reads as follows: 

§405.2452 Services and supplies incident to clinical psychologist and clinical social worker 

services. 

 (a) * * * 

(5) Furnished under the direct supervision of a clinical psychologist or clinical social 

worker. 

 * * * * * 

PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 

 15. The authority citation for part 410 continues to read as follows: 

Authority: Secs. 1102, 1834, 1871, 1881, and 1893 of the Social Security Act (42 

U.S.C. 1302. 1395m, 1395hh, and 1395ddd. 

 16. Section 410.26 is amended by revising paragraphs (b)(5) and (6) to read as follows: 

§410.26 Services and supplies incident to a physician's professional services: Conditions. 

 * * * * * 

 (b) * * * 

 (5) In general, services and supplies must be furnished under the direct supervision of the 

physician (or other practitioner). Services and supplies furnished incident to transitional care 
 582 

management and chronic care management services can be furnished under general supervision 

of the physician (or other practitioner) when these services or supplies are provided by clinical 

staff. The physician (or other practitioner) supervising the auxiliary personnel need not be the 

same physician (or other practitioner) upon whose professional service the incident to service is 

based. 

 (6) Services and supplies must be furnished by the physician, practitioner with an 

incident to benefit, or auxiliary personnel. 

 * * * * * 

17. Section 410.37 is amended by revising paragraph (a)(1)(iii) to read as follows: 

§410.37 Colorectal cancer screening tests: Conditions for and limitations on coverage.

 (a) * * * 

(1) * * * 

(iii) Screening colonoscopies, including anesthesia furnished in conjunction with the 

service. 

 * * * * * 

18. Section 410.59 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.59 Outpatient occupational therapy services: Conditions.

 * * * * * 

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of occupational therapy on a regular basis as an 

individual, in one of the following practice types: a solo practice, partnership, or group practice; 

or as an employee of one of these. 

 * * * * * 
 583 

19. Section 410.60 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.60 Outpatient physical therapy services: Conditions.

 * * * * * 

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of physical therapy on a regular basis as an individual, 

in one of the following practice types: a solo practice, partnership, or group practice; or as an 

employee of one of these. 

 * * * * * 

20. Section 410.62 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.62 Outpatient speech-language pathology services: Conditions and exclusions. 

 * * * * * 

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of speech-language pathology on a regular basis as an 

individual, in one of the following practice types: a solo practice, partnership, or group practice; 

or as an employee of one of these. 

 * * * * * 

21. Section 410.78 is amended by revising paragraph (b) introductory text and paragraph 

(f) to read as follows: 

§410.78 Telehealth services. 

 * * * * * 
 584 

 (b) General rule. Medicare Part B pays for covered telehealth services included on the 

telehealth list when furnished by an interactive telecommunications system if the following 

conditions are met: 

 * * * * * 

 (f) Process for adding or deleting services. Changes to the list of Medicare telehealth 

services are made through the annual physician fee schedule rulemaking process. A list of the 

services covered as telehealth services under this section is available on the CMS website. 

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES 

22. The authority citation for part 414 continues to read as follows: 

Authority: Secs. 1102, 1871, and 1881(b)(l) of the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395rr(b)(l)). 

 23. Section 414.24 is amended by— 

a. Revising the section heading and paragraphs (a) and (b). 

b. Redesignating paragraph (c) as paragraph (d). 

c. Adding new paragraph (c). 

The revisions and addition read as follows: 

§414.24 Publication of RVUs and direct PE inputs. 

(a) Definitions. For purposes of this section, the following definitions apply: 

Existing code means a code that is not a new code under paragraph (c)(2) of this section, 

and includes codes for which the descriptor is revised and codes that are combinations or 

subdivisions of previously existing codes. 

New code means a code that describes a service that was not previously described or 

valued under the PFS using any other code or combination of codes. 
 585 

(b) Revisions of RVUs and direct PE Inputs. CMS publishes, through notice and 

comment rulemaking in the Federal Register (including proposals in a proposed rule), changes 

in RVUs or direct PE inputs for existing codes. 

(c) Establishing RVUs and direct PE inputs for new codes. (1) General rule. CMS 

establishes RVUs and direct PE inputs for new codes in the manner described in paragraph (b) of 

this section. 

(2) Exception for new codes for which CMS does not have sufficient information. When 

CMS determines for a new code that it does not have sufficient information in order to include 

proposed RVUs or direct PE inputs in the proposed rule, but that it is in the public interest for 

Medicare to use a new code during a payment year, CMS will publish in the Federal Register

RVUs and direct PE inputs that are applicable on an interim basis subject to public 

comment. After considering public comments and other information on interim RVUs and PE 

inputs for the new code, CMS publishes in the Federal Register the final RVUs and PE inputs 

for the code. 

 * * * * * 

 24. Section 414.90 is amended by— 

a. Removing the phrase “CG CAHPS” and adding in its place the phrase “CAHPS for 

PQRS” everywhere it appears. 

b. Removing the phrase “CAHPS” and adding in its place the phrase “CAHPS for 

PQRS” everywhere it appears. 

c. In paragraph (b) revising the definition of “Measures group”. 

d. Revising paragraphs (j)(4) and (m)(1) and (3). 

e. Adding paragraphs (j)(6) and (k)(4). 

The revisions read as follows: 
 586 

§414.90 Physician Quality Reporting System (PQRS). 

 * * * * * 

(b) * * * 

Measures group means a subset of six or more PQRS measures that have a particular 

clinical condition or focus in common. The denominator definition and coding of the measures 

group identifies the condition or focus that is shared across the measures within a particular 

measures group. 

 * * * * * 

(j) * * * 

(4) Satisfactory reporting criteria for individual eligible professionals for the 2017 PQRS 

payment adjustment. An individual eligible professional who wishes to meet the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment must report information on PQRS 

quality measures identified by CMS in one of the following manners: 

(i) Via claims. (A) For the 12-month 2017 PQRS payment adjustment reporting period--

(1)(i) Report at least 9 measures, covering at least 3 of the NQS domains and report each 

measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Of the 9 measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 

professional must report on at least 2 measures contained in the proposed cross-cutting measure 

set specified by CMS. If less than 9 measures apply to the eligible professional, report up to 8 

measures and report each measure for at least 50 percent of the Medicare Part B FFS patients 

seen during the reporting period to which the measure applies. Of the measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 
 587 

professional must report on at least 2 measures contained in the cross-cutting measure set. 

Measures with a 0 percent performance rate would not be counted. 

(ii) [Reserved] 

(2) [Reserved] 

(B) [Reserved] 

(ii) Via qualified registry. (A) For the 12-month 2017 PQRS payment adjustment 

reporting period--

(1)(i) Report at least 9 measures, covering at least 3 of the NQS domains and report each 

measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Of the 9 measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 

professional must report on at least 2 measures contained in the proposed cross-cutting measure 

set specified by CMS. If less than 9 measures apply to the eligible professional, report up to 8 

measures and report each measure for at least 50 percent of the Medicare Part B FFS patients 

seen during the reporting period to which the measure applies. Of the measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 

professional must report on at least 2 measures contained in the cross-cutting measure set. 

(ii) Report at least 1 measures group and report each measures group for at least 20 

patients, a majority of which much be Medicare Part B FFS patients. 

(2) Measures with a 0 percent performance rate or measures groups containing a measure 

with a 0 percent performance rate will not be counted. 

(B) [Reserved] 

(iii) Via EHR direct product. For the 12-month 2017 PQRS payment adjustment 

reporting period, report 9 measures covering at least 3 of the NQS domains. If an eligible 
 588 

professional's CEHRT does not contain patient data for at least 9 measures covering at least 3 

domains, then the eligible professional must report the measures for which there is Medicare 

patient data. An eligible professional must report on at least 1 measure for which there is 

Medicare patient data. 

(iv) Via EHR data submission vendor. For the 12-month 2017 PQRS payment 

adjustment reporting period, report 9 measures covering at least 3 of the NQS domains. If an 

eligible professional's CEHRT does not contain patient data for at least 9 measures covering at 

least 3 domains, then the eligible professional must report the measures for which there is 

Medicare patient data. An eligible professional must report on at least 1 measure for which there 

is Medicare patient data. 

 * * * * * 

(6) Satisfactory reporting criteria for group practices for the 2017 PQRS payment 

adjustment. A group practice who wishes to meet the criteria for satisfactory reporting for the 

2017 PQRS payment adjustment must report information on PQRS quality measures identified 

by CMS in one of the following manners: 

(i) Via the GPRO web interface. For the 12-month 2017 PQRS payment adjustment 

reporting period, for a group practice of 25 or more eligible professionals, 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 percent of assigned beneficiaries. A group practice must report on at least 1 

measure for which there is Medicare patient data. 

(ii) Via qualified registry. For a group practice of 2 or more eligible professionals, for the 

12-month 2017 PQRS payment adjustment reporting period, report at least 9 measures, covering 
 589 

at least 3 of the NQS domains and report each measure for at least 50 percent of the group 

practice's Medicare Part B FFS patients seen during the reporting period to which the measure 

applies; or if less than 9 measures covering at least 3 NQS domains apply to the eligible 

professional, then the group practice must report up to measures for which there is Medicare 

patient data and report each measure for at least 50 percent of the group practice's Medicare Part 

B FFS patients seen during the reporting period to which the measure applies. Of the measures 

reported, if the eligible professional sees at least 1 Medicare patient in a face-to-face encounter, 

the eligible professional must report on at least 2 measures contained in the cross-cutting 

measure set. Measures with a 0 percent performance rate would not be counted; or 

(iii) Via EHR direct product. For a group practice of 2 or more eligible professionals, for 

the 12-month 2017 PQRS payment adjustment reporting period, report 9 measures covering at 

least 3 of the NQS domains. If a group practice's CEHRT does not contain patient data for at 

least 9 measures covering at least 3 domains, then the group practice must report the measures 

for which there is Medicare patient data. A group practice must report on at least 1 measure for 

which there is Medicare patient data. 

(iv) Via EHR data submission vendor. For a group practice of 2 or more eligible 

professionals, for the 12-month 2017 PQRS payment adjustment reporting period, report 9 

measures covering at least 3 of the NQS domains. If a group practice's CEHRT does not contain 

patient data for at least 9 measures covering at least 3 domains, then the group practice must 

report the measures for which there is Medicare patient data. A group practice must report on at 

least 1 measure for which there is Medicare patient data. 

(v) Via a certified survey vendor in addition to a qualified registry. For a group practice 

of 25 or more eligible professionals, for the 12-month 2017 PQRS payment adjustment reporting 

period, report all CAHPS for PQRS survey measures via a CMS-certified survey vendor and 
 590 

report at least 6 additional measures covering at least 2 of the NQS domains using a qualified 

registry. If less than 6 measures apply to the group practice, the group practice must report up to 

6 measures. Of these 6 measures, if any eligible professional in the group practice sees at least 1 

Medicare patient in a face-to-face encounter, the group practice must report on at least 1 measure 

in the cross-cutting measure set. 

(vi) Via a certified survey vendor in addition a direct EHR product or EHR data 

submission vendor. For a group practice of 25 or more eligible professionals, for the 12-month 

2017 PQRS payment adjustment reporting period, report all CAHPS for PQRS survey measures 

via a CMS-certified survey vendor and report at least 6 additional measures, outside of CAHPS 

for PQRS, covering at least 2 of the NQS domains using the direct EHR product that is CEHRT 

or EHR data submission vendor that is CEHRT. If less than 6 measures apply to the group 

practice, the group practice must report up to 6 measures. Of the additional 6 measures that must 

be reported in conjunction with reporting the CAHPS for PQRS survey measures, a group 

practice would be required to report on at least 1 measure for which there is Medicare patient 

data. 

(vii) Via a certified survey vendor in addition to the GPRO web interface. (A) For a 

group practice of 25 to 99 eligible professionals, for the 12-month 2017 PQRS payment 

adjustment reporting period, report all CAHPS for PQRS survey measures via a CMS-certified 

survey vendor and report on all measures included in the GPRO 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 the group practice would report on 100 

percent of assigned beneficiaries. A group practice would be required to report on at least 1 

measure for which there is Medicare patient data. 
 591 

(B) For a group practice of 100 or more eligible professionals, for the 12-month 2017 

PQRS payment adjustment reporting period, report all CAHPS for PQRS survey measures via a 

certified survey vendor. In addition, the group practice would report on all measures included in 

the GPRO 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 the 

group practice would report on 100 percent of assigned beneficiaries. A group practice would be 

required to report on at least 1 measure for which there is Medicare patient data. 

(k) * * * 

(4) Satisfactory participation criteria for individual eligible professionals for the 2017 

PQRS payment adjustment. An individual eligible professional who wishes to meet the criteria 

for satisfactory participation in a QCDR for the 2017 PQRS payment adjustment must report 

information on quality measures identified by the QCDR in one of the following manner: 

(i) For the 12-month 2017 PQRS payment adjustment reporting period, report at least 9 

measures available for reporting under a QCDR covering at least 3 of the NQS domains, and 

report each measure for at least 50 percent of the eligible professional’s patients. Of these 

measures, report on at least 3 outcome measures, or, if 3 outcomes measures are not available, 

report on at least 2 outcome measures and at least 1 of the following types of measures – 

resource use, patient experience of care, or efficiency/appropriate use. 

(ii) [Reserved] 

 * * * * * 

(m) * * * 

(1) To request an informal review for reporting periods that occur prior to 2014, an 

eligible professional or group practice must submit a request to CMS within 90 days of the 
 592 

release of the feedback reports. To request an informal review for reporting periods that occur in 

2014 and subsequent years, an eligible professional or group practice must submit a request to 

CMS within 30 days of the release of the feedback reports. The request must be submitted in 

writing and summarize the concern(s) and reasons for requesting an informal review and may 

also include information to assist in the review. 

 * * * * * 

(3) If, during the informal review process, CMS finds errors in data that was submitted 

using a third-party vendor using either the qualified registry, EHR data submission vendor, or 

QCDR reporting mechanisms, CMS may allow for the resubmission of data to correct these 

errors on an ad-hoc basis. 

(i) CMS will not allow resubmission of data submitted via claims, direct EHR, and the 

GPRO web interface reporting mechanisms. 

(ii) CMS will only allow resubmission of data that was already previously submitted to 

CMS. 

(iii) CMS will only accept data that was previously submitted for the reporting periods 

for which the corresponding informal review period applies. 

 * * * * * 

§414.511 [Removed]

25. Section 414.511 is removed. 

26. Section 414.610 is amended by revising paragraphs (c)(1)(ii) introductory text and 

(c)(5)(ii) to read as follows: 

§414.610 Basis of payment.

 * * * * * 

 (c) * * * 
 593 

 (1) * * * 

(ii) For services furnished during the period July 1, 2008 through March 31, 2015, 

ambulance services originating in: 

 * * * * * 

 (5) * * * 

(ii) For services furnished during the period July 1, 2004 through March 31, 2015, the 

payment amount for the ground ambulance base rate is increased by 22.6 percent where the point 

of pickup is in a rural area determined to be in the lowest 25 percent of rural population arrayed 

by population density. The amount of this increase is based on CMS’s estimate of the ratio of 

the average cost per trip for the rural areas in the lowest quartile of population compared to the 

average cost per trip for the rural areas in the highest quartile of population. In making this 

estimate, CMS may use data provided by the GAO. 

 * * * * * 

27. Section 414.1200 is amended by revising paragraphs (a) and (b)(5) to read as 

follows: 

§414.1200 Basis and scope. 

(a) Basis. This subpart implements section 1848(p) of the Act by establishing a payment 

modifier that provides for differential payment starting in 2015 to a group of physicians and 

starting in 2017 to a group and a solo practitioner under the Medicare Physician Fee Schedule 

based on the quality of care furnished compared to cost during a performance period. 

(b) * * * 

(5) Additional measures for groups and solo practitioners. 

* * * * * 

28. Section 414.1205 is amended by— 
 594 

a. Revising the definitions of “Group of physicians” and “Value-based payment 

modifier”. 

b. Adding the definition of “Solo practitioner” in alphabetical order. 

The addition and revisions read as follows: 

§414.1205 Definitions. 

* * * * * 

Group of physicians (Group) means a single Taxpayer Identification Number (TIN) with 

2 or more eligible professionals, as identified by their individual National Provider Identifier 

(NPI), who have reassigned their Medicare billing rights to the TIN. 

* * * * * 

Solo practitioner means a single TIN with 1 eligible professional as identified by an 

individual NPI billing under the TIN. 

* * * * * 

Value-based payment modifier means the percentage as determined under §414.1270 by 

which amounts paid to a group or solo practitioner under the Medicare Physician Fee Schedule 

established under section 1848 of the Act are adjusted based upon a comparison of the quality of 

care furnished to cost as determined by this subpart. 

29. Section 414.1210 is amended by— 

a. Adding paragraphs (a)(3) and (b)(2), (3), and (4). 

b. Revising paragraph (c). 

The additions and revision reads as follows: 

§414.1210 Application of the value-based payment modifier.

(a) * * * 
 595 

(3) For the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period, to physicians and eligible professionals in groups with 2 or more 

eligible professionals and to physicians and eligible professionals who are solo practitioners 

based on the performance period described at §414.1215(c). 

(b) * * * 

(2) For the CY 2017 payment adjustment period and each subsequent payment 

adjustment period, the value-based payment modifier is applicable to physicians and eligible 

professionals in groups with 2 or more eligible professionals and to physicians and eligible 

professionals who are solo practitioners that participate in the Shared Savings Program. The 

value-based payment modifier for groups and solo practitioners that participate in the Shared 

Savings Program during the payment adjustment period is determined based on paragraphs 

(b)(2)(i) through (iv) of this section. For groups and solo practitioners that participate in the 

Shared Savings Program during the performance period, but do not participate in the Shared 

Savings Program during the payment adjustment period, the quality composite is classified as 

“average” under §414.1275(b)(1) and the cost composite score is calculated under §414.1260(b) 

based on performance on the cost measures identified under §414.1235 during the performance 

period. 

(i) The cost composite is classified as “average” under §414.1275(b)(2) for the payment 

adjustment period. 

(ii) The quality composite score is calculated under §414.1260(a) using quality data from 

the ACO in which the groups and solo practitioners participate during the payment adjustment 

period, as collected under §425.500 of this chapter for the performance period. 
 596 

(iii) If the ACO did not exist during the performance period, then the quality composite 

for the groups and solo practitioners is classified as “average” under §414.1275(b)(1) for the 

payment adjustment period. 

(iv) The same value-based payment modifier applies to all groups and solo practitioners 

participating in an ACO during the payment adjustment period. 

(3) For the CY 2017 payment adjustment period and each subsequent payment 

adjustment period, the value-based payment modifier is applicable to physicians and eligible 

professionals in groups with 2 or more eligible professionals and to physicians and eligible 

professionals who are solo practitioners that participate in the Pioneer ACO Model or the 

Comprehensive Primary Care (CPC) Initiative during the performance period. The value-based 

payment modifier for groups and solo practitioners that participate in the Pioneer ACO Model or 

the CPC Initiative during the performance period and do not participate in the Shared Savings 

Program or other similar Innovation Center models or CMS initiatives during the payment 

adjustment period is determined based on paragraphs (b)(3)(i) through (iv) of this section. 

(i) If a group reports under PQRS GPRO for the performance period and meets the 

criteria for satisfactory reporting for the PQRS payment adjustment, then the quality composite 

score is calculated under §414.1260(a) based on the PQRS GPRO quality data, and the cost 

composite score is calculated under §414.1260(b) based on performance on the cost measures 

identified under §414.1235 during the performance period. If the group fails to meet the criteria 

for satisfactory reporting, then the group is in Category 2 and receives a downward adjustment 

under the value-based payment modifier for the payment adjustment period equal to the 

percentage applied for high cost/low quality under §414.1275(c). 

(ii) If a group is composed of one or more eligible professionals that participate in the 

Pioneer ACO Model or CPC Initiative and others who do not participate, and at least 50 percent 
 597 

of all eligible professionals in the group satisfactorily report quality data to CMS for the 

performance period, then the quality composite score is calculated under §414.1260(a) based on 

the quality data reported under PQRS by individual eligible professionals in the group, and the 

group receives the higher of “average quality” or the actual classification under §414.1275(b)(1), 

and the cost composite score is calculated under §414.1260(b) based on performance on the cost 

measures identified under §414.1235 during the performance period. If less than 50 percent of 

all eligible professionals in the group satisfactorily report quality data to CMS for the 

performance period, then the group is in Category 2 and receives a downward adjustment under 

the value-based payment modifier for the payment adjustment period equal to the percentage 

applied for high cost/low quality under §414.1275(c). 

(iii) If a group is composed entirely of eligible professionals that participate in the 

Pioneer ACO Model or CPC Initiative, and the group successfully reports quality data to the 

Pioneer ACO Model or CPC Initiative for the performance period, then the quality composite is 

classified as “average” under §414.1275(b)(1), and the cost composite score is calculated under 

§414.1260(b) based on performance on the cost measures identified under §414.1235 during the 

performance period. If the group fails to successfully report quality data to the Pioneer ACO 

Model or the CPC Initiative for the performance period, then the group is in Category 2 and 

receives a downward adjustment under the value-based payment modifier for the payment 

adjustment period equal to the percentage applied for high cost/low quality under §414.1275(c). 

(iv) If a solo practitioner successfully reports quality data to the Pioneer ACO Model or 

CPC Initiative for the performance period, then the quality composite is classified as “average” 

under §414.1275(b)(1), and the cost composite score is calculated under §414.1260(b) based on 

performance on the cost measures identified under §414.1235 during the performance period. If 

the solo practitioner fails to successfully report quality data to the Pioneer ACO Model or the 
 598 

CPC Initiative for the performance period, then the solo practitioner is in Category 2 and 

receives a downward adjustment under the value-based payment modifier for the payment 

adjustment period equal to the percentage applied for high cost/low quality under §414.1275(c). 

(v) For groups and solo practitioners that participate in the Pioneer ACO Model or the 

CPC Initiative during the performance period and participate in other similar Innovation Center 

models or CMS initiatives during the payment adjustment period (but not the Shared Savings 

Program), the quality composite is determined based on paragraphs (b)(3)(i) through (iv) of this 

section for the payment adjustment period. The cost composite is classified as “average” under 

§414.1275(b)(2) for the payment adjustment period. 

 (4) For the CY 2017 payment adjustment period and each subsequent payment 

adjustment period, the value-based payment modifier is applicable to physicians and eligible 

professionals in groups with 2 or more eligible professionals and to physicians and eligible 

professionals who are solo practitioners that participate in other similar Innovation Center 

models or CMS initiatives during the performance period. The quality composite and cost 

composite are determined based on paragraphs (b)(3)(i) through (v) of this section. 

(c) Group size determination. The list of groups of physicians subject to the value-based 

payment modifier for the CY 2015 payment adjustment period is based on a query of PECOS on 

October 15, 2013. For each subsequent calendar year payment adjustment period, the list of 

groups and solo practitioners subject to the value-based payment modifier is based on a query of 

PECOS that occurs within 10 days of the close of the Physician Quality Reporting System group 

registration process during the applicable performance period described at §414.1215. Groups 

are removed from the PECOS-generated list if, based on a claims analysis, the group did not 

have the required number of eligible professionals, as defined in §414.1210(a), that submitted 

claims during the performance period for the applicable calendar year payment adjustment 
 599 

period. Solo practitioners are removed from the PECOS-generated list if, based on a claims 

analysis, the solo practitioner did not submit claims during the performance period for the 

applicable calendar year payment adjustment period. 

§414.1220 [Amended] 

30. Section 414.1220 is amended by removing the phrase “Groups of physicians” and 

adding in its place the phrase “Solo practitioners and groups”. 

31. Section 414.1225 is revised to read as follows: 

§414.1225 Alignment of Physician Quality Reporting System quality measures and quality 

measures for the value-based payment modifier. 

All of the quality measures for which solo practitioners and groups (or individual eligible 

professionals within such groups) are eligible to report under the Physician Quality Reporting 

System in a given calendar year are used to calculate the value-based payment modifier for the 

applicable payment adjustment period, as defined in §414.1215, to the extent a solo practitioner 

or a group (or individual eligible professionals within such group) submit data on such measures. 

32. Section 414.1230 is amended by revising the section heading and the introductory 

text to read as follows: 

§414.1230 Additional measures for groups and solo practitioners. 

The value-based payment modifier includes the following additional quality measures 

(outcome measures) as applicable for all groups and solo practitioners subject to the value-based 

payment modifier: 

* * * * * 

§414.1235 [Amended] 

33. Section 414.1235 is amended in paragraph (a) introductory text by removing the 

phrase “of physicians subject” and add in its place the phrase “and solo practitioners subject”. 
 600 

34. Section 414.1240 is revised to read as follows: 

§414.1240 Attribution for quality of care and cost measures. 

(a) Beneficiaries are attributed to groups and solo practitioners subject to the value-based 

payment modifier using a method generally consistent with the method of assignment of 

beneficiaries under §425.402 of this chapter, for measures other than the Medicare Spending per 

Beneficiary measure. 

(b) For the Medicare Spending per Beneficiary (MSPB) measure, an MSPB episode is 

attributed to the group or the solo practitioner subject to the value-based payment modifier 

whose eligible professionals submitted the plurality of claims (as measured by allowable 

charges) under the group's or solo practitioner’s TIN for Medicare Part B services, rendered 

during an inpatient hospitalization that is an index admission for the MSPB measure during the 

applicable performance period described at §414.1215. 

§414.1245 [Amended] 

35. Section 414.1245 is amended in the introductory text by removing the phrase “of 

physicians subject” and adding in its place the phrase “and solo practitioner subject”. 

36. Section 414.1250 is amended by revising paragraph (a) to read as follows: 

§414.1250 Benchmarks for quality of care measures. 

(a) The benchmark for quality of care measures reported through the PQRS using the 

claims, registries, EHR, or web interface is the national mean for that measure's performance rate 

(regardless of the reporting mechanism) during the year prior to the performance period. In 

calculating the national benchmark, solo practitioners’ and groups’ (or individual eligible 

professionals’ within such groups) performance rates are weighted by the number of 

beneficiaries used to calculate the solo practitioners’ or groups’ (or individual eligible 

professionals’ within such groups) performance rate. 
 601 

* * * * * 

37. Section 414.1255 is amended by revising paragraphs (b) and (c) to read as follows: 

§414.1255 Benchmarks for cost measures. 

* * * * * 

(b) Beginning with the CY 2016 payment adjustment period, the cost measures of a 

group and solo practitioner subject to the value-based payment modifier are adjusted to account 

for the group's and solo practitioner’s specialty mix, by computing the weighted average of the 

national specialty-specific expected costs. Each national specialty-specific expected cost is 

weighted by the proportion of each specialty in the group, the number of eligible professionals of 

each specialty in the group, and the number of beneficiaries attributed to the group. 

(c) The national specialty-specific expected costs referenced in paragraph (b) of this 

section are derived by calculating, for each specialty, the average cost of beneficiaries attributed 

to groups and solo practitioners that include that specialty. 

38. Section 414.1265 is amended by— 

a. In the introductory text, removing the phrase “of physicians subject” and add in its 

place the phrase “or solo practitioner subject”. 

b. Revising paragraph (a) 

The addition reads as follows: 

§414.1265 Reliability of measures. 

* * * * * 

(a) In a performance period, if a group or a solo practitioner has fewer than 20 cases for a 

measure, that measure is excluded from its domain and the remaining measures in the domain are 

given equal weight. 
 602 

(1) Starting with the CY 2017 payment adjustment period, the exception to paragraph (a) 

of this section is the all-cause hospital readmission measure described at §414.1230(c). In a 

performance period, if a group or a solo practitioner has fewer than 200 cases for this all-cause 

hospital readmission measure, that measure is excluded from its domain and the remaining 

measures in the domain are given equal weight. 

(2) [Reserved] 

* * * * * 

39. Section 414.1270 is amended by adding paragraph (c) to read as follows: 

§414.1270 Determination and calculation of Value-Based Payment Modifier adjustments. 

* * * * * 

(c) For the CY 2017 payment adjustment period: 

(1) A downward payment adjustment of −4.0 percent will be applied to a group and a 

solo practitioner subject to the value-based payment modifier if, during the applicable 

performance period as defined in §414.1215, the following apply: 

(i) Such group does not self-nominate for the PQRS GPRO and meet the criteria as a 

group to avoid the PQRS payment adjustment for CY 2017 as specified by CMS; and 

(ii) Fifty percent of the eligible professionals in such group do not meet the criteria as 

individuals to avoid the PQRS payment adjustment for CY 2017 as specified by CMS; or 

(iii) Such solo practitioner does not meet the criteria as an individual to avoid the PQRS 

payment adjustment for CY 2017 as specified by CMS. 

(2) For a group comprised of 10 or more eligible professionals that is not included in 

paragraph (c)(1) of this section, the value-based payment modifier adjustment will be equal to 

the amount determined under §414.1275(c)(3). 
 603 

(3) For a group comprised of between 2 and 9 eligible professionals and a solo 

practitioner that are not included in paragraph (c)(1) of this section, the value-based payment 

modifier adjustment will be equal to the amount determined under §414.1275(c)(3), except that 

such adjustment will be 0.0 percent if the group and the solo practitioner are determined to be 

low quality/high cost, low quality/average cost, or average quality/high cost. 

(4) If all of the eligible professionals in a group and a solo practitioner subject to the 

value-based payment modifier participate as individuals in the PQRS using a qualified clinical 

data registry or any other reporting mechanism available to them, and CMS is unable to receive 

quality performance data for those eligible professionals and the solo practitioner under that 

reporting mechanism, the quality composite score for such group and solo practitioner will be 

classified as “average” under §414.1275(b)(1). 

(5) A group and a solo practitioner subject to the value-based payment modifier will 

receive a cost composite score that is classified as “average” under §414.1275(b)(2) if such 

group and solo practitioner do not have at least one cost measure with at least 20 cases. 

40. Section 414.1275 is amended by— 

a. Revising paragraph (a). 

b. Redesignating paragraphs (d), (d)(1), and (d)(2) as paragraphs (d)(1), (d)(1)(i), and 

(d)(1)(ii), respectively. 

c. Adding paragraphs (c)(3) and (d)(2). 

The revision and additions read as follows: 

§414.1275 Value-based payment modifier quality-tiering scoring methodology.

(a) The value-based payment modifier amount for a group and a solo practitioner subject 

to the value-based payment modifier is based upon a comparison of the composite of quality of 

care measures and a composite of cost measures. 
 604 

* * * * * 

(c) * * * 

(3) The following value-based payment modifier percentages apply to the CY 2017 

payment adjustment period: 

CY 2017 VALUE-BASED PAYMENT MODIFIER AMOUNTS FOR THE QUALITY-TIERING 

APPROACH

Cost/Quality Low Quality Average 

Quality 

High Quality 

Low Cost +0.0% +2.0x* +4.0x* 

Average Cost -2.0% +0.0% +2.0x* 

High Cost -4.0% -2.0% +0.0% 

*Groups and solo practitioners eligible for an additional +1.0x if reporting Physician Quality Reporting System 

quality measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores. 

(d) * * * 

(2) Groups and solo practitioners subject to the value-based payment modifier that have 

an attributed beneficiary population with an average risk score in the top 25 percent of the risk 

scores of beneficiaries nationwide and for the CY 2017 payment adjustment period are subject to 

the quality-tiering approach, receive a greater upward payment adjustment as follows: 

(i) Classified as high quality/low cost receive an upward adjustment of +5x (rather than 

+4x); and 

(ii) Classified as either high quality/average cost or average quality/low cost receive an 

upward adjustment of +3x (rather than +2x). 

§414.1285 [Amended] 

41. Section 414.1285 is amended by removing the phrase “of physicians may” and 

adding in its place the phrase “and a solo practitioner may”. 

PART 425--MEDICARE SHARED SAVINGS PROGRAM

42. The authority citation for part 425 continues to read as follows: 
 605 

Authority: Secs. 1102, 1106, 1871, and 1899 of the Social Security Act (42 U.S.C. 1302 

and 1395hh). 

43. Section 425.502 is amended by-- 

a. In paragraph (a)(1), removing the phrase “of an ACO’s agreement, CMS” and adding 

in its place the phrase “of an ACO’s first agreement period, CMS” 

b. In paragraph (b)(2)(ii), removing the phrase “80.00 percent.” and adding in its place 

the phrase “80.00 percent, or when the 90th percentile is equal to or greater than 95%.” 

c. Revising paragraph (a)(2). 

d. Adding paragraphs (a)(3) and (4), (b)(4), and (e)(4). 

The revision and additions read as follows:

§425.502 Calculating the ACO quality performance score. 

(a) * * * 

(2) During subsequent performance years of the ACO’s first agreement period, the 

quality performance standard will be phased in such that the ACO must continue to report all 

measures but the ACO will be assessed on performance based on the quality performance 

benchmark and minimum attainment level of certain measures. 

(3) Under the quality performance standard for each performance year of an ACO’s 

subsequent agreement period, the ACO must continue to report on all measures but the ACO will 

be assessed on performance based on the quality performance benchmark and minimum 

attainment level of certain measures. 

(4) The quality performance standard for a measure introduced during an ACO’s 

agreement period is set at the level of complete and accurate reporting for the first performance 

year for which reporting of the measure is required. For subsequent performance years, the 
 606 

quality performance standard for the measure will be assessed according to the phase-in schedule 

for the measure. 

(b) * * * 

(4) (i) CMS will update the quality performance benchmarks every 2 years. 

(ii) For measures introduced in the first year of the 2-year benchmarking cycle, the 

benchmark will be established in the second year and updated along with the other measures at 

the start of the next 2-year benchmarking cycle. 

* * * * * 

(e) * * * 

(4) (i) ACOs that demonstrate quality improvement on established quality measures from 

year to year will be eligible for up to 2 bonus points per domain. 

(ii) Bonus points are awarded based on an ACO’s net improvement in measures within a 

domain, which is calculated by determining the total number of significantly improved measures 

and subtracting the total number of significantly declined measures. 

(iii) Up to two bonus points are awarded based on a comparison of the ACO’s net 

improvement in performance on the measures for the domain to the total number of individual 

measures in the domain. 

(iv) When bonus points are added to points earned for the quality measures in the 

domain, the total points received for the domain may not exceed the maximum total points for 

the domain in the absence of the quality improvement measure. 

(v) If an ACO renews its participation agreement for a subsequent agreement period, 

quality improvement will be measured based on a comparison between performance in the first 

year of the new agreement period and performance in the third year of the previous agreement 

period. 
 607 

44. Section 425.506 is amended by revising the section heading and adding paragraph 

(d) to read as follows:

§425.506 Incorporating reporting requirements related to adoption of electronic health 

records technology. 

* * * * * * 

(d) Eligible professionals participating in an ACO under the Shared Savings Program 

satisfy the CQM reporting component of meaningful use for the Medicare EHR Incentive 

Program when the following occurs: 

(1) The eligible professional extracts data necessary for the ACO to satisfy the quality 

reporting requirements under this subpart from certified EHR technology. 

(2) The ACO reports the ACO GPRO measures through a CMS web interface. 

PART 498—APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT 

PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS 

THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE 

MEDICAID PROGRAM 

45. The authority citation for part 498 continues to read as follows: 

Authority: Secs. 1102, 1128I and 1871 of the Social Security Act (42 U.S.C. 1302, 

1320a-7j, and 1395hh). 

46. Section 498.3 is amended by adding paragraph (b)(19) to read as follows: 

§498.3 Scope and applicability. 

 * * * * * 

(b) * * * 
 608 

(19) Whether a physician or practitioner has failed to properly opt-out, failed to maintain 

opt-out, failed to timely renew opt-out, failed to privately contract, or failed to properly terminate 

opt-out. 

 * * * * * 
 

Dated: June 13, 2014. 

 _______________________________ 

Marilyn Tavenner, 

Administrator, 

 Centers for Medicare & Medicaid Services. 

Approved: June 19, 2014. 

 __________________________________ 

Sylvia M. Burwell, 

Secretary, 

Department of Health and Human Services. 

BILLING CODE 4120-01-P

[FR Doc. 2014-15948 Filed 07/03/2014 at 4:15 pm; Publication Date: 07/11/2014]