Vol. 79 Friday, 

No. 133 July 11, 2014 

Part III 

Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

42 CFR Parts 403, 405, 410, et al. 

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; Proposed Rule 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40318 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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, 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-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. 

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 confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http:// 

www.regulations.gov. Follow the search 

instructions on that Web site 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, 


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Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40319 

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 

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 Web site 

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 

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 

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 

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 

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 

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 

TAP Technical Advisory Panel 

TC Technical component 

TIN Tax identification number 

UAF Update adjustment factor 


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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 Web Site 

The PFS Addenda along with other 

supporting documents and tables 

referenced in this proposed rule are 

available through the Internet on the 

CMS Web site at http://www.cms.gov/

Medicare/Medicare-Fee-for-ServicePayment/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 

Web site 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 

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 Web site. 

++ Physician Quality Reporting 

System. 

++ 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 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 


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Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40321 

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 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 resourcebased 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) 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 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. 

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 


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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 productivityadjusted 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 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 × GPCI work) + 

(RVU PE × GPCI PE) + (RVU MP × 

GPCI MP)] × 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. 

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 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. 

• 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 


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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 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 HIEfocused 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 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/policyresearchers-implementers/standardsand-certification-regulations. 

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 servicespecific 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 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). 


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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 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 Medicarerecognized 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 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: 

• 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, 


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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 specialtyspecific indirect PE/HR data into the 

calculation. In our example, if, based on 

the survey data, the average indirect 

cost of the 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.) 

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 

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 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. 

Step 12: Using the results of Step 11, 

calculate aggregate pools of specialtyspecific adjusted indirect PE allocators 

for all PFS services for a specialty by 

adding the product of the adjusted 


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indirect PE allocator for each service 

and the utilization data for that service. 

Step 13: Using the specialty-specific 

indirect PE/HR data, calculate specialtyspecific 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 specialtyspecific 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 

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 lowvolume 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. 

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, 

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. 

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. 


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TABLE 2—APPLICATION OF PAYMENT MODIFIERS TO UTILIZATION FILES—Continued 

Modifier Description Volume adjustment Time adjustment 

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 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 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 

(percent) 

<$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 

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 

x-ray, 

Nonfacility 

71020–26 

Chest xray, 

Nonfacility 

93000 

ECG, 

complete, 

Nonfacility 

93005 

ECG, 

tracing 

Nonfacility 

(1) Labor cost (Lab) ...................... Step 1 ...... AMA ........................ ................................. 13.32 77.52 5.74 5.74 0.00 5.10 5.10 0.00 

(2) Supply cost (Sup) .................... Step 1 ...... AMA ........................ ................................. 2.98 7.34 .53 .53 0.00 1.19 1.19 0.00 

(3) Equipment cost (Eqp) ............. Step 1 ...... AMA ........................ ................................. 0.17 0.58 6.92 6.92 0.00 0.09 0.09 0.00 

(4) Direct cost (Dir) ....................... Step 1 ...... ................................. =(1)+(2)+(3) ............ 16.48 85.45 13.19 13.19 0.00 6.38 6.38 0.00 

(5) Direct adjustment (Dir. Adj.) .... Steps 2–4 See footnote* .......... ................................. 0.5898 0.5898 0.5898 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 3.01 3.01 0.00 

(7) Adjusted Supplies ................... Steps 2–4 =Eqp * Dir Adj ........ =(2)*(5) ................... 1.76 4.33 .31 .31 0.00 .70 .70 0.00 

(8) Adjusted Equipment ................ Steps 2–4 =Sup * Dir Adj ........ =(3)*(5) ................... .10 0.34 4.08 4.08 0.00 0.05 0.05 0.00 

(9) Adjusted Direct ........................ Steps 2–4 ................................. =(6)+(7)+(8) ............ 9.72 50.40 7.78 7.78 0.00 3.77 3.77 0.00 

(10) Conversion Factor (CF) ........ Step 5 ...... PFS ......................... ................................. 35.8228 35.8228 35.8228 35.8228 35.8228 35.8228 35.8228 35.8228 

(11) Adj. labor cost converted ...... Step 5 ...... =(Lab * Dir Adj)/CF =(6)/(10) .................. 0.22 1.28 0.09 0.09 0.00 0.08 0.08 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 0.02 0.02 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 0.00 0.00 0.00 

(14) Adj. direct cost converted ..... Step 5 ...... ................................. =(11)+(12)+(13) ...... 0.27 1.41 0.22 0.22 0.00 0.11 0.11 0.00 

(15) Work RVU ............................. Setup File PFS ......................... ................................. 0.97 33.75 0.22 0.00 0.22 0.17 0.00 0.17 

(16) Dir_pct ................................... Steps 6,7 Surveys ................... ................................. 0.25 0.17 0.29 0.29 .29 .29 .29 .29 

(17) Ind_pct ................................... Steps 6,7 Surveys ................... ................................. 0.75 .83 .71 .71 .71 .71 .71 .71 

(18) Ind. Alloc. Formula (1st part) Step 8 ...... See Step 8 ............. ................................. ((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

((14)/ 

(16))*(17) 

(19) Ind. Alloc.(1st part) ................ Step 8 ...... ................................. See 18 .................... 0.82 6.67 .53 .53 0 0.26 0.26 0 

(20) Ind. Alloc. Formula (2nd part) Step 8 ...... See Step 8 ............. ................................. (15) (15) (15+11) (11) (15) (15+11) (11) (15) 

(21) Ind. Alloc.(2nd part) ............... Step 8 ...... ................................. See 20 .................... 0.97 33.75 0.31 0.09 0.22 0.25 0.08 0.17 

(22) Indirect Allocator (1st + 2nd) Step 8 ...... ................................. =(19)+(21) ............... 1.79 40.42 .84 .62 0.22 0.51 0.34 0.17 


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TABLE 4—CALCULATION OF PE RVUS UNDER METHODOLOGY FOR SELECTED CODES—Continued 

Step Source Formula 

99213 

Office 

visit, est 

Nonfacility 

33533 

CABG, 

arterial, 

single 

Facility 

71020 

Chest xray 

Nonfacility 

71020– 

TC Chest 

x-ray, 

Nonfacility 

71020–26 

Chest xray, 

Nonfacility 

93000 

ECG, 

complete, Nonfacility 

93005 

ECG, 

tracing 

Nonfacility 

(23) Indirect Adjustment (Ind. Adj.) Steps 9– 

11.

See Footnote** ....... ................................. .3813 .3813 .3813 .3813 .3813 .3813 .3813 .3813 

(24) Adjusted Indirect Allocator .... Steps 9– 

11.

=Ind Alloc * Ind Adj ................................. 0.68 15.41 .32 .24 0.08 0.20 0.13 .06 

(25) Ind. Practice Cost Index 

(IPCI).

Steps 12– 

16.

................................. ................................. 1.07 0.75 .99 .99 .99 0.91 0.91 0.91 

(26) Adjusted Indirect ................... Step 17 .... = Adj.Ind Alloc * PCI =(24)*(25) ............... 0.73 11.59 .32 .24 0.08 0.18 0.12 0.06 

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

* Other Adj.

=((14)+(26)) * Other 

Adj).

1.01 13.05 .53 .45 .08 .29 .23 0.06 

* 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. 

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 Web site under 

downloads for the CY 2015 PFS 

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

Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFSFederal-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 postprocedure 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 Web site under 

the supporting data files for the CY 2015 

PFS proposed rule at http:// 

www.cms.gov/PhysicianFeeSched/. 

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 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 


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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 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 postservice clinical labor time to ED021, 

since the film supply and/or equipment 

inputs were previously associated with 

the post-service period. 

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 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. 

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. 


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TABLE 7—CODES CONTAINING FILM

INPUTS BUT EXCLUDED FROM THE

RUC RECOMMENDATION—Continued 

HCPCS Short descriptor 

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. 

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 labor-intensive 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 post-service 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 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 Web site 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. 

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 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 


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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. 

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, intraservice, 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 prepositioning 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. 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 Web site 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-Fee-for-ServicePayment/PhysicianFeeSched/PFSFederal-Regulation-Notices-Items/CMS1600-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 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 


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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 

Web site under the supporting data files 

for the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFee

Sched/. 

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 Web site 

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

Medical supply description CMS supply code Unit Quantity Price 

Imaging w/Contrast—Standard Package 

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 nonrobotic delivery methods. Until now, 

SRS services furnished using robotic 

methods were billed using contractorpriced 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 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 


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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 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 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 non-facility 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 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 

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 


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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. 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 offcampus 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 offcampus 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 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. 

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 

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 


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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. 

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; 

• Codes which have not been subject 

to review since the implementation of 

the RBRVS (the so-called ‘Harvardvalued 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, 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 five-year 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 73055 through 73958), and 

established a process for the annual 


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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 Harvardvalued 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 Harvardvalued 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 

Harvard-valued 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 postoperative 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 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. 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 Web site at 

http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/

PhysicianFeeSched/Downloads/RVUsValidation-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 

Web site. 

Descriptions of both projects are 

available on the CMS Web site at 

http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/

PhysicianFeeSched/Downloads/RVUsValidation-Model.pdf. 

3. CY 2015 Identification and Review 

of Potentially Misvalued Services 

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 


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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). 

• 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, 

automated-refraction), bilateral) was 

also nominated for review as a 

potentially misvalued code. The 

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 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. 

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. 


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TABLE 10—PROPOSED POTENTIALLY

MISVALUED CODES IDENTIFIED

THROUGH HIGH EXPENDITURE SPECIALTY SCREEN—Continued 

HCPCS Short descriptor 

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. 

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 

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 RUC-recommended 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 radiographic-fluoroscopy 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 

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 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, 


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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), 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 

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 Web 

site under downloads for the CY 2015 

PFS proposed rule at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/

PhysicianFeeSched/PFS-FederalRegulation-Notices.html. The direct PE 

inputs are displayed the file ‘‘CY 2015 

PFS Direct PE Inputs,’’ available on the 

CMS Web site under downloads for the 

CY 2015 PFS proposed rule at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/

PhysicianFeeSched/PFS-FederalRegulation-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 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 


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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 (mammography; 

unilateral), 77056 (mammography; 

bilateral) and 77057 (screening 

mammography, bilateral (2-view film 

study of each breast)) and HCPCS Gcodes, (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 Gcodes 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 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 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 Web 

site under downloads for the CY 2015 

PFS proposed rule at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/

PhysicianFeeSched/PFS-FederalRegulation-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: 

• 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 


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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 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 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 Web site 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 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—Intraoperative 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; 

• Postsurgical Pain Management—By 

the surgeon; 

• Supplies—Except for those 

identified as exclusions; and 


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• 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 resource-based 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 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 postoperative 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 postoperative portion of the 10- and 90-day 

global codes, we believe these multilayered concerns create substantial 

barriers to accurate valuation of these 

services relative to other PFS services. 

(1) Fundamental Limitations in the 

Appropriate Valuation of the Global 

Packages With Post-Operative 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 twofold, 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 

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 post-operative 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. 


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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 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 postoperative 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 postoperative 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’’ (A–05–07–00077), 

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 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 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 post-operative 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 

post-operative 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 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. 


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(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 post-operative 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 service furnished. 

When global surgery values are based on 

inaccurate assumptions about the 

typical services furnished in the postoperative 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. 

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 postoperative 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 provider-based 

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 postoperative global periods might include 

clinical labor, 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 longestablished 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 teambased 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, 


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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 

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 postoperative 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-toface 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. 

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 postoperative periods. We acknowledge that 

collecting information on these services 

through claims submission may be the 

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 postoperative 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 postoperative 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. 

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 


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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. 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 post-operative 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 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 in 2007. 

With its comment letter, the RUC sent 

us a data file with updated times for 

these post-operative 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. 


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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 

time 99231 99232 99233 99238 99291 99292 

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 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 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 


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40348 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules TABLE 11—PROPOSED

WORK

TIME

CHANGES IN

SELECTED

GLOBAL

SURGICAL

PACKAGE

VISITS—Continued 

CPT 

code Short descriptor 

Visits included in Global Package CY 2014 

time 

CY 2015 

time 99231 99232 99233 99238 99291 99292 

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 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40349 

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. 

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. 

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. 

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 specialty-specific 

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 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40350 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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. 

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. 

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. 

b. Steps for Calculating Proposed 

Malpractice RVUs 

Calculation of the proposed MP RVUs 

conceptually follows the specialtyweighted 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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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 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 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 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. 


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• 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. 

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 TConly 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 

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 ............................


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TABLE 14—RISK FACTORS BY SPECIALTY TYPE—Continued 

Specialty 

code Medicare specialty name Non-surgical risk factor 

Surgical risk 

factor 

46 ................. Endocrinology ........................................................................................................................ 1.65 4.23 

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 

(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 specialty-specific 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 specialty-specific 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. 

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. 


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TABLE 15—SERVICES OUTSIDE OF

SURGICAL HCPCS CODE RANGE

CONSIDERED SURGERY—Continued 

HCPCS 

code Short descriptor 

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. 

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 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 Web site 

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. 

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 Web site. 

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 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 


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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. 

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 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 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 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 


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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

GPCI/GAF 

1/1/2015 through 3/31/2015 

(with 1.0 work GPCI floor) 

4/1/2015 through 12/31/2015 

(without 1.0 work GPCI floor) 

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 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 Web site. It is located under the 

supporting documents section of the CY 

2015 PFS proposed rule located at 

http://www.cms.gov/

PhysicianFeeSched/. 

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, 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), store-and-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 


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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. 

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 Web site tool to 

provide assistance to potential 

originating sites to determine their 

geographic status. To access this tool, 

see the CMS Web site 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 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 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 in-person 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 Web site 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 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 Web site 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 


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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); 

• 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, realtime 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 m-mode 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). 

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. 

• 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 testing (eg, 

Halstead-Reitan Neuropsychological 


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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 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 G–codes. 

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 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 Web site. 

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 fiveyear 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 five-year 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 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 


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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 

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 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. 

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 Web site 

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 


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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 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 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 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 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 


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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. 

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 

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. 

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 


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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. 

(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 Web 

site 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 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 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 Gcodes 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 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 


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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 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 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 fiveyear 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 any additional 

data for our consideration and 

discussing any concerns with our 

proposed values than the current 

refinement process. 

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 long-term 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) Web 

site 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 

Web site at http://innovation.cms.gov/

initiatives/Advance-Payment-ACOModel/). 

• The Primary Care Incentive 

Payment (PCIP) Program (described on 

the CMS Web site 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 

Web site at www.cms.gov/Medicare/

Demonstration-Projects/

DemoProjectsEvalRpts/downloads/

mapcpdemo_Factsheet.pdf). 


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• The Federally Qualified Health 

Center (FQHC) Advanced Primary Care 

Practice demonstration (described on 

the CMS Web site at http:// 

www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/ 

Downloads/FQHC_APCP_

Demo_FAQsOct2011.pdf and the 

Innovation Center’s Web site at 

www.innovations.cms.gov/initiatives/

FQHCs/index.html). 

• The Comprehensive Primary Care 

(CPC) initiative (described on the 

Innovation Center’s Web site at http:// 

innovations.cms.gov/initiatives/

Comprehensive-Primary-Care-Initiative/

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 Web site 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 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 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 nonface-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 Web site in 

the Downloads section for the CY 2015 

PFS proposed rule at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/

PhysicianFeeSched/PFS-FederalRegulation-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 Web site under 

the supporting data files for the CY 2015 

PFS proposed rule at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/

PhysicianFeeSched/PFS-FederalRegulation-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. 

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 


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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 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 

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 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-toface 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. 

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 


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‘‘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 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 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 

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 


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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 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. 

• 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 faceto-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 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 which 

these services may not actually be 

duplicative and, if so, how our 

reimbursement policy could be tailored 

to address those situations. 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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1Faulx, 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. 

2Liu 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. 

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 

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 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 

§ 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 


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4See, for example, 1997 Documentation 

Guidelines for Evaluation and Management Service, 

p. 45. 

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. 

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 

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 

consumer-mediated exchange of images, 

have greatly increased physicians’ 

access to existing diagnostic-quality 

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: 

• 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 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 


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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. 

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). 

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 ESRDrelated 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 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 face-to-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. 

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 


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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)). 

These statutory requirements are selfimplementing. 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 CMSsupplied 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 December 26, 2013, as 

Division B (Medicare and Other Health 

Provisions) of Public Law 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 selfimplementing. 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) 

++ Advanced Life Support, Level 1 

(ALS1) (emergency and nonemergency) 

++ 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 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 


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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 

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. 

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 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 Web site for a detailed listing of 

updated RUCA codes found at http:// 

www.ers.usda.gov/data-products/ruralurban-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. 


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(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 Web site: 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 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 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 

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. 


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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 

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 

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 


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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. 

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 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. 

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, 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 


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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 patientreported 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? 

• 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 cost-shifting 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 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 Governorsponsored, 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 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 


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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. 

• 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. 

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 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 timeconsuming 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, 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 


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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 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 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 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 claim-by-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 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 


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reasons: to liberalize an existing LCD; 

being issued for a compelling reason; 

making a non-substantive correction; 

providing a clarification; making a nondiscretionary 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-coveragedatabase/overview-and-quicksearch.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 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 Web 

site. 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 

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 transparent process with 

the ability to efficiently review clinical 

laboratory tests for coverage. We 

encourage public comment on all 

aspects of this proposed process. 

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 optVerDate Mar<15>2010 22:08 Jul 10, 2014 Jkt 232001 PO 00000 Frm 00064 Fmt 4701 Sfmt 4702 E:\FR\FM\11JYP3.SGM 11JYP3

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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. 

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 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 crossreference 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 

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.’’ 


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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 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 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 

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, 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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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.’’ 

(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 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 selfreferral 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. 

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 

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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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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 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 

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 

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. 


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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. 

J. Physician Compare Web site 

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 Web site 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. 

• 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 Web site 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-PatientAssessment-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. 

• 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. 

2. Public Reporting of Performance and 

Other Data 

Since the initial launch of the Web 

site, 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 


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5By ‘‘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. 

function—and considerably improving 

Web site 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, Web site 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 Web site 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 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 Web 

site 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 Web site 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 

Web site 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 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 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 betabinomial 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 


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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 

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 Web site 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 

Web site (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 

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 CG–CAHPS 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 CMSapproved 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. 

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. 


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6Tables Q1–Q27 detail proposed changes to 

available PQRS measures. Additional information 

on PQRS measures can be found on the CMS.gov 

PQRS Web site at http://www.cms.gov/Medicare/

Quality-Initiatives-Patient-Assessment-Instruments/

PQRS/index.html. 

TABLE 19—SUMMARY OF PREVIOUSLY FINALIZED POLICIES FOR PUBLIC REPORTING ON PHYSICIAN COMPARE—Continued 

Data collection year Public reporting year Reporting mechanism(s) Quality measures and data for public reporting 

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 2014 .. 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. 

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 Web site. 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 

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 


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7By 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. 

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 Web site. 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 Web 

site. 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 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. 

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 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/Medicare-Fee-for-ServicePayment/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 


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40390 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

8Tables Q1–Q27 detail proposed changes to 

available PQRS measures. Additional information 

on PQRS measures can be found on the CMS.gov 

PQRS Web site at http://www.cms.gov/Medicare/

Quality-Initiatives-Patient-Assessment-Instruments/ 

PQRS/index.html. 

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 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 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 Web site. 

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 determine specifically 

which measures are published on 

profile pages on the Web site. 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. 

Previously, we indicated an interest 

in including specialty society measures 

on Physician Compare. We now seek 

comment on posting these measures on 

the Web site. We also seek comment on 

the option of linking from Physician 

Compare to specialty society Web sites 

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 


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9http://www.cms.gov/apps/ama/

license.asp?file=/PQRS/downloads/2014_PQRS_

IndClaimsRegistry_MeasureSpecs_SupportingDocs_

12132013.zip. 

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 

Web site and allow Physician Compare 

to link to it or if they will provide data 

to us for public reporting on 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 

Web site. 

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 Web site’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.

CMS-Specified 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. 

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. 

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. 

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 


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information on the PQRS, including 

related laws and established 

requirements, are available at http:// 

www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/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-eRxExperience-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 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 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 crosscutting 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 crosscutting 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 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. 


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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 

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-and-Guidance/Legislation/

EHRIncentivePrograms/Downloads/

Guide_QRDA_2014eCQM.pdf. Updated 

guides for 2015, when available, will be 

posted on the CMS EHR Incentive 

Program Web site at http:// 

www.cms.gov/Regulations-andGuidance/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 

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 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 CMS-certified survey vendor. 

However, although CAHPS for PQRS is 

technically contained in the 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 


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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 

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 Web sites, 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 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. 

• 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, 


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2016, for reporting periods occurring in 

2015). 

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 

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 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 cross-cutting 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-to-face 

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-Rulemaking_Report_

_2014_Recommendations_on_

Measures_for_More_than_20_Federal_

Programs.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 crosscutting 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-toface 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 


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require reporting of at least 2 crosscutting 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 crosscutting measures specified in Table 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-PatientAssessment-Instruments/PQRS/

Downloads/2014_PQRS_Claims_

MeasureApplicabilityValidation_

12132013.zip. For more information on 

the registry MAV process, please visit 

http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_

PQRS_Registry_

MeasureApplicabilityValidation_

12132013.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 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 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. 

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 


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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 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. 

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/QualityInitiatives-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 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, 


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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. 

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 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 claimsbased 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 

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 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 


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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 

visit http://www.cms.gov/Medicare/ 

Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_

PQRS_Registry_MeasureApplicability

Validation_12132013.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 CMSCertified 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 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 crosscutting measure if a group practice sees 

at least 1 Medicare patient in a face-toface 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 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 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 

visit http://www.cms.gov/Medicare/ 

Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_

PQRS_Registry_MeasureApplicability

Validation_12132013.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 


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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 

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 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 

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 (S–CAHPS). 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 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 S–CAHPS 

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 


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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 

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 pre-rulemaking 

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 multistakeholder 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 

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-basedonly 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 

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. 

(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 


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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. 

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 non-substantive 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 Web site at 

http://www.cms.gov/Medicare/QualityInitiatives-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 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 first-time 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 Web site at http:// 

www.cms.gov/Medicare/QualityInitiatives-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 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 


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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 crosscutting measure set specified in Table 

21 for 2015 and beyond. 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. 

In addition to seeking comment on this 

proposed cross-cutting 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. 

BILLING CODE 4120–01–P 


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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 

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~j= .. .. "' >. ... ,..,. NQS :::: ... ~ e. g .:: s = "' s > .b a: 0'5 Measure Title and Description¥ ~ ~ ., Domain ·; r:J'J ·o;, ::: 0~ ., = = 0 O'~f 'Z ... ... ... :.;:~ u .... "' .. -c.~ 0 ... a: ... r..'J a: ... c: ~0 ... ... .. ;a: ... o- 0 

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 

N/A Community exception to the requirement that the Secretary NCQA/ 

IN/A N/A /Population select measures that have been endorsed by the NCIQM X X 

Health 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. 

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. 

Community Rationale: This measure has been identified as ACO 

0028 138 AMA- MU2 

/226 v2 /Population a cross-cutting measure as it represents a PCP£ X X X X X Million Health screening assessment for tobacco use that most Hearts 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). 

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 

0038 117 Community (HiB); three hepatitis B (Hep B); one chicken 

/240 v2 /Population pox (VZV); four pneumococcal conjugate NCQA X MU2 

Health (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 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40405 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.010</GPH>

" ~J- ~· CJJ"' .... ""O "' -- [fJ 

~~= .... .... "' » ;:::: " ~ e ~ .5 E ... IX NQS = "' .5 > .... IX 

~~ Measure Title and Description¥ ~ ~ Domain <;; '-'~ = = o~e " .. .. [fJ "61 ::: 0 .... "' c u l.l.l "' .... ....~~ ~iJi 0 " IXIX~ "o " "' .... l.l.l Po. = ~ fiiXP. o- 0 

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). 

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. 

0418 Community ACO 

1134 2v3 /Population Rationale: This measure represents a screening CMS/QIP X X X X X MU2 Health 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 rcportability 

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). 

Documentation of Current Medications in 

the :vledical 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 

0419 68v Patient medications' name, dosage, frequency and route ACO 

1130 3 Safety of administration. CMS/QIP X X X X X MU2 

Rationale: This measure targets the 

documentation of current medications in the 

medical record, which is a clinical process that 

most eligible professionals may perfonn 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). 

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 BMT is outside of normal parameters, 

0421 69v Community a follow-up plan is documented during the ACO 

1128 2 /Population encounter or during the previous 6 months of CMS/QIP X X X X X MU2 Health the encounter. 

Normal Parameters: Age 65 years and older 

BMl > 23 and< 30; Age 18-64 years BMI > 

18.5 and< 25 

Rationale: This measure has been identified as 
40406 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.011</GPH>

" .... ""O ~J- ~CJJ"' "' -- [fJ 

~~= .... .... "' » ;:::: " ~ 8- ~ .5 E ... IX NQS = "' E > .... IX 

~~ Measure Title and Description¥ ~ ~ Domain ·; [fJ '61 

<;; ::: '-'~ "' = = c o~e " "' u 0 .... ~[Ji 0 "' l.l.l IX~ "'-' "' .... -~~ ~ IX "' "' .... Po. = ~ ..SIX Po. "- 0 

a cross-cutting measure as it represents a 

screening assessment for BMI that most eligible 

professionals may perfom1 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 

mle (see Table 52 at 78 FR 74498). 

Closing the Referral Loop: Receipt of 

Specialist Report: Percentage of patients with 

referrals, regardless of age, for which the 

referring provider receives a report ti·om the 

provider to whom the patient was referred. 

Communica Rationale: This measure represents tion and NIA 50v Care communication between a variety of eligible CMS/BAH X MU2 /374 2 Coordinatio professionals and promotes positive outcomes 

for patients. It is reportable by a broad spectmm n 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). 

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 

Communica reconciliation of the discharge medications with 

tion and the current medication list in the outpatient AMA- 0097 N/A Care medical record documented. PCP!/ X /046 Coordinatio NCQA Rationale: This measure has been identified as n 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 mle (see Table 95 at 77 FR 

69215). 

Preventive Care and Screening: Influenza 

Immunization: Percentage of patients aged 6 

months and older seen for a visit between 

October 1 and March 3 I who received an 

influenza immunization OR who reported 

previous receipt of an influenza immunization. 

0041 147 Community AMA- ACO 

/110 v2 /Population Rationale: This measure represents a screening PCP I X X X X X MU2 Health 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). 

0043 127 Community Pneumonia Vaccination Status for Older ACO 

/Ill v2 /Population Adults: Percentage of patients 65 years of age NCQA X X X X X MU2 Health and older who have ever received a 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40407 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.012</GPH>

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~~ Measure Title and Description¥ ~ ~ Domain <;; '-'~ = = " .. "' [fJ '61 ~iJi 0 u ::: 

l.l.l 0 .... "' "' .... 

c ~8.~ " IXIX~ "o " "' .... l.l.l Po. = ~ fiiXP. o- 0 

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). 

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 cmTent blood pressure 

Community reading as indicated. ACO 

N/A 22v MU2 

1317 2 /Population Rationale: This measure represents a common CMS/QIP X X X X X Million Health screening assessment for high blood pressure Hearts 

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). 

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 

0101 139 Patient professionals may perform and is applicable to NCQA X X ACO 

1318 v2 Safety most elderly patients. This screen tool may be MU2 

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). 

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 

Person and surrogate decision maker or provide an care 

Caregiver- plan. AMA- 0326 N/A Centered PCP!/ X X X 1047 Experience Rationale: This measure has been identified as NCQA and a cross-cutting measure as it represents the 

Outcomes 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). 
40408 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.013</GPH>

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~~ ~ ~ = = Domain ·a [fl 'Sb = "' c 0 .... " " u 0 .... <II .... :...=..~ ~[Ji 0 " l.l.l IX~ ~ IX "''-' "' "' .... Po. = ~ ;liXP. "- 0 

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 

Communica present. 

0420 tion and Rationale: This measure represents a screening N/A Care CMS/QIP X X X /131 Coordinatio assessment for pain and follow-up care that 

most eligible professionals may perform and is n 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). 

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 

Communica based on identified functional outcome 

AQA tion and deficiencies on the date of the identified 

Adopt N/A Care deficiencies. CMS/QTP X X ed 

/182 Coordinatio Rationale: This measure has been identified as n 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). 

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: 

Person and • Between Visit Communication; 

0005 Caregiver • Helping Your to Take Medication as Directed; 

&000 and 

6 N/A Experience • Stewardship of Patient Resources AHRQ X ACO 

and /321 Outcomes 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). 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40409 

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 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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.014</GPH>
40410 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.015</GPH>

TABLE 22: Proposed Individual Quality Measures and Those Included in Measures 

Groups for the PQRS to Be Available for Satisfactory Reporting Beginning in 2015 

"""0 ~ -}: "' OJ)"' 

-oo ill ... ... "' ;.. 

~'"' "" "' .... c.s s '""::t:: NQS = " s >- .;;: ::t:: .... c. Measure Title and Description' ~ ~ --~ = = Qj•- ..... C: 0' 0' . Domain "' ;-a;~ "' "' ·; "' ... ::X: 0 ... "' ~ Z:l.. u "" " .... 0 =c.~ ~00 0 ::t:: "" ::t:: "" ::;o =-~ o ..... o- ::t::=.. 

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 

187 medication [defined as a Proportion of Days 

9 N/A Patient Safety Covered (PDC)] of at least 0.8 during the CMS/ X IN/ measurement period (12 consecutive months). FMQAI 

A 

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. 

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 1 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). 

N/A CMS/FMQ IN/ N/A Patient Safety Rationale: We are proposing this measure based X 

A on our exception authority under section AI 

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. 

Adult Primary Rhegmatogenous Retinal 

Detachment Reoperation Rate: % of surgeries 

for primary rhef,rmatogenous retinal detachment 

where the retina remains attached after only one 

surgery. 

N/A Rationale: We are proposing this measure based 

IN/ N/A Effective on our exception authority under section AA X 

A Clinical Care 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 

IE] Opthamologists. 

Effective Adult Primary Rhegmatogenous Retinal American 

Clinical Care Detachment Surgery Success Rate: Percentage Association X 

(% ) of Retinal Detachment cases achieving f1at of Eye and 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40411 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.016</GPH>

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retinas 6 months post surgery. Ear Centers 

"-

of 

Rationale: We are proposing this measure based Excellence 

on our exception authority under section I The 

1848(k)(2)(C)(ii) of the Act that provides an Australian 

exception to the requirement that the Secretary Council on 

select measures that have been endorsed by the Healthcare 

entity with a contract under section 1890(a) of Standards 

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. 

ALS Patient Care Preferences: Percentage of 

patients diagnosed with ALS who were offered at 

least once annually assistance in planning for end 

oflife issues (e.g., advance directives, invasive 

ventilation, hospice). 

Person and Rationale: We are proposing this measure based 

N/A Caregiver- on our exception authority under section 

IN/ N/A Centered 1848(k)(2)(C)(ii) of the Act that provides an AAN X 

A Experience exception to the requirement that the Secretary 

and select measures that have been endorsed by the 

Outcomes 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 cLment clinical gap in the 

program for neurodegenerative disease. This 

measure would be reportable for eligible 

professionals within the scope of neurology. 

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. 

N/A Rationale: We are proposing this measure based AGA/ 

!NI N/A Effective on our exception authority under section AASLD/ X 

A Clinical Care l848(k)(2)(C)(ii) of the Act that provides an PCP! 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. 

Average change in functional status following 

lumbar spine fusion surgery: Average change 

from pre-operative timctional status assessment 

to 1 year (9 to 15 months) post-operative 

Person and functional status using the Oswestry Disability 

N/A Caregiver- Index (ODI version 2.la) patient reported 

IN/ N/A Centered outcome tool. MNCM X 

A Experience 

and Rationale: We are proposing this measure based 

Outcomes 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 
40412 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.017</GPH>

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.... '-'~ = = Qj ·- -- ~ "' z2' ""- Domain ·; 00 '51 = "' 0 -sc;~Si; u~ "" "" u "" 0 .. "' .. 0 = Q.. 0 ~tZi u "' C:::.;l ~ c::: ~" C'"' .. Q.. = C:::i:l.. 1.:)-

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. 

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. 

N/A Efficiency Rationale: We are proposing this measure based 

IN/ N/A and Cost on our exception authority under section ACEP X 

A Reduction 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 prof,rram gap and targets a provider 

group currently under represented in the 

program, imaging specialists and radiologists. 

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 

N/A on our exception authority under section AAEECE/ IN/ N/A Patient Safety 1848(k)(2)(C)(ii) of the Act that provides an ACHS X X 

A 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. 

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 

N/A Effective 1848(k)(2)(C)(ii) of the Act that provides an AAEECE/ IN/ N/A Clinical Care exception to the requirement that the Secretary ACHS X X 

A 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. 

Depression Response at Twelve MonthsPerson and Progress Towards Remission: Adult patients 

188 Caregiver- age 18 and older with major depression or 

5 N/A Centered dysthymia and an initial PHQ-9 score > 9 who MNCM X IN! Experience demonstrate a response to treatment at twelve 

A and months defined as a PHQ-9 score that is reduced 

Outcomes by 50% or f,>Teater from the initial PHQ-9 score. 

This measure applies to both patients with newly 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40413 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.018</GPH>

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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. 

Discontinuation of Antiviral Therapy for 

Inadequate Viral Response: Percentage of 

patients aged 18 years and older with a diagnosis 

of hepatitis C genotype I who have an 

inadequate response to antiviral treatment for 

whom antiviral treatment was discontinued. 

N/A Rationale: We are proposing this measure based AGA/ 

IN/ N/A Patient Safety on our exception authority under section AASLD/ X 

A l848(k)(2)(C)(ii) of the Act that provides an PCP! 

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. 

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: 

Person and • Treatment choices appropriate to genotype 

Caregiver- • Risks and benefits 

N/A • Evidence of effectiveness AGA/ 

IN/ N/A Centered • Patient preferences toward the outcome of AASLD/ X X Experience A and the treatment. PCPI 

Outcomes 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. 

Follow-up After Hospitalization for Mental 

Illness: The percentage of discharges for 

N/A Communicati patients 6 years of age and older who were 

IN/ N!A on and Care hospitalized for treatment of selected mental NCQA X 

A Coordination illness diagnoses and who had an outpatient visit, 

an intensive outpatient encounter or partial 

hospitalization with a mental health practitioner. 

Two rates are reported: 
40414 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.019</GPH>

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- 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. 

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 

N/A exception to the requirement that the Secretary 

IN/ N/A Patient Safety select measures that have been endorsed by the HRS X 

A 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-9: Infection within 180 Days of Cardiac 

Implantable Electronic Device (CIED) 

Implantation, Replacement, or Revision: 

Infection rate following ClEO 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 

N/A exception to the requirement that the Secretary 

IN/ N!A Patient Safety select measures that have been endorsed by the HRS X 

A 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 arf)1hmia. 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 ( lCD) Complications 

Rate, reportable within the scope of 

electrophysiology. 

140 Community/P Immunizations for Adolescents: The 

7 N/A opulation percentage of adolescents 13 years of age who NCQA X 

IN! Health had the recommended immunizations by their 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40415 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.020</GPH>

.. "" """C ~ ·~ "' Cl}"' ii;oo 00 ;; .. .. "' ... ~'OJ' "" "' NQS ... .c.: e 

= "' s > .. c::: ... Q.. C'c::: ~OIQ Measure Title and Description¥ ~ == 

.... '-'~ = = Qj ·- -- ~ "' z2' ""- Domain ·; 00 '51 = "' 0 -sc;~Si; u~ "" "" u "" 0 .. "' .. 0 = Q.. 0 ~tZi u "' C:::.;l ~ c::: ~" C'"' .. Q.. = C:::i:l.. 1.:)-

A 13th birthday. 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorscd. 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. 

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. 

N/A Communicati 

IN/ N/A on and Care Rationale: We are proposing this measure based CAP X X 

A Coordination 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. 

Lung Cancer Reporting (Resection 

Specimens): Pathology reports based on 

resection specimens with a dial,'110sis of primary 

lung carcinoma that include the pT category, pN 

category and for non small cell lung cancer, 

histologic type. 

N/A Communicati Rationale: We are proposing this measure based IN/ N/A on and Care CAP X X 

A Coordination 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. 

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 

662 Communicati emergency department patients with a principal 

IN/ N/A on and Care diagnosis of long bone fracture (LBF). CMS/OFM X 

A Coordination Q 

Rationale: This measure satisfies 

1848(k)(2)(C)(i) of the Act as this measure is 

NQF-endorscd. This outcome measure provides 

alignment across programs and settings and 

addresses a clinical gap in the program. 

Melanoma Reporting: Pathology reports for 

primary malignant cutaneous melanoma that 

include the pT category and a statement on 

N/A Communicati thickness and ulceration and for pTI, mitotic 

IN/ N/A on and Care rate. CAP X X 

A Coordination 

Rationale: We are proposing this measure based 

on our exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 
40416 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.021</GPH>

.. "" """C ~ ·~ "' Cl}"' ii;oo 00 ;; .. .. "' ... ~'OJ' "" "' NQS ... .c.: e 

= "' s > .. c::: ... Q.. C'c::: ~OIQ Measure Title and Description¥ ~ == 

.... '-'~ = = Qj ·- -- ~ "' z2' ""- Domain ·; 00 '51 = "' 0 -sc;~Si; u~ "" "" u "" 0 .. "' .. 0 = Q.. 0 ~tZi u "' C:::.;l ~ c::: ~" C'"' .. Q.. = C:::i:l.. 1.:)-

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 specialtv. 

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. 

Person and Rationale: We are proposing this measure based Caregiver- N/A Centered on our exception authority under section 

IN/ N/A Experience 1848(k)(2)(C)(ii) of the Act that provides an MNCM X 

A and exception to the requirement that the Secretary 

Outcomes 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. 

Post-procedural Optimal medical therapy 

Composite (percutaneous coronary 

intervention): Percentage of patients aged 18 

years and older for whom PC! is performed who 

are prescribed optimal medical therapy at 

discharge. 

N/A Rationale: We are proposing this measure based 

IN/ N/A Effective on our exception authority under section ACC-AHA X 

A Clinical Care 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. 

Recurrence or amputation following 

endovascular infrainquinallower extremity 

revascularization: Percentage of patients 

undergoing endovascular infrainguinal 

revascularization for non-limb threatening 

ischemia (claudication or asymptomatic) require 

repeat ipsilateral revascularization or any 

N/A amputation within I year. 

IN/ N/A Effective svs X 

A Clinical Care 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. 

Recurrence or amputation following open 

N/A Effective infrainquinallower extremity 

IN/ N/A Clinical Care revascularization: Percentage of patients svs X 

A undergoing open inftainguinal revascularization 

for non-limb threatening ischemia (claudication 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40417 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.022</GPH>

.. "" "'"C ~ ·~ "' Cl}"' ii;oo 00 ;; .. .. "' ... ~'OJ' "" "' NQS .. .c.: e 

= "' s > .. c::: .. Q.. C'c::: ~OIQ Measure Title and Description¥ ~ == 

.... '-'~ = = QJ·---~ "' z2' .. _ Domain ·; 00 '51 = "' 0 -:c;~Si; U:;:E "" ... u i.ol 0 .. ~00 u "' .. 0 = Q.. 0 "" c:::.s ~ c::: ~" C'"' .. Q.. = C:::i:l.. 

or asymptomatic) who require ipsilateral repeat 

"-

revascularization or any amputation within I 

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. 

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. 

N/A Community/P Rationale: We are proposing this measure based AGA/ 

IN/ N/A opulation on our exception authority under section AASLD/ X 

A Health 1848(k)(2)(C)(ii) of the Act that provides an AMA-PCPI 

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. 

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. 

N/A Effective Rationale: We are proposing this measure based AGA/ 

IN! N!A Clinical Care on our exception authority under section AASLD/ X X 

A 1848(k)(2)(C)(ii) of the Act that provides an AMA-PCPI 

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. 

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 usc status 

N/A Community/P was documented and received help quitting if 

IN/ N/A opulation identified as a tobacco user. NCQA/ X X NCIQM A Health 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 
40418 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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. 


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TABLE 23: Proposed NQS Domain Changes for Individual Quality Measures and Those 

Included in Measures Groups for the PQRS Beginning in 2015 

"' s NQS ~ .. c. 

= 0 

" NQS Domain "' :.:: ~ ~ ~ 00 00 :... "' ;... 

~0 :... g; .5 = '""'O:: :; = 2015 e ~ ~ 0:: 0 

~~ "' Domain Measure Title and Description ~~ ::~~ .: ·; 00 'Sil = u "' "' 2014 0 u "' " "" :... :; 0:: = ... ... :... 

~- "' tlO::~ ~ .: 

"" 0 :; 

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 

Communi of the discharge medications with the current medication list 

009 cation and in the outpatient medical record documented 

7/0 N/ Patient Care X 

46 A Safety Coordinat Rationale: CMS is recategorizing this measure from the 

patient safety domain to the communication and care IOU 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 H HS 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. 

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 

Communi • A process to follow up with patients who either did not 

065 N/ Effective cation and make an appointment within the specified timeframe or who 

0/1 A Clinical Care missed a scheduled appointment X 

37 Care Coordinat 

IOU 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. 

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 

Communi period 

N/ N/ Effective cation and Rationale: CMS is recategorizing this measure from the A/2 Clinical Care X 

88 A Care Coordinat effective clinical care domain to the communication and care 

ion 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. 

N/ N/ Effective Communi Parkinson's Disease: Rehabilitative Therapy Options: All X A/2 A Clinical cation and patients with a diagnosis of Parkinson's disease (or 
40420 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


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93 

Nl 

A/2 

94 

N/ 

A/3 

25 

N/ 

A/3 

56 

N/ 

A 

N/ 

A 

N/ 

A 

NQS 

Domain 

2014 

Care 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

NQS 

Domain 

2015 Measure Title and Description 

Care caregiver(s), as appropriate) who had rehabilitative therapy 

Coordinat options (e.g., physical, occupational, or speech therapy) 

ion 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 tor 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. 

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 

Communi annually 

cation and 

Care 

Coordinat 

ion 

Communi 

cation and 

Care 

Coordinat 

ion 

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. 

Adult Major Depressive Disorder (MDD): Coordination of 

Care of Patients with Specific Co morbid 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 efto11 and is 

available to patients and providers as well as communicated 

between health care providers. 

Unplanned Hospital Readmission within 30 Days of 

Principal Procedure: Percentage of patients aged 18 years 

and older who had an unplanned hospital readmission within 

Communi 30 days of principal procedure 

cation and 

Care 

Coordinat 

Rationale: CMS is recategorizing this measure from the 

effective clinical care domain to the communication and care 

ion 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 

> 00 

u 

X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40421 


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N/ 

N3 

03 

Nl 

N3 

31 

N/ 

N3 

32 

N/ 

A/3 

47 

N/ 

A 

N/ 

A 

N/ 

A 

N/ 

A 

NQS 

Domain 

2014 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

NQS 

Domain 

2015 

Person 

and 

Caregiver 

-Centered 

Experienc 

e and 

Outcomes 

Efficiency 

and Cost 

Reduction 

Efficiency 

and Cost 

Reduction 

Patient 

Safety 

Measure Title and Description 

constitutes the deliberate organization of patient care activities 

to facilitate appropriate delivery of health care services and 

outcomes that primarily reflect successful care coordination. 

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. 

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis 

(Appropriate Use): Percentage of patients, agecll8 years and 

older, with a diagnosis of acute sinusitis who were prescribed 

an antibiotic within 7 days of diagnosis or within I 0 clays 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 usc of health care services in the 

provision of patient care. 

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 clavulanle, 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. 

Rate of Endovascular Aneurysm Repair (EV AR) of Small 

or Moderate Non-Ruptured Abdominal Aortic Aneurysms 

(AAA) Who Die While in Hospital: Percent of patients 

undergoing enclovascular 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 

for Categorizing Measures. According to the HHS guidelines 

> 00 

u 

X X 

X X 

X X 

X 
40422 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


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"' s NQS 

u 

Q. 

= c Q,l NQS Domain .... e :: CJ)rl':l 

~Cfl Cf1"" "' ~ .5 8 ""'" ~;;; 8 > "" Q:: C!l 

0'0' Domain 2015 Measure Title and Description t; 

u ~ ... Cf1 ·s;, :r: "' o~f ZQ, 2014 u Q,l 

u Q,l r..c.~ '"" ~ "" Q:: ;;; "' Q,l ... 

...:. "' ;SQ::l:., Q,l 0 ~ 

for categorizing measures. this measure rel1ects an etTort 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. 

HRS-3: Implantable Cardioverter-Defibrillator (lCD) 

Complications Rate: Patients with physician-specific riskstandardized rates of procedural complications following the 

first time implantation of an !CD 

N/ Effective Rationale: CMS is recategorizing this measure from the 

N3 N/ Clinical Patient effective clinical care domain to the patient safety domain in X 

48 A Care Safety 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. 

Anastomotic Leak Intervention: Percentage of patients aged 

18 years and older who required an anastomotic leak 

intervention following gasttic bypass or colectomy surgery 

Rationale: CMS is recategorizing this measure from the 

N/ N/ Effective Patient effective clinical care domain to the patient safety domain in 

N3 A Clinical Safety accordance with NQS priorities which follow the General X 

54 Care 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. 

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 

N/ Effective Rationale: CMS is recategorizing this measure from the 

N3 Nl Clinical Patient effective clinical care domain to the patient safety domain in X 

55 A Care Safety 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 resu Its from the absence of 

appropriate stmctures or processed. 

Pneumonia Vaccination Status for Older Adults: 

Percentage of patients 65 years of age and older who have 

ever received a pneumococcal vaccine. 

004 Effective Communi Rationale: CMS is recategorizing this measure from the 

3 127 Clinical ty/Populat effective clinical care domain to the community/ population X X X X X ACO 

I II v2 Care ion Health health domain in accordance with NQS priorities which follow MU2 

l 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. 

Communi Adult Kidney Disease: Peritoneal Dialysis Adequacy: 

032 N/ cation and Effective Solute: Percentage of patients aged 18 years and older with a 

l/0 A Care Clinical diagnosis of End Stage Renal Disease (ESRD) receiving X 

82 Coordinat Care peritoneal dialysis who have a total Kt/V 2: 1.7 per week 

ion measured once every 4 months 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40423 


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N/ 

All 

80 

N/ 

A/2 

80 

065 

410 

93 

N/ 

A/2 

58 

N/ 

A 

N/ 

A 

N/ 

A 

Nl 

A 

NQS 

Domain 

2014 

Communi 

cation and 

Care 

Coordinat 

ion 

Communi 

cation and 

Care 

Coordinat 

ion 

Communi 

cation and 

Care 

Coordinat 

ion 

Communi 

cation and 

Care 

Coordinat 

ion 

NQS 

Domain 

2015 

Effective 

Clinical 

Care 

Effective 

Clinical 

Care 

Efficiency 

and Cost 

Reduction 

Patient 

Safety 

Measure Title and Description 

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. 

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 glucocmiicoid use and, for those on prolonged 

doses of prednisone 2:: 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. 

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 ef1ective 

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. 

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. 

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) 

> 00 

u 

X AQA 

X 

X X 

X 
40424 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.029</GPH>

"' s NQS II 

Q. 

= c Q,l NQS Domain .... e :: CJ)rl':l 

~Cfl Cf1"" "' ~ .5 8 ""'" ~;;; 8 > "" " C!l 

0'0' Domain 2015 Measure Title and Description t; 

u ~ ... Cf1 ·s;, :r: "' o~f ZQ, 2014 u Q,l 

u Q,l r..c.~ '"" ~ "" " = "' Q,l ... 

' "' -s"Q, .... "' Q,l 0 ~ 

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. 

Rate of Endovascular Aneurysm Repair (EV AR) 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 

endovascu Jar repair of small or moderate non-ruptured 

abdominal aortic aneurysms (AAA) that do not experience a 

Communi major complication (discharged to home no later than postN/ cation and operative day #2) 

A/2 N/ Care Patient X 

59 A Coordinat Safety Rationale: CMS is recategorizing this measure from the 

ion 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 

ref1ects 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. 

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 

Communi 

N/ N/ cation and Patient Rationale: CMS is recategorizing this measure from the 

A/2 A Care Safety communication and care coordination domain to the patient X 

60 Coordinat safety domain in accordance with NQS priorities which follow 

ion 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. 

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-tisk 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 

152 N/ Patient Effective approved for the prevention of thromboembolism 

5/3 A Safety Clinical X 

26 Care 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 altematives. 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40425 

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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.030</GPH>
40426 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.031</GPH>

TABLE 24: Measures Proposed for Removal from the Existing PQRS Measure Set 

Beginning in 2015 

"'""' 

i-l= "' <ol)"' 

s ;;.., 

~'"" .. "' -r.n NQS ,. c.s a '"' '"' > !: c::: .... Q. 

""c::: Measure Title and Description' = "' "' ~~ = = ~ ·- ....... e'd 

oo Domain ~ ~ ·;; r.n "St, ::: 0 .... "' 0 :e;SSiJ .. .. 0 Zc., u .. .... "' .... 0 = Q. 0 ::E'-'i c::: c.!:: c::: "' ~0 o .... o- c:::c.. 

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 

0093 Effective electrocardiogram (ECG) perfonned AMA-PCPI X X !055 Clinical Care !NCQA 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

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 

0232 Effective and reviewed AMA-PCPI X X !056 Clinical Care !NCQA 

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. 

Emergency Medicine: Community-Acquired 

Bacterial Pneumonia (CAP): Empiric 

Antibiotic: Percentage of patients aged 18 years 

and older with a diagnosis of communityacquired bacterial pneumonia (CAP) with an 

0096 Effective appropriate empiric antibiotic prescribed AMA-PCPI X X !059 Clinical Care !NCQA 

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. 

Heart Failure (HF): Left Ventricular Function 

(L VF) Testing: Percentage of patients 18 years 

and older with Left Ventricular Function (LVF) 

testing documented as being performed within the 

previous 12 months or L VF testing performed 

prior to discharge for patients who are 

hospitalized with a principal diagnosis of Heart 

Failure (HF) during the reporting period 

N/A Effective Rationale: CMS recommends removal due to CMS/QIP X /228 Clinical Care this measure representing a clinical concept that 

does not add clinical value to PQRS. L VF 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. 

AQA Effective Chronic Wound Care: Use of Wound Surface AMA-PCPI Adopted Clinical Care Culture Technique in Patients with Chronic !NCQA X X 

!245 Skin Ulcers (Overuse Measure: Percentage of 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40427 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.032</GPH>

AQA 

Adopted 

/246 

NIA 

/266 

N/A295 

N/A297 

N/A298 

NQS 

Domain 

Effective 

Clinical Care 

Measure Title and Description' 

patient visits for those patients aged 18 years and 

older with a diat,'l!osis of chronic skin ulcer 

without the use of a wound surface culture 

technique 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

perfonnance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

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 I 00% suggesting there is no gap in 

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 cuiTent seizure frequency(ies) for 

each seizure type documented in the medical 

Effective record 

Clinical Care 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to l 00% suggesting there is no gap in 

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 

Effective antithrombotic therapy who were prescribed 

Clinical Care aspirin or other antithrombotic therapy. 

Effective 

Clinical Care 

Effective 

Clinical Care 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

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. 

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. 

AM A-PCP! 

INCQA 

AAN 

ABIM 

ABIM 

ABIM 

X 

X 

> rJ) 

u 

X 

X 

X 

X 

X 
40428 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.033</GPH>

.. ., >. ~~ "' OJJ"' 

"' ;s: " " "' -oo NQS .. .. .. c.s 8 ..:: .. Q., 1:1;.~ Measure Title and Description' = '" 8 > ~ ---~ = = ~ ·- ..... c: Do Domain ~ :: ·; "' -~ := "' 0 ;-a;~ 

" " 0 u <oJJ 

"'" 

0 .. :Z:c.., .. '" .. 0 = Q., 0 :;;:tj:j ~ c.C: ~ " ~0 o .... o- ~Q... 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

Hypertension: Diabetes Mellitus Screening 

Test: Percentage of patients aged 18 through 90 

years old with a diagnosis of hypertension who 

N/A299 Effective had a diabetes screening test within 36 months. ABIM X Clinical Care 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

Hypertension: Blood Pressure Control: 

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension whose most 

Effective recent blood pressure was under control (< 

N/A300 Clinical Care 140/90 mmHg). ABIM X 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

Hypertension: Dietary and Physical Activity 

Modifications Appropriately Prescribed: 

Percentage of patients aged 18 through 90 years 

old with a diagnosis of hypertension who 

N/A302 Effective received dietary and physical activity counseling ABIM X Clinical Care at least once within 12 months. 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

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 

which included documentation of the presence or 

Effective absence of macular thickening or hemorrhage AMA-PCPI 0087/0014 Clinical Care AND the level of macular degeneration severity NCQA X X 

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 I 00% suggesting there is no gap in 

care. 

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 

0270/0020 Patient vancomycin, 2 hours), prior to the surgical AMA-PCPI X X X Safety incision (or start of procedure when no incision is NCQA 

required) 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

perfonnance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

care. 

Patient Perioperative Care: Selection of Prophylactic AMA-PCPI 0268/0021 Safety Antibiotic - First OR Second Generation NCQA X X X 

Cephalosporin: Percentage of surgical patients 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40429 


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027110022 

0239/0023 

0092/0028 

0269/0030 

NQS 

Domain 

Patient 

Safety 

Patient 

Safety 

Effective 

Clinical Care 

Patient 

Safety 

Measure Title and Description' 

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 I 00% suggesting there is no gap in 

care. 

Pcrioperativc 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. 

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 

hours prior to incision time or within 24 hours 

after surgery end time 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

perfonnance on this measure with performance 

rates close to l 00% suggesting there is no gap in 

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 sutJering from acute 

myocardial infarction when clinically indicated. 

Perioperative Care:Timing of Prophylactic 

Antiobiotic-Administering Physician: 

Percentage of surgical patients aged 18 years and 

older who receive an anesthetic wlwn undergoing 

procedures with the indications for prophylactic 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPJ 

NCQA 

X 

X 

X 

X 

> rJ) 

u 

X X 

X X 

X 

X 
40430 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


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0240/0031 

0325/0032 

0241/0033 

0243/0035 

NQS 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description' 

parenteral antibiotics for whom administration of 

a prophylactic parenteral antibiotic ordered has 

been initiated within I hour (iffluoroquinolone 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 

perfmmance on this measure with perfom1ance 

rates close to 1 00% suggesting there is no gap in 

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. 

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 

(TlA) 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 

when clinically indicated. 

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 

(TlA) with documented pennanent, 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. 

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 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

X 

X 

X 

> rJ) 

u 

X 

X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40431 


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0244/0036 

0637/0045 

0099/0049 

0001/0064 

0393/0083 

NQS 

Domain 

Effective 

Clinical Care 

Patient 

Safety 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Measure Title and Description' 

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 intmcranial stroke 

when clinically indicated. 

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. 

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. 

Urinary Incontinence: Characterization of 

Urinary Incontinence in Women Aged 65 

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 

perfonnance on this measure with performance 

rates close to 100% suggesting there is no gap in 

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 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

Hepatitis C: Confirmation of Hepatitis C AVIA-PCPI 

X 

X 

X 

> rJ) 

u 

X 

X 

X 

X X 

X 
40432 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.037</GPH>

0103/0106 

1666/0123 

0566/0140 

0051/0142 

NQS 

Domain Measure Title and Description' 

Clinical Care 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 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Rationale: CMS recommends removal due to 

eligible professionals are consistently meeting 

performance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

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 

recunent 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. 

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 

this measure representing a medical concept of 

completion of a required diagnostic level in order 

to provide erythropoiesis-stimulating agent when 

clinically appropriate. 

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 I 00% suggesting there is no gap in 

care. 

AMA-PCPI 

AMA-PCPI 

AMA-PCPI 

NCQA 

Effective Osteoarthritis (OA): Assessment for Use of AMA-PCPI 

Clinical Care Anti-Inflammatory or Analgesic Over-theX 

X 

X 

X 

> 

u "' 

X 

X X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40433 


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0508/0146 

2080/341 

NIN 

301 

N/N 

272 

NIN 

273 

NQS 

Domain 

Efficiency 

and Cost 

Reduction 

Efficiency 

and Cost 

Reduction 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description' 

Counter (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' cunent medications is 

cmcial to patient safety. Furthermore, the 

measure steward has indicated they will no longer 

maintain this measure. 

Radiology: Inappropriate Use of "Probably 

Benign" Assessment Category in 

Mammography Screening: Percentage of final 

repmts 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 I 00% suggesting there is no gap in 

care. 

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. 

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. 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Influenza Immunization: 

Percentage of patients aged 18 years and older 

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 #II 0). 

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 cunent 

A\1A-PCPI 

NCQA 

HRSA 

ABIM 

AGA 

AGA 

X 

> rJ) 

u 

X 

X X 

X 

X 

X 
40434 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.039</GPH>

N/AI 

269 

N/A/ 

267 

N/AI 

261 

0643/243 

AQA 

Adopted/2 

47 

NQS 

Domain 

Effective 

Clinical Care 

Measure Title and Description' 

measure Pneumonia Vaccination Status for Older 

Adults (PQRS II Ill). 

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 eflective treatment 

ofiBD. 

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, 

Effective or documented as unknown or cryptogenic 

Clinical Care 

Communicat 

ion and Care 

Coordination 

Effeclive 

Clinical Care 

Effective 

Clinical Care 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with performance 

rates close to l 00% suggesting there is no gap in 

care. 

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 audio logic 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. 

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 (Ml), coronary artery 

bypass graft (CABO) surgery, a percutaneous 

coronary intervention (PC!), 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. 

Substance Use Disorders: Counseling 

Regarding Psychosocial and Pharmacologic 

Treatment Options for Alcohol Dependence: 

AGA 

AAN 

AQC 

ACCF 

AHA 

A:\!IA-PCPI 

NCQA 

X 

X 

X 

> rJ) 

u 

X 

X 

X 

X 

X 

AQA 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40435 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.040</GPH>

AQA 

Adopted/2 

48 

N/A/231 

N/A/232 

0457/233 

NQS 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description' 

Percentage of patients aged 18 years and older 

with a diagnosis of current alcohol dependence 

who were counseled regarding psychosocial AND 

phannacologic 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. 

Substance Usc 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)). 

Asthma: Tobacco Use: Screening -

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64years with a diagnosis 

of asthma (or their primmy 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 

(PQRS226). 

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 

Use: Screening and Cessation Intervention 

(PQRS 226). 

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 

Effective was documented and reviewed within 2 weeks 

Clinical Care prior to surgery 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

performance on this measure with perfonnance 

rates close to I 00% suggesting there is no gap in 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

AMA-PCPI 

NCQA 

STS 

X 

X 

X 

> rJ) 

u 

X AQA 

X X 

X X 

X 
40436 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.041</GPH>

0458/234 

0074/197 

0079/198 

0115/168 

0116/169 

NQS 

Domain 

Patient 

Safety 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description' 

care. 

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 

perfotmance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

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< I 00 mg/dL OR patients who have 

a LDL-C result 2: 100 mg/dL and have a 

documented plan of care to achieve LDL-C <I 00 

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 1s also 

being proposed for removal from the GPRO WI. 

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. L VF testing 

is basic assessment for patients with heart failure. 

Coronary Artery Bypass Graft (CABG): 

Surgical Re-Exploration: Percentage of patients 

aged 18 years and older undergoing isolated 

CABG surgery who require a retum to the 

operating room (OR) during the current 

hospitalization for mediastinal bleeding with or 

Effective without tamponade, graft occlusion, valve 

Clinical Care dysfunction, or other cardiac reason 

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. 

Coronary Artery Bypass Graft (CABG): 

Antiplatelet Medications at Discharge: 

Percentage of patients aged 18 years and older 

Effective undergoing isolated CABG surgery who were 

Clinical Care discharged on antiplatelet medication 

Rationale: CMS recommends removal due to 

eligible professionals consistently meeting 

STS 

AM A-PCP! 

ACCF 

AHA 

AMA-PCPI 

ACCF 

AHA 

STS 

STS 

> rJ) 

u 

X 

X 

X 

X 

X 

X X 

X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40437 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.042</GPH>

0117/170 

0118/171 

0455/157 

0404/159 

NIN 

257 

NIN 

296 

NQS 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Patient 

Safety 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description' 

performance on this measure with performance 

rates close to 100% suggesting there is no gap in 

care. 

Coronary Artery Bypass Graft (CABG): BetaBlockers Administered at Discharge: 

Percentage of patients aged 18 years and older 

undergoing isolated CABO 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. 

Coronary Artery Bypass Graft (CABG): AntiLipid Treatment at Discharge: Percentage of 

patients aged 18 years and older undergoing 

isolated CABO surgery who were discharged on a 

stalin 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. 

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 

perfonnance on this measure with performance 

rates close to I 00% suggesting there is no gap in 

care. 

HIV/AIDS: CD4+ Cell Count or CD4+ 

Percentage Performed: Percentage of patients 

aged 6 months and older with a diagnosis of 

HIV I 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 I 00% suggesting there is no gap in 

care. 

Statin Therapy at Discharge after I ,ower 

Extremity Bypass (LEB): Percentage of patients 

aged 18 years and older undergoing infra-inguinal 

lower extremity bypass who are prescribed a 

stalin medication at discharge 

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. 

Hypertension: Complete Lipid Profile: 

Percentage of patients aged 18 through 90 years 

old with a diabrnosis of hypertension who 

received a complete lipid profile within 60 

STS 

STS 

STS 

AMA-PCPI 

NCQA 

svs 

ABlM 

X 

> rJ) 

u 

X 

X 

X 

X 

X 

X 

X 

X 

X 
40438 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.043</GPH>

0322/148 

0319/149 

0314/150 

0313/151 

0091/051 

0102/052 

NQS 

Domain 

Efficiency 

and Cost 

Reduction 

Measure Title and Description' 

months 

Rationale: CMS recommends removal due to 

measure steward indicating they will no longer 

maintain this measure. 

Back Pain: Initial Visit: The percentage of NCQA 

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. 

Effective Back Pain: Physical Exam: Percentage of NCQA 

Clinical Care 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 

Effective 

Rationale: CMS recommends removal due to 

this measure representing clinical assessments 

commonly utilized to provide effective treatment 

for patients diagnosed with back pain. 

Back Pain: Advice for Normal Activities: The NCQA 

Clinical Care percentage of patients aged 18 through 79 years 

with a diagnosis of back pain or undergoing back 

surgery who received advice for nonnal 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 tor 

patients diagnosed with back pain when clinically 

indicated. 

Effective Back Pain: Advice Against Bed Rest: The NCQA 

Clinical Care 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. 

Effective Chronic Obstructive Pulmonary Disease AMA-PCPI 

Clinical Care (COPil): Spirometry Evaluation: Percentage of 

patients aged 18 years and older with a diagnosis 

of COPD who had spirometry evaluation results 

documented 

Effective 

Clinical Care 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

Chronic Obstructive Pulmonary Disease AMA-PCPI 

(COPD): Inhaled Bronchodilator Therapy: 

Percentage of patients aged 18 years and older 

> rJ) 

u 

X 

X 

X 

X 

X 

X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40439 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.044</GPH>

0050/109 

N/A/276 

NIN277 

N/A/278 

N/A/279 

N/A/147 

NQS 

Domain Measure Title and Description' 

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. 

Person and Osteoarthritis (OA): Function and Pain AMA-PCPl 

CaregiverCentered 

Experience 

and 

Outcomes 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Communicat 

ion and Care 

Coordination 

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. 

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. 

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 (AHl) 

or a respiratory disturbance index (RDl) 

measured at the time of initial diagnosis 

Rationale: CMS recommends removal due to the 

measure steward indicating they will no longer 

maintain this measure. 

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. 

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. 

AMAPCPl/NCQ 

A 

AMAPCPI/NCQ 

A 

AMAPCPI/NCQ 

A 

AMAPCPI/NCQ 

A 

Nuclear Medicine: Correlation with Existing AMA-PCPI 

Imaging Studies for All Patients Undergoing 

Bone Scintigraphy: Percentage of final reports 

for all patients, regardless of age, tmdergoing 

bone scintigraphy that include physician 

X 

> 

u "' 

X 

X 

X 

X 

X 

X 
40440 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.045</GPH>
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40441 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.046</GPH>

TABLE 25: Existing Individual Quality Measures and Those Included in Measures Groups 

~ or th e PQRS ~ or Wh' IC h M R easure epor f mg U p a d t es WI ·n b e EU ec f IVe B egmnmg m 2015 

-= I.. 

eo:) 

Q :::: ;;., 

- ~ 

I.. 

~ National 1Jl 

- -= ~ :; - ~ .. ell 

= ~ 

,-., "' = "' Quality c ~ ~ 

0~ s "' I.. "' eo:) 

= "' ~ I.. a. eo:) .._1Jj 

1Jl ~ "' s - 0 = I.. I.. I.. 

'""ex:: ~ Strategy eo:) ·; > "' ex:: ex:: I.. "' = ~ 0 ell oo ~ ~ ·s-J) ~ eo:) 0 -= c. 0 I Measure Title and Description¥ ~ 0 1Jl 

~ ~ ~- ~ I.. 

z~ u f;o.l Domain u IJ.S ~ IJ o~&:: 

Coronary Artery Disease (CAD): Antiplatelet 

Therapy: Percentage of patients aged 18 years and 

older with a diaf,rnosis of coronary artery disease 

seen within a 12 month period who were AMA006 Effective prescribed aspirin or clopidogrel PCPI 

ACO 

7/6 Clinical Care ACCF 

X X X 

Rationale: CMS proposes to remove the claims AHA 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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 

Effective 

head evaluation during one or more office visits AMA008 143 

within 12 months PCPI X X MU2 

6/12 v2 Clinical Care 

NCQA 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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 perfonned with 

documented communication to the physician who 

Effective manages the ongoing care of the patient with AMA008 142 

9/19 Clinical Care 

diabetes mellitus regarding the findings of the PCPI X X MU2 

v2 

macular or fundus exam at least once within 12 NCQA 

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. 

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 

004 

Communicati treated for a hip, spine or distal radial fracture with AMA5/24 on and Care documentation of communication with the PCPI X 

Coordination physician managing the patient's on-going care NCQA 

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 
40442 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.047</GPH>

004 

6/39 

004 

8/40 

013 

4/43 

009 

7/46 

National 

Quality 

Strategy 

Domain Measure Title and Description¥ 

move the PQRS program away from claims 

reporting. 

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 

Effective since age 60 or pharmacologic therapy prescribed 

Clinical Care within 12 months 

Effective 

Clinical Care 

Rationale: CMS proposes to remove the claims 

repmiing option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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. 

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 

Effective isolated CABG surgery who received an IMA graft 

Clinical Care 

Communicati 

on and Care 

Coordination 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

repmiing. 

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 

AMAPCPl 

NCQA 

AMAPCPI 

NCQA 

STS 

AMAPCPI 

NCQA 

> 1JJ 

u 

X X 

X 

X X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40443 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.048</GPH>

010 

0150 

009 

0/54 

037 

7/67 

037 

8/68 

National 

Quality 

Strategy 

Domain 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Measure Title and Description¥ 

move the PQRS program away from claims 

reporting. 

Urinary Incontinence: Plan of Care for Urinary 

Incontinence in Women Aged 65 Years and 

Older: Percentage of female patients aged 65 

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. 

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 

Effective chest pain who had a 12-lead electrocardiogram 

Clinical Care (ECG) performed 

Rationale: CMS proposes to remove the claims 

repmiing option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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 

Effective an acute leukemia who had baseline cytogenetic 

Clinical Care testing performed on bone marrow 

Effective 

Clinical 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. 

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 

docwnentation 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. 

AMAPCPl 

NCQA 

AMAPCPI 

NCQA 

AM APCP I 

ASH 

AMAPCPI 

ASH 

> 1JJ 

u 

X 

X 

X 

X 
40444 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.049</GPH>

038 

0/69 

037 

9/70 

038 

7171 

038 

5172 

038 

140 

vi 

141 

v3 

129 

National 

Quality 

Strategy 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Efficiency 

Measure Title and Description¥ 

Hematology: Multiple Myeloma: Treatment 

with Bisphosphonates: Percentage of patients 

aged 18 years and older with a dia,b'liOsis 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 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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. 

Breast Cancer: Hormonal Therapy for Stage IC 

- liiC 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. 

Colon Cancer: Chemotherapy for AJCC Stage 

Ill Colon Cancer Patients: Percentage of patients 

aged 18 through 80 years with AJCC Stage Ill 

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. 

Prostate Cancer: Avoidance of Overuse of Bone 

AMAPCPI 

ASH 

AM APCP! 

ASH 

AMAPCPT 

ASCO 

NCCN 

AM APCP! 

ASCO 

NCCN 

AMA-

> 1JJ 

u 

X 

X 

X X X MU2 

X X X MU2 

X X MU2 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40445 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.050</GPH>

9 

/102 

039 

0 

/I04 

N/A 

/112 

003 

4 

/113 

005 

5 

/117 

v3 

130 

v2 

131 

v2 

National 

Quality 

Strategy 

Domain 

and Cost 

Reduction 

Measure Title and Description¥ 

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 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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 

Effective the prostate who were prescribed adjuvant 

Clinical Care hormonal therapy (GnRH agonist or antagonist) 

Effective 

Clinical Care 

Effective 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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. 

Colo rectal Cancer Screening: Percentage of 

patients 50 through 75 years of age who had 

appropriate screening for colorectal cancer 

Clinical 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. 

Diabetes: Eye Exam: Percentage of patients 18 

through 7 5 years of age with a diagnosis of 

diabetes (type 1 and type 2) who had a retinal or 

Effective dilated eye exam in the measurement period or a 

Clinical Care negative retinal or dilated eye exam (negative for 

retinopathy) in the year prior to the measurement 

period 

PCPI 

AM APCP! 

NCQA 

NCQA 

NCQA 

> 1JJ 

u 

X 

X X X 

X X X 

X X X 

X 

X 

X 

MU2 

MU2 

ACO 

MU2 
40446 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.051</GPH>

006 

2 

/119 

166 

8 

/121 

AQ 

A 

Ado 

pted 

/122 

056 

3 

/141 

134 

v2 

National 

Quality 

Strategy 

Domain Measure Title and Description¥ 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

repmiing. 

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 

Effective period 

Clinical 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. 

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 

Effective fasting lipid profile performed at least once within 

Clinical Care a 12-month period 

Effective 

Clinical Care 

Communicati 

on and Care 

Coordination 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

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 2: 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. 

Primary Open-Angle Glaucoma (POAG): 

Reduction of Intraocular Pressure (lOP) 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 lOP was not reduced by at least 15% from 

the pre- intervention level, a plan of care was 

documented within 12 months 

NCQA 

AM APCP I 

AMAPCPI 

AMAPCPI 

NCQA 

> 1JJ 

u 

X X X MU2 

X X 

X X AQA 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40447 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.052</GPH>

005 

6 

/163 

065 

9 

/185 

038 

6 

/194 

065 

l 

/254 

123 

v2 

National 

Quality 

Strategy 

Domain 

Effective 

Measure Title and Description¥ 

Rationale: CMS proposes to remove the claims 

reporting option for this measure as CMS seeks to 

move the PQRS pro~orram away from claims 

reporting. 

Diabetes: Foot Exam: Percentage of patients aged 

18-75 years of age with diabetes who had a foot 

exam during the measurement period 

Clinical 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. 

Communicati 

on and Care 

Coordination 

Effective 

Clinical Care 

Endoscopy /Polyp Surveillance: Colonoscopy 

Interval for Patients with a History of 

Adenomatous Polyps- Avoidance of 

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. 

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. 

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 

Effective vaginal bleeding who receive a trans-abdominal or 

Clinical Care 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 

NCQA 

AMAPCPI 

ASCO 

AMAPCPI 

NCQA 

ACEP 

> 1JJ 

u 

X X X 

X 

X 

X 

X 

ACO 

MU2 
40448 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.053</GPH>

065 

2 

/255 

N/A 

/268 

065 

8 

/320 

152 

5 

/326 

National 

Quality 

Strategy 

Domain 

Effective 

Clinical Care 

Measure Title and Description¥ 

reporting. 

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-lmmunoglobulin 

(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. 

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 

Effective may affect contraception and pregnancy at least 

Clinical Care 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. 

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 

Communicati had a recommended follow-up interval of at least 

on and Care I 0 years for repeat colonoscopy documented in 

Coordination 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. 

Atrial Fibrillation and Atrial Flutter: Chronic 

Anticoagulation Therapy: Percentage of patients 

aged 18 and older with a diagnosis ofnonvalvular 

atrial fibrillation ( AF) or atrial flutter whose 

assessment of the specified thromboembolic risk 

factors indicate one or more high-risk factors or 

Effective more than one moderate risk factor, as determined 

Clinical Care 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 

ACEP 

AAN 

AMAPCPI 

AMAPCPI 

ACCF 

AHA 

> 1JJ 

u 

X 

X 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40449 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.054</GPH>

N/A 

/327 

166 

7 

/328 

010 

4/10 

7 

010 

5/9 

161 

v2 

128 

v2 

National 

Quality 

Strategy 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description¥ 

move the PQRS program away from claims 

reporting. 

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 ofthe adequacy of 

volume management from a nephrologist 

Rationale: CMS proposes to remove the claims 

reporting option tor this measure as CMS seeks to 

move the PQRS program away from claims 

reporting. 

Pediatric Kidney Disease: ESRD Patients 

Receiving Dialysis: Hemoglobin Level< lOg/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 

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. 

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 

tor EHR reporting only, removing all other 

reporting options. 

Anti-Depressant Medication Management: 

"Percentage of patients 18 years of age and older 

who were diagnosed with major depression and 

Effective treated with antidepressant medication, and who 

Clinical Care 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 

AMAPCPI 

AMAPCPI 

AMAPCPI 

NCQA 

> 1JJ 

u 

X 

X 

X MU2 

X MU2 
40450 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.055</GPH>

006 

4/2 

008 

8/00 

18 

006 

8/20 

4 

163 

v2 

167 

v2 

164 

v2 

National 

Quality 

Strategy 

Domain Measure Title and Description¥ 

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. 

Diabetes: Low Density Lipoprotein (LDL-C) 

Control (<100 mg/DI: Percentage of patients 18-

75 years of age with diabetes whose LDL-C was 

adequately controlled(< I 00 mg/dL) during the 

measurement period 

Effective Rationale: CMS initially wanted to propose 

Clinical Care 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 

available for reporting in 2015, CMS proposes to 

maintain this measure in PQRS for EHR reporting 

only, removing all other reporting options. 

Effective 

Clinical Care 

Effective 

Clinical Care 

Diabetic Retinopathy: Documentation of 

Presence or Absence of Macular Edema and 

I ,eve I 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 ofthis measure as eligible professionals 

are consistently meeting performance on this 

measure with perfom1ance 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. 

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 

NCQA 

AMAPCPI 

NCQA 

NCQA 

> 1JJ 

u 

X 

X 

X 

MU2 

Million 

Hearts 

MU2 

MU2 

Million 

Hearts 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40451 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.056</GPH>

007 

5/24 

I 

002 

2/23 

8 

039 

182 

v3 

156 

v2 

National 

Quality 

Strategy 

Domain Measure Title and Description¥ 

(AMI), coronary artery bypass graft (CABG) or 

percutaneous coronary interventions (PC!) 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 Probrram, 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. 

Ischemic Vascular Disease (IVD): Complete 

Lipid Profile and LDL-C Control (<I 00 

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 (PC!) 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 

Effective of the following during the measurement period: a 

Clinical Care complete lipid profile and LDL-C was adequately 

controlled(< 100 mg/dL) 

Patient Safety 

Effective 

Rationale: CMS initially wanted to propose 

removal of this measure due to changing clinical 

bruidelines (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. 

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. 

Hepatitis C: Ribonucleic Acid (RNA) Testing 

NCQA 

NCQA 

AMA-

> 1JJ 

u 

X 

X 

X 

X 

MU2 

Million 

Hearts 

MU2 
40452 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.057</GPH>

5 

/84 

039 

6 

/85 

039 

8/87 

National 

Quality 

Strategy 

Domain 

Clinical Care 

Measure Title and Description¥ 

Before Initiating Treatment: Percentage of 

patients aged 18 years and older with a diabrnosis 

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. 

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 

Effective Rationale: CMS proposes to make this individual 

Clinical Care measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of9 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. 

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 pertonned 

Effective between 4-12 weeks after the initiation of antiviral 

Clinical Care 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 of9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

PCP! 

AMAPCPI 

AMAPCPI 

> 1JJ 

u 

X 

X 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40453 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.058</GPH>

005 

4 

/108 

040 

5 52v 

1!60 2 

AQ 

A 

Ado 

pted 

1176 

National 

Quality 

Strategy 

Domain 

Effective 

Clinical Care 

Measure Title and Description¥ 

contained within the Hepatitis C measures group 

allows CMS to evaluate patients diagnosed with 

Hepatitis C to be assessed in a more 

comprehensive manner. 

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. 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia 

(PCP) Prophylaxis: Percentage of patients aged 6 

weeks and older with a diagnosis of HIV I AIDS 

who were prescribed Pneumocystis Jiroveci 

Pneumonia (PCP) prophylaxis 

Rationale: CMS proposes to make this individual 

Effective measure reportable via measures group only to 

Clinical Care help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

contained within the Hl VI AIDS measures group 

allows CMS to evaluate patients diagnosed with 

HlV/AlDS to be assessed in a more comprehensive 

manner. 

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 of9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

NCQA 

NCQA 

AMAPCPl 

> 1JJ 

u 

X 

X MU2 

X AQA 
40454 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.059</GPH>

AQ 

A 

Ado 

pted 

/177 

AQ 

A 

Ado 

pted 

/179 

AQ 

A 

Ado 

pted 

/180 

National 

Quality 

Strategy 

Domain 

Effective 

Clinical Care 

Effective 

Clinical Care 

Measure Title and Description¥ 

contained within the Rheumatoid Arthritis 

measures group allows CMS to evaluate patients 

diagnosed with Rheumatoid Arthritis to be 

assessed in a more comprehensive manner. 

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. 

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 tu 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of9 measures over 3 domains. 

Additionally, the clinical topic ofthis 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. 

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 2: 10 mg daily (or equivalent) 

Effective with improvement or no change in disease activity, 

Clinical Care 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 

AMAPCPI 

AMAPCPI 

AMAPCPl 

> 1JJ 

u 

X AQA 

X AQA 

X AQA 
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40455 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.060</GPH>

039 

9 

/183 

040 

9 

/205 

208 

2 

/338 

National 

Quality 

Strategy 

Domain 

Community/ 

Population 

Health 

Measure Title and Description¥ 

requirement of9 measures over 3 domains. 

Additionally, the clinical topic ofthis 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. 

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 of9 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. 

HIV/AJDS: Sexually Transmitted Disease 

Screening for Chlamydia, Gonorrhea, and 

Syphilis: Percentage of patients aged 13 years and 

older with a diagnosis of HJV/ AIDS for whom 

chlamydia, gonorrhea and syphilis screenings were 

performed at least once since the diagnosis of HIV 

infection 

Effective Rationale: CMS proposes to make this individual 

Clinical Care measure reportable via measures group only to 

help mitigate the burden of eligible professionals 

reporting individual measures based on the current 

requirement of9 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. 

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 of9 measures over 3 domains. 

Additionally, the clinical topic of this measure 

AM APCP! 

AMAPCPI 

HRSA 

> 1JJ 

u 

X 

X 

X 
40456 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

BILLING CODE 4120–01–C 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.061</GPH>
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40457 

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: 

• 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. 

• 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 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40458 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

TABLE 26—PROPOSED ASTHMA MEASURES GROUP FOR 2015 AND BEYOND—Continued 

NQF/ 

PQRS Measure title and description Measure developer 

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 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40459 

TABLE 28—PROPOSED CATARACTS MEASURES GROUP FOR 2015 AND BEYOND—Continued 

NQF/ 

PQRS Measure title and description Measure developer 

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 

pre-operative 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 

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 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40460 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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.

AMA–PCPI/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 

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.

AMA–PCPI/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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40461 

TABLE 32—PROPOSED CORONARY ARTERY DISEASE (CAD) MEASURES GROUP FOR 2015 AND BEYOND—Continued 

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/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.

AMA–PCPI/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 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40462 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

TABLE 34—PROPOSED DIABETES MEASURES GROUP FOR 2015 AND BEYOND—Continued 

NQF/ 

PQRS Measure title and description Measure developer 

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 

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.

AMA–PCPI/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.

AMA–PCPI/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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40463 

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 

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/AMA– 

PCPI 

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/AMA– 

PCPI 

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 


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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 

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 Anti-TNF 

(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 AntiTNF (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.

AMA–PCPI/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.

AMA–PCPI/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 


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TABLE 41—PROPOSED OPTIMIZING PATIENT EXPOSURE TO IONIZING RADIATION MEASURES GROUP FOR 2015 AND

BEYOND—Continued 

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 

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 


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40466 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

TABLE 43—PROPOSED PREVENTIVE CARE MEASURES GROUP FOR 2015 AND BEYOND—Continued 

NQF/ 

PQRS Measure title and description Measure developer 

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 

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 


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TABLE 45—PROPOSED SINUSITIS MEASURES GROUP FOR 2015 AND BEYOND—Continued 

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/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 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40468 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

TABLE 47—PROPOSED TOTAL KNEE REPLACEMENT (TKR) MEASURES GROUP FOR 2015 AND BEYOND—Continued 

NQF/PQRS Measure title and description Measure developer 

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 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. 

BILLING CODE 4120–01–P 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40469 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3EP11JY14.062</GPH>

TABLE 48: Proposed Measures for Removal from the Group Practice Reporting Option Web 

Interface Beginning in 2015 and Beyond 

"'"" OJ) <I> 

a;;oo GPRO NQS ... ... ... c.: e 

= "' ~=t:~ o" Measure and Title DescriptionY ~ ::: z~ Module Domain ...... ~ 0 bJ) 

"' "' 0 = Q.. 0 

~(;) 0''-''"' c::c.. 

0097/ Care Patient Medication Reconciliation: NCQA 

46 Coordination/ Safety Percentage of patients aged 65 years and older discharged from any 

Patient Safety inpatient facility (e.g., hospital, ski lied 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 detennine 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. 

0074/ Coronary Effective Coronary Artery Disease (CAD): Lipid Control: Percentage of AMA197 Artery Clinical patients aged 18 years and older with a diagnosis of coronary artery PCP!/ 

Disease Care disease seen within a 12 month period who have a LDL-C result< 100 ACCF/ 

mg/dL OR patients who have a LDL-C result 2: 100 mg/dL and have a AHA 

documented plan of care to achieve LDL-C < I 00 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/20 13111/ II /0 l.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. 
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"'"0 Oll"' 

~"' GPRO NQS .. .. .. .c.: e 

"'"cr:: Measure and Title Description" ~ ~ IQj ·- ...... eo: -=- ,.. .. oo Zc.., Module Domain og~g}' ~~ "' "' o., .. cr::c... 

0729/ Diabetes Effective Diabetes Composite: Optimal Diabetes Care: Patients ages 18 MNC 

319 Mellitus Clinical through 75 with a diagnosis of diabetes, who meet all the numerator M 

Care targets of this composite measure: 

• Diabetes Mellitus: High Blood Pressure Control. 

• Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control. 

• Diabetes Mellitus: Hemoglobin A I c 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.ahajoumals.org/content/early/20 13111/ 11/0l.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 Ale Control (<8%) component is being 

proposed for removal as there are concerns that the A I c level 

monitored in this measure is considered too low to comprehensively 

evaluate the Ale is in control for the elder, frail population. 

0075/ Ischemic Effective Ischemic Vascular Disease (IVD): Complete Lipid Profile and NCQA MU2 

241 Vascular Clinical LDL-C Control(< 100 mg/dL): Percentage of patients 18 years of Million 

Disease Care age and older who were discharged alive for acute myocardial Hearts 

infarction (AMI), coronary artery bypass graft (CABG) or 

percutaneous coronary interventions (PC I) 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 ofthe 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 ofthe new clinical guidelines for statin treatment, as discussed 

for other LDL measures in this table. 

0068/ Ischemic Effective Ischemic Vascular Disease (IVD): Use of Aspirin or Another NCQA MU2 

204 Vascular Clinical Antithrombotic: Percentage of patients 18 years of age and older who Million 

Disease Care were discharged alive for acute myocardial infarction (AMI), coronary Hearts 

artery bypass graft (CABG) or percutaneous coronary interventions 

(PC!) 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. 
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TABLE 49: Proposed New Measures That Will Be Available for Reporting by the Group Practice 

Reporting Option Web Interface Beginning in 2015 and Beyond 

""0 ell"' 

-en GPRO ... ... ""C: ~ £~ ~ oo Measure and Title Description¥ = "' 

Module NQSDomain ~ :: ;c;2;~ 

z~ " " 0 = Q. 0 ::;,z; 0'"'" c:~ 

0059/ Diabetes Effective Diabetes: Hemoglobin A lc Poor Control: Percentage of patients 18- NCQA MU2 

1 Mellitus Clinical Care 75 years of age with diabetes who had hemoglobin Ale> 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 A 1 c 

component. 

00671 Coronary Effective Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage AMA- MU2 

6 Artery Clinical Care of patients aged 18 years and older with a diagnosis of coronary artery PCP I/ 

Disease disease seen within a 12 month period who were prescribed aspirin or ACCF/ 

clopidogrel. AHA 

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. 

00701 Coronary Effective Coronary Artery Disease (CAD): Beta-Blocker Therapy- Prior AMA- MU2 

7 Artery Clinical Care Myocardial Infarction (MI) or Left Ventricular Systolic PCP!/ 

Disease Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and ACCF/ 

older with a diagnosis of coronary artery disease seen within a 12 month AHA 

period who also have prior M I OR a current or L VEF < 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. 

0055/ Diabetes Effective Diabetes: Eye Exam: Percentage of patients 18 through 75 years of age NCQA MU2 

117 Mellitus Clinical Care 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 A TP4 and 

JNC8 clinical guidelines. We believe eye exams are an important part 

of quality care for diabetic patients. 

0419/ Care Patient Safety Documentation of Current Medications in the Medical Record: CMS/QIP MU2 

130 Coordinatio Percentage of visits for patients aged 18 years and older for which the 

n/ eligible professional attests to documenting a list of current medications 

Patient using all immediate resources available on the date of the encounter. 

Safety 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-l 

(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. 
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BILLING CODE 4120–01–C 

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-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 


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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: 

• 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. 

• 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_IndClaimsRegistry_

MeasureSpecs_SupportingDocs_

12132013.zip. 

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 

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 


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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 third-party 

vendors, because we believe that thirdparty 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 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 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. (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. 

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 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 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. 


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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 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-Care-Initiative/

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 

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. 

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. 

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 performance-based 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 


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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 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 

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 evidencebased care processes. Thus far, 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 NQFendorsed 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 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 


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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 

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 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 AllCause 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 postacute 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: allcause unplanned Admissions for 

Patients with Diabetes Mellitus (DM), 

all-cause unplanned Admissions for 

Patients with Heart Failure (HF) and allcause unplanned Admissions for 

Patients with Multiple Chronic 

Conditions. These three measures are 

under development though 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 PopulationDiabetes 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 


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appropriate additional measures for 

assessing quality of care furnished in 

ACOs to help prevent diabetes-related 

foot amputations and blindness. 

• 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 PopulationCoronary 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 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: 

• 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. 

• 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). 


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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. 

• 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 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 Web 

site 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. 

TABLE 50—MEASURES FOR USE IN ESTABLISHING QUALITY PERFORMANCE STANDARDS THAT ACOS MUST MEET FOR

SHARED SAVINGS

Domain ACO 

Measure No. Measure title 

Proposed 

new 

measure 

NQF No./ 

Measure 

steward 

Method of data 

submission 

Pay for performance 

phase in 

R—Reporting 

P—Performance 

PY1 PY2 PY3 

AIM: Better Care for Individuals 

Patient/Caregiver Experience.ACO–1 ........ CAHPS: Getting Timely Care, 

Appointments, and Information.

................ NQF #0005, 

AHRQ.

Survey ............. R P P 

ACO–2 ........ CAHPS: How Well Your Doctors Communicate................. NQF #0005 

AHRQ.

Survey ............. R P P 

ACO–3 ........ CAHPS: Patients’ Rating of 

Doctor.

................ NQF #0005 

AHRQ.

Survey ............. R P P 

ACO–4 ........ CAHPS: Access to Specialists ................ NQF #N/A 

CMS/AHRQ.

Survey ............. R P P 

ACO–5 ........ CAHPS: Health Promotion and 

Education.

................ NQF #N/A 

CMS/AHRQ.

Survey ............. R P P 

ACO–6 ........ CAHPS: Shared Decision Making................. NQF #N/A 

CMS/AHRQ.

Survey ............. R P P 

ACO–7 ........ CAHPS: Health Status/Functional Status................. NQF #N/A 

CMS/AHRQ.

Survey ............. R R R 

ACO–34 ...... CAHPS: Stewardship of Patient 

Resources.

X NQF #N/A 

CMS/AHRQ.

Survey ............. R P P 

Care Coordination/Safety.ACO–8 ........ Risk-Standardized, All Condition Readmission................. Adapted NQF 

#1789 CMS.

Claims ............. R R P 

ACO–35 ...... Skilled Nursing Facility 30-Day 

All-Cause Readmission 

Measure (SNFRM).

X NQF #TBD 

CMS.

Claims ............. R R P 


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TABLE 50—MEASURES FOR USE IN ESTABLISHING QUALITY PERFORMANCE STANDARDS THAT ACOS MUST MEET FOR

SHARED SAVINGS—Continued 

Domain ACO 

Measure No. Measure title 

Proposed 

new 

measure 

NQF No./ 

Measure 

steward 

Method of data 

submission 

Pay for performance 

phase in 

R—Reporting 

P—Performance 

PY1 PY2 PY3 

ACO–36 ...... All-Cause Unplanned Admissions for Patients with Diabetes.X NQF #TBD 

CMS.

Claims ............. R R P 

ACO–37 ...... All-Cause Unplanned Admissions for Patients with Heart 

Failure.

X NQF #TBD 

CMS.

Claims ............. R R P 

ACO–38 ...... All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions.X NQF #TBD 

CMS.

Claims ............. R R P 

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 P P 

ACO–10 ...... Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 )................. Adapted NQF 

#0277 AHRQ.

Claims ............. R P P 

ACO–11 ...... Percent of PCPs who Successfully Meet Meaningful Use 

Requirements.

................ NQF #N/A 

CMS.

EHR Incentive 

Program Reporting.

R P P 

ACO–39 ...... Documentation of Current 

Medications in the Medical 

Record.

X NQF #0419 

CMS.

CMS Web 

Interface.

R P P 

ACO–13 ...... Falls: Screening for Future Fall 

Risk.

................ NQF #0101 

NCQA.

CMS Web 

Interface.

R P P 

AIM: Better Health for Populations 

Preventive 

Health.

ACO–14 ...... Preventive Care and Screening: Influenza Immunization................. NQF #0041 

AMA–PCPI.

CMS Web 

Interface.

R P P 

ACO–15 ...... Pneumonia Vaccination Status 

for Older Adults.

................ NQF #0043 

NCQA.

CMS Web 

Interface.

R P P 

ACO–16 ...... Preventive Care and Screening: Body Mass Index (BMI) 

Screening and Follow Up.

................ NQF #0421 

CMS.

CMS Web 

Interface.

R P P 

ACO–17 ...... Preventive Care and Screening: Tobacco Use: Screening 

and Cessation Intervention.

................ NQF #0028 

AMA–PCPI.

CMS Web 

Interface.

R P P 

ACO–18 ...... Preventive Care and Screening: Screening for Clinical 

Depression and Follow-up 

Plan.

................ NQF #0418 

CMS.

CMS Web 

Interface.

R P P 

ACO–19 ...... Colorectal Cancer Screening ... ................ NQF #0034 

NCQA.

CMS Web 

Interface.

R R P 

ACO–20 ...... Breast Cancer Screening ......... ................ NQF #NA 

NCQA.

CMS Web 

Interface.

R R P 

ACO–21 ...... Preventive Care and Screening: Screening for High Blood 

Pressure and Follow-up Documented.

................ CMS ................ CMS Web 

Interface.

R R P 

Clinical Care for 

At Risk Population—Depression.

ACO–40 ...... Depression Remission at 

Twelve Months.

X NQF #0710 

MNCM.

CMS Web 

Interface.

R P P 

Clinical Care for 

At Risk Population—Diabetes.

..................... Diabetes Composite (All or 

Nothing Scoring).

................ CMS composite CMS Web 

Interface.

R P P 


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TABLE 50—MEASURES FOR USE IN ESTABLISHING QUALITY PERFORMANCE STANDARDS THAT ACOS MUST MEET FOR

SHARED SAVINGS—Continued 

Domain ACO 

Measure No. Measure title 

Proposed 

new 

measure 

NQF No./ 

Measure 

steward 

Method of data 

submission 

Pay for performance 

phase in 

R—Reporting 

P—Performance 

PY1 PY2 PY3 

ACO–26 ...... ACO–26: Diabetes 

Mellitus: Daily Aspirin or 

Antiplatelet Medication 

Use for Patients with Diabetes Mellitus and 

Ischemic Vascular Disease.

................ NQF #0729 

MNCN (individual measure).

......................... R P P 

ACO–27 ...... ACO–27: Diabetes 

Mellitus: Hemoglobin 

A1c Poor Control.

................ NQF #0059 

NCQA (individual component).

CMS Web 

Interface.

R P P 

ACO– 

41:.

ACO–41: Diabetes: Foot Exam X NQF #0056 

NCQA (individual component).

CMS Web 

Interface.

R P P 

ACO–42 ACO–42: Diabetes: Eye Exam X NQF #0055 

NCQA (individual component).

CMS Web 

Interface.

R P P 

Clinical Care for 

At Risk Population—Hypertension.

ACO–28 ...... Hypertension (HTN): Controlling High Blood Pressure................. NQF #0018 

NCQA.

CMS Web 

Interface.

R P P 

Clinical Care for 

At Risk Population—Heart 

Failure.

ACO–31 ...... Heart Failure (HF): BetaBlocker Therapy for Left Ventricular Systolic Dysfunction 

(LVSD).

................ NQF #0083 

AMA–PCPI.

CMS Web 

Interface.

R R P 

Clinical Care for 

At Risk Population—Coronary Artery 

Disease.

..................... Coronary Artery Disease (CAD) 

Composite (All or Nothing 

Scoring).

................ CMS composite CMS Web 

Interface.

R R P 

ACO–33 ...... 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%).

................ NQF #0066 

ACC (individual component).

CMS Web 

Interface.

R P P 

ACO–43 ...... ACO–43: Antiplatelet Therapy.X NQF #0067 

ACC (individual component).

CMS Web 

Interface.

R R P 

ACO–44 ...... ACO–44 :Symptom Management.X NQF #N/A 

AMA–PCPI 

(individual 

component).

CMS Web 

Interface.

R R P 

ACO–45 ...... ACO–45: Beta-Blocker 

Therapy—Prior Myocardial Infarction (MI) or 

Left Ventricular Systolic 

Dysfunction (LVEF 

<40%).

X NQF #0070 

ACC (individual component).

CMS Web 

Interface.

R R P 

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. 


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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 

(percent) 

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 

(percent) 

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 

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 

Year 1 

Performance 

Year 2 

Performance 

Year 3 

ACO #12 Replaced.Care Coordination/Patient 

Safety.

Medication Reconciliation: 

Reconciliation 

After Discharge from 

an Inpatient 

Facility.

NQF #97 AMA– 

PCPI/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 

-Redundant 

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—Redundant 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 


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TABLE 53—SHARED SAVINGS PROGRAM MEASURES RETIRED/REPLACED—Continued 

Notes Domain Measure title NQF measure #/

measure steward 

Method of data 

submission 

Pay for Performance Phase In 

R = Reporting P=Performance 

Performance 

Year 1 

Performance 

Year 2 

Performance 

Year 3 

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 

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 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 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, 


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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 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 multistakeholder 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 

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-Service-Payment/

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. 

• 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 


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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. 

• 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 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-health-informationexchange-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 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 HIEfocused 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-researchersimplementers/standards-andcertification-regulations. 

b. Electronic Reporting of Quality 

Measure Data 

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 


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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 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 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 Medicare-enrolled 

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 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 EHRbased 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 


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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 

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 

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 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 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 


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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 to 

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 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 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 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 


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frequently if appropriate. We note, 

however, that we may revisit this policy 

as more ACOs enter the program, more 

FFS data is collected 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 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 at-risk 

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. 

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 ValueBased 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. 

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 


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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. 

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 Web site at 

http://www.cms.gov/Medicare/

Prescription-Drug-Coverage/

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 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 

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 payfor-reporting measures and pay-forperformance measures. We believe it 

would be appropriate to include payfor-reporting measures for purposes of 

determining quality improvement and 


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awarding bonus points since under 

§ 425.500(f) ACOs that fail to report all 

quality measures, including pay-forreporting 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. 

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 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 Web 

site at http://www.cms.gov/Medicare/

Prescription-Drug-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. 

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 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 


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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-forreporting 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 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 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. 

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 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. 


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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 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 PQRS-qualified 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. 

• 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 nonassigned 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 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 and 

210,000 solo practitioners (as identified 

by their TINs) that consist of 

approximately 815,000 physicians and 

315,000 nonphysician eligible 

professionals. 


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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 

50–99 EPs ....................... 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 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 percent of the eligible 

professionals in the group participate in 

the PQRS as individuals (78 FR 74767 

through 74768). 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 

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 through 74781). 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 

through 74781) 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 

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 


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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 qualitytiering 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 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 Medicare-enrolled 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. 

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 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 


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40496 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

10 Johnson JK, Miller SH, Horowitz SD. Systemsbased 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. 

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 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 PQRSqualified 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 twocategory 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 PQRSqualified 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 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 PQRSqualified 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 

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 qualityVerDate Mar<15>2010 22:08 Jul 10, 2014 Jkt 232001 PO 00000 Frm 00180 Fmt 4701 Sfmt 4702 E:\FR\FM\11JYP3.SGM 11JYP3

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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 quality-tiering 

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 quality-tiering 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 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 

quality-tiering 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 specialtyadjusted cost measures. 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 

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. 


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(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 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-for-service 

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-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 

quality-tiering 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 

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 

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 


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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 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 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) 

TIN A is not part of 

any ACO and ACO 

1 exists 

OR 

TIN A is not part of 

ACO 2 and ACO 1 

exists 

TIN A is part of ACO 

1.

Based on ACO 1’s 

quality data from 

the performance period (for example, 

CY 2015.

Average cost. 

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. 


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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 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 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. 

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 

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. 


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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 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. 

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-forservice 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. 

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 

PQRS-qualified 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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eligible professionals in a 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 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 

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 qualitytiering 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. 

(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 


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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 qualitytiering 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 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 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) 

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. 


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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— 

Continued 

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 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 non-participating 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 

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 NonParticipating Physicians 

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 non-assigned 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 


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have not signed an agreement 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 nonparticipating 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 non-participating 

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 nonassigned claims, application of the VM 

would not affect the limiting charge. 

Rather, Medicare makes payment for the 

non-assigned services directly to the 

beneficiary and the physician receives 

all payment for a non-assigned 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 nonassigned services starting in 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 nonassigned 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 

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 quality-tiering 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 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 qualitytiering methodology in CY 2017 to +4.0× 

for groups and solo practitioners 

classified as high quality/low cost and 

to set the adjustment to +2.0× 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 +1.0× to 

groups and solo practitioners that care 

for high-risk beneficiaries (as evidenced 

by the average HCC risk score of the 


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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% +2.0×* +4.0×* 

Average Cost ............................................................................................................................... ¥2.0% +0.0% +2.0x* 

High Cost ..................................................................................................................................... ¥4.0% ¥2.0% +0.0% 

* Groups and solo practitioners eligible for an additional +1.0× if reporting Physician Quality Reporting System quality measures and average 

beneficiary risk score is in the top 25 percent of all beneficiary risk scores. 

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. 

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 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 


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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 qualitytiering 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. 

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 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 

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 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). 


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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 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 all-cause 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 allcause 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 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 allcause 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; 

• 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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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; 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 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 

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 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40510 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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 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 nonprimary 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-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 ‘‘prestep’’) 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 non-assigned 

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 prestep 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. 

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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40511 

11Please 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). 

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 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 part-year 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 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 

stand-alone 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 hospitalbased 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 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 selfnomination, 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 selfnomination. 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 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 


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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 

hospital-based 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 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’ Web site at http:// 

www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/hospital-value-basedpurchasing/index.html?redirect=/

hospital-value-based-purchasing/. 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 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. 

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 


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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. 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 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 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 episodebased 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 qualitytiering information on 2012 data that 

they could use to decide whether to 

elect to be assessed under the qualitytiering 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, 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 


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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). 

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 EPs 12

EPs) that included a broader set of 

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 inpatientbased episodes, attribution was based 

the plurality of inpatient E&M visits 

during the trigger event; for outpatientbased 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 

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-EpisodeGrouper.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 nonhealth (for example, age) explanatory 

variables. Using these variables, the 

risk-adjustment 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 payment-standardized. 

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 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 conditionspecific 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 


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13There are a few difference between the risk 

adjustment approaches for the six clinical episodebased 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 riskadjusted at the specific episode type level, to 

recognize the distinctions. 

Feedback Program, through the 2012 

Supplemental QRURs, and we would 

consider whether to propose their 

inclusion in the VM through future 

rulemaking. 

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/Content

Server?c=Page&pagename

=QnetPublic%2FPage

%2FQnetTier4&cid=1228772057350. 

The risk adjustment methodology 

specific to these six episode-based 

standardized payment measures can be 

found on the CMS Web site at http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/Physician

FeedbackProgram/Episode-Costs-andMedicare-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-EpisodeGrouper.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-Payment/

PhysicianFeedbackProgram/EpisodeCosts-and-Medicare-EpisodeGrouper.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-Service-Payment/

PhysicianFeedbackProgram/EpisodeCosts-and-Medicare-EpisodeGrouper.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 Web site and the 

construction of the episode-based 

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 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 


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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. 

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 

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 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 


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14Centers 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 15 Id. at XV. 

recipients as compensation for speaking 

at a 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 PRA-related 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) EHRbased 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. 

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 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 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 


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16 Id. at xvi. See Figure 4. 

17 Id. 

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 

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 × $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

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 × 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 

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 × $41/hour) to $73.80 

(108 minutes or 1.8 hours × $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 × 9 

measures × 6 cases per measure) to 648 

minutes (12 minutes per measure × 9 

measures × 6 cases per measure), with 

the burden to the median practice being 

94.5 minutes (1.75 minutes per measure 

× 9 measures × 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 × 9 measures × 6 

cases per measure) to $442.80 ($8.20 per 

measure × 9 measures × 6 cases per 

measure), with the cost to the median 

practice being $64.58 per eligible 

professional ($1.20 per measure × 9 

measures × 6 cases per measure). 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
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18 Id. at xvi. See Figure 4. 19 Id. at xv. 

20 Id. at xv. 21 Id. at xvi. 22 Id. at 18. 

c. Burden Estimate for PQRS Reporting 

by Individual Eligible Professionals and 

Group Practices: Qualified Registrybased 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 registrybased 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 registrybased measures. 

• 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 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 claimsbased 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 

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 

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 


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eligible professionals) will participate in 

the PQRS using the GPRO web interface 

in 2015. 

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 selfnomination process is handled by a 

group practice’s administrative staff. 

Therefore, we estimate that the selfnomination 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 selfnomination, 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 × 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 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 

Nos. Respondents Responses (total) 

Burden (time) 

per 

response 

Total annual 

burden 

(hours) 

Labor cost of 

reporting 

($/hr) 

Total cost 

($) 

403.904(d)(3) ..... 0938–1173 

(CMS–10419.

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 

0.5 hr (system 

upgrades).

210 47.55 9,986 

CY 2015 PQRS 

(start up for 

first time participants).

0938–1059 

(CMS–10276).

164,000 ............ 164,000 ............ 5 hr ................... 820,000 16.00 13,120,000 

CY 2015 PQRS 

(Claims-Based 

Reporting 

Mechanism).

0938–1059 

(CMS–10276).

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 

QCDR-based 

Reporting 

Mechanisms).

0938–1059 

(CMS–10276).

165,000 ............ 165,000 ............ 5 min ................ 13,750 N/A** N/A 

CY 2015 PQRS 

(EHR-Based 

Reporting 

Mechanism).

0938–1059 

(CMS–10276).

50,000 .............. 50,000 .............. N/A*** ............... N/A N/A N/A 


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TABLE 59—PROPOSED ANNUAL RECORDKEEPING AND REPORTING REQUIREMENTS AND BURDEN—Continued 

Regulation 

section(s) 

OMB & CMS ID 

Nos. Respondents Responses (total) 

Burden (time) 

per 

response 

Total annual 

burden 

(hours) 

Labor cost of 

reporting 

($/hr) 

Total cost 

($) 

CY 2015 PQRS 

(Group Practices Using the 

GPRO Web 

Interface).

0938–1059 

(CMS–10276).

200 ................... 200 (self-nomination 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 × number of measures (9) × 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. 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web site 

at http://www.cms.hhs.gov/Paperwork

ReductionActof1995; 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. 

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 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 Web site at http:// 

www.sba.gov/content/table-smallbusiness-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 


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located outside of a 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 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 

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 Web 

site at http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/

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. 

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 


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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 fiveyear review and update of MP RVUs. 

• 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 * 

Specialty Allowed 

charges (mil) 

Impact of work 

RVU changes 

Impact of PE 

RVU changes 

Impact of MP 

RVU changes 

Combined impact ** 

(A) (B) (C) (D) (E) (F) 

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 PHY ........................... 83 0 0 0 1 

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. 


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** Column F may not equal the sum of columns C, D, and E due to rounding. 

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-todigital 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 the last fiveyear 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. 

TABLE 61—IMPACT OF PROPOSED RULE ON CY 2015 PAYMENT FOR SELECTED PROCEDURES

[Based on the March 2014 Preliminary Physician Update] 

Facility Non-facility 

CPT 1/HCPCS MOD Short Descriptor CY 2014 2

CY 2015 

Jan 1– 

March 313

Change CY 2014 2

CY 2015 

Jan 1– 

March 31 3

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 1,397.90 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 

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 .............. ........ Office/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 


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TABLE 61—IMPACT OF PROPOSED RULE ON CY 2015 PAYMENT FOR SELECTED PROCEDURES—Continued 

[Based on the March 2014 Preliminary Physician Update] 

Facility Non-facility 

CPT 1/HCPCS MOD Short Descriptor CY 2014 2

CY 2015 

Jan 1– 

March 313

Change CY 2014 2

CY 2015 

Jan 1– 

March 31 3

Change 

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 

1CPT codes and descriptions are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 

2The CY 2014 CF is 35.8228. 

3Payments 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. 

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 self-implementing 

statutory provisions. 

The geographic designations for 

approximately 99.48 percent of ZIP 

codes would be 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 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 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40526 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

23Centers 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. 

24Id. at XV. 

25 Id. at xvi. See Figure 4. 

26 Id. 

27 Id. at xvi. See Figure 4. 

28 Id. at xv. 

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 Web site because we 

are not collecting any information for 

the Physician Compare Web site. 

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 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 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 claims-based 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 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 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 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 


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29 Id. at xv. 

30 Id. at xvi. 

31 Id. at 18. 

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 claims-based to the EHR-based 

reporting mechanisms. 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 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 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 

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 believe 

that the start-up cost for an eligible 

professional to report PQRS quality 

measures data is 5 hours × $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 


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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 × 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 

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 × $41/hour) to $73.80 (108 

minutes or 1.8 hours × $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 claimsbased 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 claimsbased reporting will range from 13.5 

minutes (0.25 minutes per measure × 9 

measures × 6 cases per measure) to 648 

minutes (12 minutes per measure × 9 

measures × 6 cases per measure), with 

the burden to the median practice being 

94.5 minutes (1.75 minutes per measure 

× 9 measures × 6 cases). We estimate the 

total annual reporting cost per eligible 

professional or eligible professional in a 

group practice associated with claimsbased reporting will range from $9.18 

($0.17 per measure × 9 measures × 6 

cases per measure) to $442.80 ($8.20 per 

measure × 9 measures × 6 cases per 

measure), with the cost to the median 

practice being $64.58 per eligible 

professional ($1.20 per measure × 9 

measures × 6 cases per measure). 

(c) Burden Estimate for PQRS Reporting 

by Individual Eligible Professionals and 

Group Practices: Qualified RegistryBased 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 registrybased 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 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 

minimal as all of the information 

required to report the measure should 

already reside in the eligible 

professional’s or group practice’s EHR. 


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(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 selfnomination process is handled by a 

group practice’s administrative staff. 

Therefore, we estimate that the selfnomination 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 selfnomination, 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 × 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 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 

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 


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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 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 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) selfnominate 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 quality-tiering 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. 

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 

Web site at http://www.cms.gov/

Medicare/Medicare-Fee-for-ServicePayment/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 percent) are in the average 

quality and average cost tiers (this 


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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 

(percent) 

Average quality 

(percent) 

High quality 

(percent) 

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 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 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). 


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TABLE 67—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED COSTS, TRANSFER, AND SAVINGS

Category Transfers 

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. 

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. 

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. 

(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. 

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 patient-level 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 


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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). 

■ 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’’. 

■ 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 opted-out. 

* * * * * 

■ 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) * * * 

(5) Furnished under the direct 

supervision of a nurse practitioner, 

physician assistant, or certified nursemidwife. 

* * * * * 

■ 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 

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. 

* * * * * 

■ 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: 


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§ 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. 

* * * * * 

(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 Web site. 

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. 

(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: 

§ 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-toface 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 crosscutting 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-toface 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 crosscutting 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. 


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(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 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 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 crosscutting 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 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 crosscutting 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. 

(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, 


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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 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) * * * 

(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— 

■ 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) * * * 

(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 valuebased 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 valuebased 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. 

(iii) If the ACO did not exist during 

the performance period, then the quality 

composite for the groups and solo 


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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 valuebased 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 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 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 valuebased 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 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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40538 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

■ 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’’. 

■ 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 valuebased 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. 

* * * * * 

■ 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. 

(1) Starting with the CY 2017 payment 

adjustment period, the exception to 

paragraph (a) of this section is the allcause 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). 

(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). 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 40539 

■ 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. 

* * * * * 

(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 

(percent) 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: 

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 

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. 

■ 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. 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3
40540 Federal Register / Vol. 79, No. 133 / Friday, July 11, 2014 / Proposed Rules 

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) * * * 

(19) Whether a physician or 

practitioner has failed to properly optout, 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. 

[FR Doc. 2014–15948 Filed 7–3–14; 4:15 pm] 

BILLING CODE 4120–01–P 


EMCDONALD on DSK67QTVN1PROD with PROPOSALS3